Original Contribution Predictors of a drainable suppurative adenitis among children presenting with cervical adenopathy Amir A. Kimia, MD ⁎, Tiffany F. Rudloe, MD, Nadine Aprahamian, MD, Jennifer McNamara, PNP, David Roberson, MD, Assaf Landschaft, MSc, Jennifer Vaughn, MD, Marvin B. Harper, MD Boston Children's Hospital, United States abstract article info Article history: Received 14 March 2018 Received in revised form 25 April 2018 Accepted 5 May 2018 Objectives: We sought to identify predictors for a drainable suppurative adenitis [DSA] among patients presenting with acute cervical lymphadenitis. Methods: A retrospective cross sectional study of all patients admitted to an urban pediatric tertiary care emer- gency department over a 15 year period. Otherwise healthy patients who underwent imaging for an evaluation of cervical lymphadenitis were included. Cases were identified using a text-search module followed by manual review. We excluded immunocompromised patients and those with lymphadenopathy felt to be not directly in- fected (i.e. reactive) or that was not acute (symptom duration N28 days). Data collected included: age, gender, duration of symptoms, highest recorded temperature, physical exam findings, laboratory and imaging results, and surgical findings. A DSA was defined as N1.5 cm in diameter on imaging. We performed binary logistic regres- sion to determine independent clinical predictors of a DSA. Results: Three hundred sixty-one patients met inclusion criteria. Three hundred six patients (85%) had a CT scan, 55 (15%) had an ultrasound and 33 (9%) had both. DSA was identified in 71 (20%) patients. Clinical features in- dependently associated with a DSA included absence of clinical pharyngitis, WBC N15,000/mm 3 , age ≤3 years, an- terior cervical chain location, largest palpable diameter on exam N3 cm and prior antibiotic treatment of N24 h. The presence of fever, skin erythema, or fluctuance on examination, was not found to be predictive of DSA. Conclusions: We identified independent predictors of DSA among children presenting with cervical adenitis. Risk can be stratified into risk groups based on these clinical features. © 2018 Published by Elsevier Inc. Keywords: Adenopathy Cervical Suppurative Adenitis 1. Introduction Cervical lymphadenopathy is a common pediatric complaint, raising concern for infection, autoimmune disease, or malignancy [1-3]. In the context of an infection, a local inflammatory process may result in reac- tive lymphoid hyperplasia [3]. This response normally functions to pre- vent microbial invasion of the host. However, bacterial inoculation of lymphatic tissue can occur, resulting in a local suppurative process [1,4-6]. Pathogens most commonly arise from the oropharynx, sinuses, or the nares [4,7]. Antibiotic therapy is often effective and selected to provide coverage for staphylococcal and streptococcal species [1,5,6,8]. Once liquefaction has occurred, surgical drainage may be necessary to mitigate the risk for spread of the infection beyond the node and into the deep soft tissues of the neck [9]. Factors previously shown to be associated with need for surgical drainage include unilateral lymph node, age b1 year, and duration of symptoms N48 h [10,11]. When drainage is being considered, either by needle aspiration [7,12] or by incision and drainage Ultrasound (US) or Computed Tomog- raphy (CT) imaging is often obtained [11,13]. Decisions on imaging be- yond bedside ultrasound, are dependent upon clinical impression considering factors such as overlying erythema or fluctuance on exam, as with the evaluation of skin and soft-tissue abscess assessment. CT may also be obtained to guide surgical intervention and to assess poten- tial airway compromise. There are clear reasons to avoid the radiation risk associated with CT of the neck as children are much more suscepti- ble to the detrimental effects of radiation exposure compared to adults, with the thyroid gland being particularly sensitive to radiation exposure [14,15]. The primary goal of this study was to identify clinical predictors of a lymph node that has undergone suppuration, forming a drainable American Journal of Emergency Medicine 37 (2019) 109–113 ⁎ Corresponding author at: Boston Children's Hospital, Division of Emergency Medicine, 300 Longwood Ave., Boston, MA 02115, United States. E-mail addresses: Amir.kimia@childrens.harvard.edu, (A.A. Kimia), Nadine.aprahamian@childrens.harvard.edu, (N. Aprahamian), Jennifer.mcnamara@childrens.harvard.edu, (J. McNamara), David.roberson@childrens.harvard.edu, (D. Roberson), Jennifer.vaughn@childrens.harvard.edu, (J. Vaughn), Marvin.harper@childrens.harvard.edu (M.B. Harper). https://doi.org/10.1016/j.ajem.2018.05.004 0735-6757/© 2018 Published by Elsevier Inc. Contents lists available at ScienceDirect American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem