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Pecora F, Abate L, Scavone S, Petrucci I, Costa F, Caminiti C, Argentiero A, Esposito S. Management of Infectious Lymphadenitis in Children. CHILDREN-BASEL 2021; 8:children8100860. [PMID: 34682125 PMCID: PMC8535130 DOI: 10.3390/children8100860] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/22/2021] [Accepted: 09/22/2021] [Indexed: 01/22/2023]
Abstract
Lymphadenopathy is an irregularity in the size and texture of the lymph nodes, which is quite common in childhood. When the enlargement of lymph nodes is caused by inflammatory and infectious processes, it is called lymphadenitis. The main objective of this manuscript is to summarize the common infectious etiologies and presentations of lymphadenitis in children providing a management guide for clinical practice. PubMed was used to search for all of the studies published up to April 2021 using keywords such as "lymphadenitis" and "children". Literature analysis showed that the differential diagnosis for lymphadenitis in pediatrics is broad. Although lymph node enlargement in children is usually benign and self-limited, it is important to exclude malignant etiology. In most cases, history and physical examination allow to identify the correct diagnosis and start a proper treatment with a prompt resolution of the lymphadenopathy. However, particularly in the case of persistent lymphadenitis, determining the cause of lymph node enlargement may be difficult, and the exact etiology may not be identified despite extensive investigations. Further studies should develop and validate an algorithm to assist pediatricians in the diagnosis and timely treatment of lymphadenitis, suggesting situations in which a watchful waiting may be considered a safe approach, those in which empiric antibiotic therapy should be administered, and those requiring a timely diagnostic work-up.
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Affiliation(s)
- Francesco Pecora
- Paediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (F.P.); (L.A.); (S.S.); (I.P.); (F.C.); (A.A.)
| | - Luciana Abate
- Paediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (F.P.); (L.A.); (S.S.); (I.P.); (F.C.); (A.A.)
| | - Sara Scavone
- Paediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (F.P.); (L.A.); (S.S.); (I.P.); (F.C.); (A.A.)
| | - Irene Petrucci
- Paediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (F.P.); (L.A.); (S.S.); (I.P.); (F.C.); (A.A.)
| | - Federico Costa
- Paediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (F.P.); (L.A.); (S.S.); (I.P.); (F.C.); (A.A.)
| | - Caterina Caminiti
- Research an Innovation Unit, University Hospital of Parma, via Gramsci 14, 43126 Parma, Italy;
| | - Alberto Argentiero
- Paediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (F.P.); (L.A.); (S.S.); (I.P.); (F.C.); (A.A.)
| | - Susanna Esposito
- Paediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (F.P.); (L.A.); (S.S.); (I.P.); (F.C.); (A.A.)
- Correspondence: ; Tel.: +39-0521-903-524
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Olivas-Mazón R, Blázquez-Gamero D, Alberti-Masgrau N, López-Roa P, Delgado-Muñoz MD, Epalza C. Diagnosis of nontuberculous mycobacterial lymphadenitis: the role of fine-needle aspiration. Eur J Pediatr 2021; 180:1279-1286. [PMID: 33205252 DOI: 10.1007/s00431-020-03875-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 11/02/2020] [Accepted: 11/11/2020] [Indexed: 11/26/2022]
Abstract
Nontuberculous mycobacterial lymphadenitis often presents a diagnostic challenge. This study aimed to evaluate the role of fine-needle aspiration cytology in the diagnosis of nontuberculous mycobacterial lymphadenitis in children. We conducted a retrospective review of fine-needle aspiration cytology performed in patients < 17 year-old with subacute lymphadenitis from 2003 to 2016 in a tertiary hospital in Spain. Confirmed nontuberculous mycobacterial lymphadenitis (isolation of nontuberculous mycobacterial in culture from fine-needle aspiration cytology or biopsy samples) and probable nontuberculous mycobacterial lymphadenitis ("granulomatous inflammation" in cytopathologic examinations from fine-needle aspiration cytology or biopsy and clinical-epidemiological history compatible with nontuberculous mycobacterial) were selected. Forty-one patients with nontuberculous mycobacterial lymphadenitis were included: 14 confirmed and 27 probable. Fine-needle aspiration cytology was done in all of them. For 34 patients with excised lymphadenopathy, cytopathology from fine-needle aspiration cytology was concordant with biopsy in 100% cases. Culture results were available from 78.0% (32/41) of patients with fine-needle aspiration cytology and from 85.3% (29/34) with excisional biopsy. Among 22 patients with microbiological results from fine-needle aspiration cytology and biopsy, fine-needle aspiration cytology allowed advanced results in concordance with biopsy or with positive isolation not found in biopsy in 90.1% (20/22) of patients. Sensitivity of nontuberculous mycobacterial cultures obtained by fine-needle aspiration cytology compared to biopsy was 45.5% vs. 36.4% (p = 0.07). Two patients with previous skin alterations presented fistulas after fine-needle aspiration cytology (4.9%); no other complications were described.Conclusion: Fine-needle aspiration cytology provides quick cytopathologic information and is an accurate and safe technique for the diagnosis of nontuberculous mycobacterial lymphadenitis, especially in cases with challenging work-up. What is Known: • Nontuberculous mycobacterial (NTM) infection is an important cause of subacute lymphadenitis in children. • Fine-needle aspiration cytology (FNAC) is an available technique for the diagnosis of lymphadenitis of unknown etiology. What is New: • FNAC is an accurate and safe technique for the diagnosis of NTM lymphadenitis in children. • FNAC can provide reliable samples for cytopathological studies and even a better sensitivity for microbiological culture than excisional biopsy in the study of suspected NTM lymphadenitis.
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Affiliation(s)
- Raquel Olivas-Mazón
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Avenida de Córdoba S/N, 28048, Madrid, Spain
| | - Daniel Blázquez-Gamero
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Avenida de Córdoba S/N, 28048, Madrid, Spain.
- Instituto de Investigación 12 de Octubre (imas12), Madrid, Spain.
- Red de Investigación Traslacional en Infectología Pediátrica (RITIP), Madrid, Spain.
| | | | - Paula López-Roa
- Department of Microbiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Cristina Epalza
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Avenida de Córdoba S/N, 28048, Madrid, Spain
- Instituto de Investigación 12 de Octubre (imas12), Madrid, Spain
- Red de Investigación Traslacional en Infectología Pediátrica (RITIP), Madrid, Spain
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Le Naour S, Boyer J, Malard O, Guillouzouic A, Aubry A, Launay E, Barbarot S. Adénites cervico-faciales à mycobactéries atypiques de l’enfant : caractéristiques cliniques, microbiologiques et thérapeutiques. Étude rétrospective et revue de la littérature. Ann Dermatol Venereol 2020; 147:618-628. [DOI: 10.1016/j.annder.2020.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 02/06/2020] [Accepted: 06/23/2020] [Indexed: 10/23/2022]
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Papatsoutsos E, Aumann V, Vorwerk P, Redlich A, Tammer I, Arens C, Vorwerk U. [Cervical lymphadenitis caused by non-tuberculous mycobacteria in children with different residence]. Laryngorhinootologie 2020; 99:628-636. [PMID: 32268397 DOI: 10.1055/a-1146-3118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Atypical mycobacteria form a heterogeneous group. Although more than 140 species have been identified, only 25 of them are considered responsible for infection in humans. The most frequent manifestation of the disease in immunocompetent children is the cervical lymphadenitis. Aims of this study were to identify a correlation of the location of residence with patients' demographics and disease characteristics, to evaluate the ultrasonographic findings and the different operative treatments modalities and to develop an algorithm for the diagnosis and treatment. MATERIALS AND METHODS Cases were identified by using the hospital's correspondence, microbiology and pathology databases. Demographic and clinical data were collected. A statistical analysis of the results was performed. RESULTS 32 patients were included. Our data revealed no significant correlation between area of residence and disease characteristics. Hypoechoic lymph nodes with intraglandular necrosis and low vascularity were observed in the majority of patients. Surgical treatment included abscess incision with biopsy, lymphadenectomy, selective neck dissection and partial parotidectomy. A recurrent disease was significantly more frequent after abscess incision. CONCLUSIONS Further studies with prospective design are required, in order to confidently identify the correlation between area of residence and disease characteristics. Similar ultrasonographic findings suggest a constant constellation of changes that facilitate diagnostic evaluation. Complete surgical excision offers an effective management option as it combines definitive treatment and histological confirmation with low risk of complications.
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Affiliation(s)
- Efstathios Papatsoutsos
- Universitätsklinik für Hals-, Nasen- und Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Magdeburg, Germany
| | - Volker Aumann
- Pädiatrische Hämatologie und Onkologie, Universitätsklinikum Magdeburg Kinderklinik, Magdeburg, Germany
| | - Peter Vorwerk
- Pädiatrische Hämatologie und Onkologie, Universitätsklinikum Magdeburg Kinderklinik, Magdeburg, Germany
| | - Antje Redlich
- Pädiatrische Hämatologie und Onkologie, Universitätsklinikum Magdeburg Kinderklinik, Magdeburg, Germany
| | - Ina Tammer
- Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Universitätsklinikum Magdeburg, Germany
| | - Christoph Arens
- Universitätsklinik für Hals-, Nasen- und Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Magdeburg, Germany
| | - Ulrich Vorwerk
- Universitätsklinik für Hals-, Nasen- und Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Magdeburg, Germany
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Long M, Reddy DN, Akiki S, Barrowman NJ, Zemek R. Paediatric acute lymphadenitis: Emergency department management and clinical course. Paediatr Child Health 2019; 25:534-542. [PMID: 33354264 DOI: 10.1093/pch/pxz125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 07/19/2019] [Indexed: 11/13/2022] Open
Abstract
Objectives To describe clinical characteristics and management of acute lymphadenitis and to identify risk factors for complications. Methods Health record review of children ≤17 years with acute lymphadenitis (≤2 weeks) in a tertiary paediatric emergency department (2009-2014); 10% of charts were reviewed by a blinded second reviewer. Multivariate logistic regression identified factors associated with intravenous antibiotic treatment, unplanned return visits warranting intervention, and surgical drainage. Results Of 1,023 health records, 567 participants with acute lymphadenitis were analyzed. The median age = 4 years (interquartile range [IQR]: 2 to 8 years), and median duration of symptoms = 1.0 day (IQR: 0.5 to 3.0 days). Cervical lymphadenitis was most common. Antibiotics were prescribed in 73.5% of initial visits; 86.9% of participants were discharged home. 29.0% received intravenous antibiotics, 19.3% had unplanned emergency department return visits, and 7.4% underwent surgical drainage. On multivariate analysis, factors associated with intravenous antibiotic use included history of fever (odds ratio [OR]=2.07, 95% confidence interval [CI]: 1.11 to 3.92), size (OR=1.74 per cm, 95% CI: 1.44 to 2.14), age (OR=0.84 per year, 95% CI: 0.76 to 0.92), and prior antibiotic use (OR=4.45, 95% CI: 2.03 to 9.88). The factors associated with unplanned return visit warranting intervention was size (OR=1.30 per cm, 95% CI: 1.06 to 1.59) and age (OR=0.89, 95% CI: 0.80 to 0.97). Factors associated with surgical drainage were age (OR=0.68 per year, 95% CI: 0.53 to 0.83) and size (OR=1.80 per cm, 95% CI: 1.41 to 2.36). Conclusions The vast majority of children with acute lymphadenitis were managed with outpatient oral antibiotics and did not require return emergency department visits or surgical drainage. Larger lymph node size and younger age were associated with increased intravenous antibiotic initiation, unplanned return visits warranting intervention and surgical drainage.
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Affiliation(s)
- Michelle Long
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario.,University of Ottawa, Ottawa, Ontario
| | - Deepti N Reddy
- University of Ottawa, Ottawa, Ontario.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
| | - Salwa Akiki
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
| | - Nicholas J Barrowman
- University of Ottawa, Ottawa, Ontario.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
| | - Roger Zemek
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario.,University of Ottawa, Ottawa, Ontario.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
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Torretta S, Gaffuri M, Ibba T, Capaccio P, Marchisio P, Maruca A, Bosis S, Pignataro L. Surgical treatment of non-tuberculous mycobacterial lymphadenitis in children: Our experience and a narrative review. Int J Immunopathol Pharmacol 2019; 32:2058738418806413. [PMID: 30354841 PMCID: PMC6202736 DOI: 10.1177/2058738418806413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Non-tuberculous mycobacterial lymphadenitis (NTML) accounts for about 95% of the cases of head-and-neck mycobacterial lymphadenitis, and its prevalence has been increasing in the Western world. The diagnostic work-up can be challenging, and differential diagnoses such as tuberculous and suppurative lymphadenitis need to be considered. It may, therefore, not be diagnosed until the disease is in a late stage, by which time it becomes locally destructive and is characterized by a chronically discharging sinus. The treatment options include a medical approach, a wait-and-see policy, and surgery, with the last being considered the treatment of choice despite the high risk of iatrogenic nerve lesions. The aim of this article is to provide an overview of pediatric, head-and-neck NTML based on the literature and our own experience, with particular emphasis on the impact and limitations of surgery.
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Affiliation(s)
- Sara Torretta
- 1 Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy.,2 Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Michele Gaffuri
- 2 Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Tullio Ibba
- 2 Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Pasquale Capaccio
- 2 Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,3 Department of Biomedical, Surgical and Odontoiatric Sciences, Università Degli Studi Di Milano, Milan, Italy
| | - Paola Marchisio
- 2 Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,4 Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
| | - Antonella Maruca
- 2 Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Samantha Bosis
- 2 Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenzo Pignataro
- 1 Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy.,2 Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Spinelli G, Mannelli G, Arcuri F, Venturini E, Chiappini E, Galli L. Surgical treatment for chronic cervical lymphadenitis in children. Experience from a tertiary care paediatric centre on non-tuberculous mycobacterial infections. Int J Pediatr Otorhinolaryngol 2018; 108:137-142. [PMID: 29605343 DOI: 10.1016/j.ijporl.2018.02.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 02/08/2018] [Accepted: 02/26/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Non-tuberculous mycobacteria are the most frequent cause of chronic lymphadenitis in children. We reviewed treatment and outcomes of paediatric patients with chronic cervical lymphadenitis, to better understand their differential diagnosis, surgical indication, complication and recover. METHODS A retrospective study was carried out on children who underwent surgery from 2013 to 2016 at Meyer Children's University Hospital, Florence, Italy. Time to cure, type of surgery, and complications rate were determined and etiologic agents were identified and correlated to their clinical presentation. RESULTS 275 children were evaluated. Nearly 98% of the patients were cured regardless of which therapeutic option was used and surgery was necessary in 38.2% of children. Complete excisional biopsy ensured recover in 97.7% of patients compared with the non-excisional surgical group 88.2% (p = 0.06). Re-interventions were needed in the 2.3% of complete excision group and in two cases of the incision and drainage group; all of them developed fistula and were caused by Mycobacterium avium complex. Excision followed by adjunctive antibiotic therapy was favoured in the majority of the patients (80.1%, n = 71). CONCLUSION In cases of non-tuberculous mycobacteria lymphadenitis, surgery is the treatment of choice and it is closely related to a favourable prognosis.
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Affiliation(s)
| | - Giuditta Mannelli
- Clinic of Otorhinolaryngology-Head and Neck Surgery, Department of Surgery and Translational Medicine, University of Florence, AOU-Careggi, Via Largo Palagi 1, 50134, Florence, Italy.
| | | | - Elisabetta Venturini
- Pediatric Infectious Diseases Unit, Meyer Children's Hospital, Department of Pediatrics, University of Florence, Italy
| | - Elena Chiappini
- Pediatric Infectious Diseases Unit, Meyer Children's Hospital, Department of Pediatrics, University of Florence, Italy
| | - Luisa Galli
- Pediatric Infectious Diseases Unit, Meyer Children's Hospital, Department of Pediatrics, University of Florence, Italy
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Xu JJ, Peer S, Papsin BC, Kitai I, Propst EJ. Tuberculous lymphadenitis of the head and neck in Canadian children: Experience from a low-burden region. Int J Pediatr Otorhinolaryngol 2016; 91:11-14. [PMID: 27863623 DOI: 10.1016/j.ijporl.2016.09.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Revised: 09/24/2016] [Accepted: 09/26/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Children are more likely than adults to develop extra-pulmonary tuberculosis (EPTB), which often presents as cervical lymphadenopathy. The role of surgery in management is uncertain. We reviewed all head and neck EPTB cases presenting to our tertiary care pediatric institution over a twelve-year period. METHODS All children 18 years of age and younger with EPTB involving the head and neck were included. We recorded clinical data and age at diagnosis, birth country, BCG vaccination status, as well as radiographic, surgical, histological, and microbiological results. RESULTS All 16 patients presented with cervical lymphadenopathy. Fourteen were born outside of Canada in TB endemic areas and all had foreign-born parents. Diagnosis was confirmed microbiologically from lymph node biopsies in 14 cases. Multi-drug resistant TB was identified in two cases: both had previous excisional node biopsies that had not been cultured. Two patients had culture negative suppuration despite adequate anti-tuberculous treatment that required surgery for cure. CONCLUSION Ongoing suppuration despite appropriate drug therapy is seen in a minority of patients. We found that excisional lymph node biopsy of diseased cervical lymph nodes is diagnostic, and also therapeutic in some cases with ongoing suppuration despite appropriate drug therapy. Mycobacterial culture of lymph nodes is important for diagnosis and determination of drug resistance patterns.
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Affiliation(s)
- Jason J Xu
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, 190 Elizabeth St., Rm 3S-438, Toronto, ON, M5G 2N2, Canada.
| | - Shazia Peer
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, 190 Elizabeth St., Rm 3S-438, Toronto, ON, M5G 2N2, Canada
| | - Blake C Papsin
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, 190 Elizabeth St., Rm 3S-438, Toronto, ON, M5G 2N2, Canada
| | - Ian Kitai
- Division of Infectious Diseases, Department of Paediatrics, Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada.
| | - Evan J Propst
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, 190 Elizabeth St., Rm 3S-438, Toronto, ON, M5G 2N2, Canada
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Elispot Igra With Purified Protein Derivative Stimulation For Diagnosing Nontuberculous Mycobacterial Cervical Lympadenitis. Pediatr Infect Dis J 2016; 35:349-51. [PMID: 26584055 DOI: 10.1097/inf.0000000000000998] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Childhood cervical lymphadenitis caused by nontuberculous mycobacteria is a diagnostic challenge for the clinician. We present a new promising diagnostic method for childhood nontuberculous mycobacterial lymphadenitis. The modified T-SPOT.TB test with purified protein derivative as an additional antigen is noninvasive with estimated sensitivity and specificity of 1.00 and 0.81, respectively.
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Berkovic J, Vanchiere JA, Gungor A. Non tuberculous mycobacterial lesion of the parotid gland and facial skin in a 4year old girl: A proposed treatment strategy. Am J Otolaryngol 2016; 37:89-94. [PMID: 26954858 DOI: 10.1016/j.amjoto.2015.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 09/08/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE We report a case of a parotid-facial caseating granulomatous infection caused by atypical mycobacteria (Mycobacterium avium) in an immuno-competent child. The size and depth of the lesion and its proximity to the facial nerve present a challenge for a purely surgical treatment strategy. An alternative treatment strategy is developed to avoid severe disfigurement. STUDY DESIGN/SUBJECT Atypical mycobacterial infection of the parotid region in a 5 year old girl: timeline and definition of a planned combined treatment strategy with antibiotics and surgical excision. RESULTS/CONCLUSION Cervicofacial infections caused by non-tuberculous mycobacteria (NTM) may present surgical challenges due to the size and depth of the lesion and its proximity to the facial nerve and major vascular structures. Even minor scars are highly visible and poorly tolerated. Close clinical monitoring combined with judicious treatment strategies is necessary for successful treatment and good cosmesis. Recent literature provides insufficient guidance in formulating the best treatment strategy for the individual patient. Comparisons of antibiotic therapy with variations of surgical excision are abundant but poorly formulated. Our case presented with a lesion involving skin, superficial and deep lobe of the parotid gland. Lesion was in immediate proximity to the distribution of the facial nerve through the parotid gland. The risk of surgical damage to the facial nerve in the acute phase of the inflammation and the required extent of skin excision were significant. We decided to start treatment with combination antimycobacterial antibiotics in close cooperation with the pediatric infectious disease specialists. We observed and documented the regress and executed a delayed surgical excision when the lesion was reduced to skin only. In our opinion this was the best treatment strategy that helped us avoid extensive dissection in the vicinity of the facial nerve as well as a parotidectomy. Excision of the involved skin with the deep portion was performed 6.5 months after initial diagnosis.
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11
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Zimmermann P, Tebruegge M, Curtis N, Ritz N. The management of non-tuberculous cervicofacial lymphadenitis in children: A systematic review and meta-analysis. J Infect 2015; 71:9-18. [PMID: 25727993 DOI: 10.1016/j.jinf.2015.02.010] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 02/16/2015] [Accepted: 02/20/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Cervicofacial lymphadenitis is the most common manifestation of infection with non-tuberculous mycobacteria (NTM) in immunocompetent children. Although complete excision is considered standard management, the optimal treatment remains controversial. This study reviews the evidence for different management options for NTM lymphadenitis. METHODS A systematic literature review and meta-analysis were performed including 1951 children from sixty publications. Generalised linear mixed model regressions were used to compare treatment modalities. RESULTS The adjusted mean cure rate was 98% (95% CI 97.0-99.5%) for complete excision, 73.1% (95% CI 49.6-88.3%) for anti-mycobacterial antibiotics, and 70.4% (95% CI 49.6-88.3%) for 'no intervention'. Compared to 'no intervention', only complete excision was significantly associated with cure (OR 33.1; 95% CI 10.8-102.9; p < 0.001). Complete excision was associated with a 10% risk of facial nerve palsy (2% permanent). 'No intervention' was associated with delayed resolution. CONCLUSIONS Complete excision is associated with the highest cure rate in NTM cervicofacial lymphadenitis, but also had the highest risk of facial nerve palsy. In the absence of large, well-designed RCTs, the choice between surgical excision, anti-mycobacterial antibiotics and 'no intervention' should be based on the location and extent of the disease, and acceptability of prolonged time to resolution.
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Affiliation(s)
- Petra Zimmermann
- Infectious Diseases Unit, University Children's Hospital, University of Berne, 3010 Berne, Switzerland.
| | - Marc Tebruegge
- Academic Unit of Clinical & Experimental Sciences, Faculty of Medicine, and Institute for Life Sciences, University of Southampton, Southampton, UK; Department of Paediatrics, The University of Melbourne, and Murdoch Children's Research Institute, The Royal Children's Hospital Melbourne, Parkville, 3052, Australia.
| | - Nigel Curtis
- Department of Paediatrics, The University of Melbourne, and Murdoch Children's Research Institute, The Royal Children's Hospital Melbourne, Parkville, 3052, Australia.
| | - Nicole Ritz
- Department of Paediatrics, The University of Melbourne, and Murdoch Children's Research Institute, The Royal Children's Hospital Melbourne, Parkville, 3052, Australia; Infectious Diseases Unit, University Children's Hospital, University of Basel, 4031 Basel, Switzerland.
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Abdissa K, Tadesse M, Bezabih M, Bekele A, Apers L, Rigouts L, Abebe G. Bacteriological methods as add on tests to fine-needle aspiration cytology in diagnosis of tuberculous lymphadenitis: can they reduce the diagnostic dilemma? BMC Infect Dis 2014; 14:720. [PMID: 25551280 PMCID: PMC4299128 DOI: 10.1186/s12879-014-0720-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 12/15/2014] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The diagnostic accuracy of fine-needle aspiration (FNA) cytology for the diagnosis of tuberculous lymphadenitis (TBLN) is confounded by mimicking cytomorphologic disorders. The objective of this study was to determine whether supplementing FNA cytology with bacteriological methods improves the overall accuracy of TBLN diagnosis. METHODS Two hundred presumptive TBLN cases were included in the study. FNA specimens were collected and examined for cytomorphologic changes, for acid-fast bacilli (AFB) by microscopy and for mycobacterial growth on culture. Culture was done using Lowenstein-Jensen (LJ) medium and mycobacteria growth indicator tube (BACTEC MGIT 960 TB detection system). Differentiation between M. tuberculosis complex (MTBc) and non-tuberculous mycobacteria (NTM) was done by using 500 μg/ml para-nitrobenzoic acid (PNB) susceptibility testing. RESULTS Cytomorphology detected TBLN among 80% (160/200) of the presumptive cases. Culture results were available for 188 cases. Twelve samples were excluded due to contamination on both culture methods. Culture confirmed cases accounted for 78% (147/188) of which MTBc constituted 97.3% (143/147). Among presumptive cases, classified by FNA cytology as 'abscess', 11 were culture positive. Microscopy detected 31.3% (46/147) of culture confirmed mycobacterial lymphadenitis of which 11% (4/37) were diagnosed non-suggestive for tuberculosis (TB) by FNA cytology. Compared to culture (LJ & BACTEC MGIT 960) and AFB microscopy as composite gold standard, FNA cytology had a sensitivity of 88.4% and a specificity of 48.8%. The positive predictive value was 86.1% while the negative predictive value was 54.1%. The confirming power and the ROC curve area was 1.73 and 0.69, respectively. CONCLUSION FNA cytology showed a relatively high sensitivity but a low specificity. Combining bacteriological methods with FNA cytology in an endemic region like Ethiopia improves the overall accuracy of the diagnosis of mycobacterial lymphadenitis, which in turn may lead to better patient management.
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Affiliation(s)
- Ketema Abdissa
- Department of Medical Laboratory Sciences and Pathology, Jimma University, Jimma, Ethiopia.
| | - Mulualem Tadesse
- Department of Medical Laboratory Sciences and Pathology, Jimma University, Jimma, Ethiopia.
| | - Mesele Bezabih
- Department of Medical Laboratory Sciences and Pathology, Jimma University, Jimma, Ethiopia.
| | - Alemayehu Bekele
- Department of Medical Laboratory Sciences and Pathology, Jimma University, Jimma, Ethiopia.
| | - Ludwig Apers
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
| | - Leen Rigouts
- Mycobacteriology Unit, Department of Microbiology, Institute of Tropical Medicine, Antwerp, Belgium.
| | - Gemeda Abebe
- Department of Medical Laboratory Sciences and Pathology, Jimma University, Jimma, Ethiopia.
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Abstract
PURPOSE OF REVIEW Skin and soft tissues infections (SSTIs) caused by nontuberculous mycobacteria (NTM) are underrecognized and difficult to treat. Controversies exist for optimal medical management and the role of surgery. Defining the epidemiology in the environment, in animals and in healthcare aids disease prevention. This review focuses on recent advances in epidemiology, risk factors, diagnostics and therapy. RECENT FINDINGS The increasing consumer appetite for cosmetic and body-modifying procedures (e.g. tattooing, mesotherapy, liposuction) has been associated with rises in sporadic cases and outbreaks of NTM SSTIs. In mainstream healthcare, recent epidemiological studies have helped to quantify the increased risk of NTM infection related to anti-tumour necrosis factor-α monoclonal antibody therapy. Cervicofacial lymphadenitis in children poses management dilemmas, but recent studies and resultant algorithms have simplified decision-making. Molecular studies have led to a better understanding of the epidemiology, therapy and course of Mycobacterium ulcerans infection (Buruli ulcer) that remains prevalent in many areas including sub-Saharan Africa and southeastern Australia. Apart from molecular methods, the widespread adoption of matrix-assisted laser desorption ionization-time of flight mass spectrometry by routine laboratories has potential to simplify and expedite the laboratory identification of NTMs. SUMMARY An improved understanding of the epidemiology of NTM SSTIs indicates a need to apply effective infection control and ensure regulation of cosmetic and related procedures associated with nonsterile fluids. Broader access to newer diagnostic methods will continue to improve recognition of NTM disease. Along with a paucity of therapeutic agents, there is need for more reliable methods to assess susceptibility and selection of effective combination therapy.
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Perdikogianni C, Galanakis E. Non-tuberculous mycobacterial cervical lymphadenitis in the immunocompetent child: diagnostic and treatment approach. Expert Rev Anti Infect Ther 2014; 12:959-65. [DOI: 10.1586/14787210.2014.920691] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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