Acute cervical lymphadenitis in a febrile child: when to think beyond infection?

A 4-year-old boy presented with fever and unilateral neck swelling, initially treated as bacterial lymphadenitis with intravenous antibiotics. Over the following days, he developed bilateral non-purulent conjunctival injection, palmar erythema, mucosal changes, raised liver transaminases and rising inflammatory markers. The evolving picture led to a diagnosis of Kawasaki disease in the second week of illness. Cervical lymphadenitis is a common paediatric presentation, with infective aetiology being the most common. However, inflammatory conditions such as Kawasaki disease and haematological malignancy can present similarly. Among these, ‘Node-first’ Kawasaki disease, in which cervical lymphadenopathy precedes other features, while a recognised phenotype, is a rarer presentation and therefore a diagnostic pitfall. The similarity to infective lymphadenitis, together with overlapping laboratory and imaging findings, may delay definitive treatment and increase the risk of complications. An acute presentation of cervical lymphadenitis in a febrile child with inadequate or no response despite antibiotics and persistent high inflammatory markers should raise suspicion of possible alternative diagnoses like Kawasaki disease.