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symptom.lymphadenopathy.v1PRODUCTION
symptom.lymphadenopathy.v1

Lymphadenopathy (localised / generalised / by location + features)

symptomsubacutechronicundifferentiatedadult
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm LAD vs lipoma / cyst / parotid / branchial / thyroid / hernia; localised vs generalised; localize by region (cervical / axillary / inguinal / supraclavicular / epitrochlear / mesenteric / hilar) (Bazemore 2002 PMID 12484692)

Inputs
5
Actions
0
Advance rule
Set
Advance when

LAD confirmed + region + distribution + features defined

Patient inputs (34)

Age >40 raises malignancy prior; pediatric mostly reactive (Bazemore AFP 2002 PMID 12484692)

<2 wk reactive likely; >4-6 wk pathologic prior; doubling in weeks → aggressive (Bazemore 2002)

Fever, drenching night sweats, ≥10% weight loss in 6 mo → lymphoma signature (Lugano Cheson 2014 PMID 25113753)

Bartonella cat (Florin Klotz 2008 PMID 21243990), Toxoplasma cat litter, Brucella livestock, TB endemic (Mohapatra 2009 PMID 20209720), tularemia rabbit

HIV / syphilis / HSV — generalised LAD common (Habermann 2002)

Phenytoin, allopurinol, hydralazine, isoniazid, sulfasalazine, lamotrigine, carbamazepine → drug-induced LAD / DRESS (RegiSCAR Kardaun 2013 PMID 23855313)

Fever + LAD pattern recognition (FUO criteria — Petersdorf)

Supraclavicular = highly concerning at any size; cervical / axillary / inguinal / hilar / mesenteric — different drainage + dx (Bazemore 2002 PMID 12484692)

Localised (single region) vs generalised (≥2 non-contiguous) — narrows differential (Habermann 2002 PMID 9803196)

≥1.5 cm persistent or ANY supraclavicular → biopsy threshold (Bazemore 2002; Lugano Cheson 2014)

Hard / matted / fixed = malignancy; rubbery = lymphoma; tender = infection (Habermann 2002)

Tender → infectious / acute; painless → malignant prior shifts up (Bazemore 2002)

Blasts → acute leukemia; atypical lymphocytes → mono (Cohen NEJM 2000 PMID 10944566); cytopenias → marrow infiltration (NCCN 2024)

Lymphoma marker; elevated correlates with bulk + IPI score (Lugano Cheson 2014)

Inflammation magnitude — Hodgkin IPS component (Engert NEJM 2010)

LFTs (DRESS pattern; hepatic infiltration); creatinine (renal infiltration); electrolytes (tumor lysis)

Mononucleosis common cause of cervical / generalised LAD (Cohen NEJM 2000 PMID 10944566); monospot if acute

HIV-associated LAD common; primary HIV → generalised LAD + mononucleosis-like syndrome

Mediastinal LAD (lymphoma, sarcoid, TB, met carcinoma) — first-line for hilar disease (Bazemore 2002)

Generalised LAD or large persistent — staging + biopsy targeting (Lugano Cheson 2014)

Lymphoma staging + hot-spot guidance for biopsy + Lugano response (Cheson 2014 PMID 25113753)

EXCISIONAL biopsy preferred over FNA for lymphoma (architecture + flow + cytogenetics + IHC); FNA inadequate (Lugano Cheson 2014; NCCN 2024)

B vs T vs NK clonality; aberrant marker patterns; rapid leukemia/lymphoma classification (NCCN 2024)

Staging lymphoma + leukemia confirmation if blasts / cytopenias (Lugano Cheson 2014)

Lymphoma sex distribution + breast / GU drainage relevance (Habermann 2002)

Hodgkin classic: pruritus + alcohol-induced nodal pain (Engert NEJM 2010 PMID 32703949)

SLE, RA, sarcoidosis, Castleman → autoimmune LAD pattern (Habermann 2002)

Tumor lysis risk if high-grade lymphoma / acute leukemia (NCCN 2024)

Syphilis (secondary) — generalised LAD + rash (Habermann 2002)

TB lymphadenitis — scrofula / mediastinal (Mohapatra 2009 PMID 20209720)

Cat-scratch — IgG/IgM (Florin Klotz 2008 PMID 21243990)

SLE, autoimmune LAD differential (Habermann 2002)

Hep B/C reactivation risk before rituximab / chemo; chronic hep can cause LAD (NCCN 2024)

Cervical LAD characterization — shape (round vs oval), hilum, vascularity (NCCN 2024)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (11)

11 need judgement
  • informationallife_threateningcytopenia_with_lymphadenopathy
    LAD + blasts on peripheral smear OR pancytopenia OR isolated cytopenia (NCCN 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmediastinal_mass_airway_compression
    Mediastinal mass on CXR with stridor, dyspnea, orthopnea, SVC syndrome features (facial swelling, distended neck veins, plethora) (NCCN 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningdrug_induced_dress
    New drug (2-8 wk latency) + LAD + morbilliform rash + eosinophilia ≥1500 OR atypical lymphocytes + LFT rise (>2× ULN) ± fever ± facial edema → DRESS (RegiSCAR Kardaun 2013 PMID 23855313)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningairway_compromise_lad
    LAD with acute upper airway compromise — stridor, drooling, voice change, accessory muscle use (NCCN 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresupraclavicular_high_concern
    Supraclavicular lymph node palpable at ANY size — left = Virchow → abdominal malignancy; right = mediastinal / lung primary
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereb_symptoms_present
    Persistent LAD + ≥1 of: fever >38°C, drenching night sweats, unintentional ≥10% weight loss in 6 mo (Lugano Cheson 2014 PMID 25113753)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehard_fixed_painless_node
    Hard / matted / fixed / painless node in any region — malignancy signature regardless of size (Bazemore AFP 2002 PMID 12484692)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererapidly_enlarging_node
    Node doubling in size within ≤2 weeks (NCCN 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderategeneralized_lymphadenopathy_workup
    Generalised LAD ≥2 non-contiguous regions without obvious explanation (Habermann 2002 PMID 9803196)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepediatric_phenotype_concerning
    Pediatric LAD with one of: persistent >6 wk, supraclavicular, hard/fixed, mediastinal, B-symptoms, atypical mycobacterial (chronic painless violaceous cervical node), Kawasaki criteria (Bazemore 2002; AAP)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildlocalized_reactive_lymphadenopathy
    Localised <1.5 cm tender soft mobile node in single drainage region with proximal infection / URI (Bazemore AFP 2002 PMID 12484692)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RED_FLAGSoptionalDrives severity classification
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Recommended regimen

Directed antibiotic for bacterial / atypical lymphadenitis (selected cases)
axis: lymphadenopathy_directed_antibiotic
Selected axis "Directed antibiotic for bacterial / atypical lymphadenitis (selected cases)" by default fallback (first axis)
  • cephalexin
    first line
    1st_gen_cephalosporin
    500 mg • PO • q6h × 7-10 d
    triggers: bacterial_cervical_lymphadenitis_strep_or_staph_likely
    Empiric outpatient — covers most strep/staph (Bazemore 2002 PMID 12484692)
    rxcui 2231
  • clindamycin
    second line
    lincosamide
    300-450 mg • PO • q6-8h × 7-10 d
    triggers: MRSA_risk, PCN_allergy
    CA-MRSA coverage; D-test for inducible resistance
    rxcui 2582
  • doxycycline
    first line
    tetracycline
    100 mg • PO • BID × 14 d
    triggers: Bartonella_henselae_cat_scratch_severe_or_immunocompromised, rickettsial_suspicion
    IDSA — cat scratch in severe / immunocompromised (Florin Klotz 2008 PMID 21243990)
    rxcui 3640
  • azithromycin
    first line
    macrolide
    500 mg day 1 then 250 mg • PO • daily × 5 d
    triggers: mycobacterium_avium_lymphadenitis_pediatric, cat_scratch_uncomplicated, PCN_allergy_alternative
    Cat-scratch first-line in mild disease (Bass 1998 RCT); MAI pediatric option alongside excision (Florin 2008 PMID 21243990)
    rxcui 18631

outpatient playbook — drug actions (6)

  1. 1. observe + reassess at 2-4 wk
    N/A • N/A • reassess q2-4 wk
    trigger: Small (<1.5 cm) localised soft mobile tender post-URI cervical / inguinal node in young patient with no B-symptoms (Bazemore 2002 PMID 12484692)
    Reactive LAD self-resolves in most cases; antibiotics not empirically indicated
  2. 2. cephalexin 500 mg PO QID × 7-10 d
    500 mg • PO • q6h × 7-10 d
    trigger: Tender / warm cervical or axillary node + likely strep/staph source (dental, skin)
    Empiric for bacterial lymphadenitis (Bazemore 2002)
  3. 3. azithromycin 500 mg day 1 then 250 mg × 4 d
    500 mg / 250 mg • PO • daily × 5 d
    trigger: Suspected cat-scratch (Bartonella) with cat exposure + epitrochlear or axillary node
    Bass RCT 1998 — modest benefit in uncomplicated cat-scratch (Florin Klotz 2008 PMID 21243990)
  4. 4. doxycycline 100 mg PO BID × 14 d
    100 mg • PO • BID × 14 d
    trigger: Severe / immunocompromised Bartonella, or rickettsial / Lyme suspicion
    IDSA — Bartonella in severe disease (Florin 2008 PMID 21243990)
  5. 5. expedited biopsy referral to surgical onc (EXCISIONAL preferred)
    N/A • N/A • within 1-2 wk
    trigger: ≥1.5 cm persistent OR supraclavicular at ANY size OR hard fixed painless OR B-symptoms OR generalised LAD + cytopenia (Bazemore 2002; Lugano Cheson 2014 PMID 25113753)
    Lymphoma / metastasis risk; EXCISIONAL preserves architecture for flow + cytogenetics (FNA inadequate for lymphoma)
  6. 6. STOP suspected drug + dermatology / ID consult
    N/A • N/A • immediate
    trigger: Drug-induced LAD with rash + eosinophilia + LFT rise (DRESS quintet) (RegiSCAR Kardaun 2013 PMID 23855313)
    Phenytoin, allopurinol, hydralazine, sulfasalazine, isoniazid, lamotrigine, carbamazepine; rapid escalation to ED if major organ involvement

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Palpable lymph node noted by patient or clinician (Bazemore AFP 2002 PMID 12484692); Incidental lymphadenopathy on imaging (NCCN 2024); Lymphadenopathy + B symptoms (fever, night sweats, >10% weight loss / 6 mo) — lymphoma signature (Lugano Cheson 2014 PMID 25113753).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Lymphadenopathy (localised / generalised / by location + features)** (symptom.lymphadenopathy.v1).
Phenotype framing: Reactive / infectious (TB, HIV, EBV, CMV, toxo, Bartonella, syphilis, tularemia, brucellosis) / malignant (Hodgkin, non-Hodgkin, leukemia, metastatic carcinoma — Virchow gastric, Sister Mary Joseph intra-abd, Delphian thyroid, epitrochlear cat-scratch/lymphoma/syphilis) / autoimmune (SLE, RA, sarcoid, Castleman, IgG4) / drug-induced (DRESS quintet) / pediatric (Kawasaki, atypical mycobacterial)
Scope: Confirm LAD vs lipoma / cyst / parotid / branchial / thyroid / hernia; localised vs generalised; localize by region (cervical / axillary / inguinal / supraclavicular / epitrochlear / mesenteric / hilar) (Bazemore 2002 PMID 12484692)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Directed antibiotic for bacterial / atypical lymphadenitis (selected cases)**.
1. cephalexin 500 mg PO q6h × 7-10 d (1st_gen_cephalosporin, first line) — Empiric outpatient — covers most strep/staph (Bazemore 2002 PMID 12484692)
2. clindamycin 300-450 mg PO q6-8h × 7-10 d (lincosamide, second line) — CA-MRSA coverage; D-test for inducible resistance
3. doxycycline 100 mg PO BID × 14 d (tetracycline, first line) — IDSA — cat scratch in severe / immunocompromised (Florin Klotz 2008 PMID 21243990)
4. azithromycin 500 mg day 1 then 250 mg PO daily × 5 d (macrolide, first line) — Cat-scratch first-line in mild disease (Bass 1998 RCT); MAI pediatric option alongside excision (Florin 2008 PMID 21243990)

Setting playbook (outpatient) — Primary care stratification of reactive vs concerning LAD; 4-week observation if low-concern reactive features; expedited biopsy + onco referral if persistent / supraclavicular / B-symptoms / hard-fixed; longitudinal monitoring of lymphoma survivors (Bazemore AFP 2002 PMID 12484692; NCCN 2024)
5. observe + reassess at 2-4 wk N/A N/A reassess q2-4 wk — Small (<1.5 cm) localised soft mobile tender post-URI cervical / inguinal node in young patient with no B-symptoms (Bazemore 2002 PMID 12484692) (Reactive LAD self-resolves in most cases; antibiotics not empirically indicated)
6. cephalexin 500 mg PO QID × 7-10 d 500 mg PO q6h × 7-10 d — Tender / warm cervical or axillary node + likely strep/staph source (dental, skin) (Empiric for bacterial lymphadenitis (Bazemore 2002))
7. azithromycin 500 mg day 1 then 250 mg × 4 d 500 mg / 250 mg PO daily × 5 d — Suspected cat-scratch (Bartonella) with cat exposure + epitrochlear or axillary node (Bass RCT 1998 — modest benefit in uncomplicated cat-scratch (Florin Klotz 2008 PMID 21243990))
8. doxycycline 100 mg PO BID × 14 d 100 mg PO BID × 14 d — Severe / immunocompromised Bartonella, or rickettsial / Lyme suspicion (IDSA — Bartonella in severe disease (Florin 2008 PMID 21243990))
9. expedited biopsy referral to surgical onc (EXCISIONAL preferred) N/A N/A within 1-2 wk — ≥1.5 cm persistent OR supraclavicular at ANY size OR hard fixed painless OR B-symptoms OR generalised LAD + cytopenia (Bazemore 2002; Lugano Cheson 2014 PMID 25113753) (Lymphoma / metastasis risk; EXCISIONAL preserves architecture for flow + cytogenetics (FNA inadequate for lymphoma))
10. STOP suspected drug + dermatology / ID consult N/A N/A immediate — Drug-induced LAD with rash + eosinophilia + LFT rise (DRESS quintet) (RegiSCAR Kardaun 2013 PMID 23855313) (Phenytoin, allopurinol, hydralazine, sulfasalazine, isoniazid, lamotrigine, carbamazepine; rapid escalation to ED if major organ involvement)

Non-pharmacologic actions:
- Photograph nodes with size ruler at baseline + every follow-up
- Surgical onc / heme-onc referral if biopsy indicated
- ID referral if HIV / TB / Bartonella / syphilis
- Rheumatology if SLE / sarcoid / Castleman
- Smoking + alcohol counseling if head-and-neck cancer concern
- Avoid empiric steroid before biopsy — masks lymphoma

AVOID / contraindication checks:
- No_empiric_steroid_until_lymphoma_excluded (NCCN 2024)
- No_empiric_chemotherapy_in_primary_care (NCCN 2024)
- Doxycycline_avoid_under_8_yr_pregnancy
- Clindamycin_C_difficile_warning
- Azithromycin_QT_prolongation

Monitoring

Regimen monitoring:
- reassess at 72h for response
- biopsy if no improvement at 2 weeks
- serial node size documentation with photographs

Setting (outpatient) monitoring:
- 2-4 week reassessment if reactive course
- Imaging (CT or PET-CT) if generalised or persistent
- Annual surveillance imaging per oncology in lymphoma survivors

Follow-up plan: Heme-onc if lymphoma / leukemia; ID if TB / HIV / Bartonella; rheumatology if SLE / sarcoid; dermatology if DRESS; surgical onc if metastatic carcinoma (NCCN 2024)
- Close-out criterion: Referrals scheduled

Monitoring phase: Reactive — q2 wk reassessment with documented size + photographs; lymphoma — Lugano response criteria (PET Deauville 5-point + CT) (Cheson 2014); DRESS — LFT + CBC + eos resolution; TB — sputum / IGRA + clinical

Disposition

Current setting: outpatient — Primary care stratification of reactive vs concerning LAD; 4-week observation if low-concern reactive features; expedited biopsy + onco referral if persistent / supraclavicular / B-symptoms / hard-fixed; longitudinal monitoring of lymphoma survivors (Bazemore AFP 2002 PMID 12484692; NCCN 2024)

Disposition criteria:
- Continue observation if shrinking
- Referral to surgical onc / heme-onc for biopsy if criteria met
- Hospital admission if airway / DRESS / cytopenia / suppurative sepsis

Escalation triggers (move to higher acuity):
- Rapid growth (doubling in <2 wk) → expedited biopsy referral + ED if cytopenia
- NEW B-symptoms → urgent biopsy referral
- NEW cytopenias on CBC → admit + heme-onc
- NEW supraclavicular node at ANY size → expedited surgical onc within 1-2 wk
- Airway / SVC compression → ED

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] LAD + blasts on peripheral smear OR pancytopenia OR isolated cytopenia (NCCN 2024)
- [LIFE_THREATENING] Mediastinal mass on CXR with stridor, dyspnea, orthopnea, SVC syndrome features (facial swelling, distended neck veins, plethora) (NCCN 2024)
- [LIFE_THREATENING] New drug (2-8 wk latency) + LAD + morbilliform rash + eosinophilia ≥1500 OR atypical lymphocytes + LFT rise (>2× ULN) ± fever ± facial edema → DRESS (RegiSCAR Kardaun 2013 PMID 23855313)

Citations

- Bazemore/Smucker AFP 2002 lymphadenopathy algorithm + Habermann/Ferrer NEJM 2002 review + Lugano classification (Cheson 2014) + NCCN B-cell + Hodgkin lymphoma 2024 + WHO 2022 lymphoma classification + RegiSCAR DRESS 2013 [PMID:12484692](https://pubmed.ncbi.nlm.nih.gov/12484692/)
- Cited evidence (PMID 9803196) [PMID:9803196](https://pubmed.ncbi.nlm.nih.gov/9803196/)
- Cited evidence (PMID 25113753) [PMID:25113753](https://pubmed.ncbi.nlm.nih.gov/25113753/)
- Cited evidence (PMID 32703949) [PMID:32703949](https://pubmed.ncbi.nlm.nih.gov/32703949/)
- Cited evidence (PMID 21243990) [PMID:21243990](https://pubmed.ncbi.nlm.nih.gov/21243990/)

Last reconciled with current guidelines: 2026-05-14.
References
  • Bazemore/Smucker AFP 2002 lymphadenopathy algorithm + Habermann/Ferrer NEJM 2002 review + Lugano classification (Cheson 2014) + NCCN B-cell + Hodgkin lymphoma 2024 + WHO 2022 lymphoma classification + RegiSCAR DRESS 2013 — PMID:12484692
  • Cited evidence (PMID 9803196) — PMID:9803196
  • Cited evidence (PMID 25113753) — PMID:25113753
  • Cited evidence (PMID 32703949) — PMID:32703949
  • Cited evidence (PMID 21243990) — PMID:21243990