Noncervicofacial atypical mycobacterial lymphadenitis in childhood

A Pseudomonas monteilii unilateral inguinofemoral granulomatous lymphadenitis in a two-year-old girl. A case report

Introduction: Pseudomonas monteilii is an environmental contaminant and is considered as an emerging human pathogen. We report the case of a Pseudomonas monteilii granulomatous lymphadenitis in a two-year-old girl.Clinical Presentation and Intervention: A two-year-old, previously healthy, Caucasian girl developed a unilateral inguinofemoral granulomatous lymphadenitis with Pseudomonas monteilii. The protracted course, the violaceous discoloration of the overlying skin, the mild tenderness without constitutional signs, the reactive tuberculin skin test with a negative interferon gamma release assay (IGRA) and the negative Bartonella henselae serology ranked non-tuberculous mycobacterial lymphadenitis high in our differential diagnosis. The ultrasonography showed signs of abcedation. We decided for surgical excision of the nodes. A P.monteilii granulomatous lymphadenitis was revealed. Treatment with an oral course of 2 weeks ciprofloxacin was prescribed. The course after treatment was uneventful and after one year of follow-up, the child is still doing well.Conclusions: Unusual clinical presentation should raise suspicion of uncommon pathogens and uncommon pathogens should raise suspicion of an underlying problem such as immunodeficiency, which was not the case in our patient.

Mycobacterium marinum: a rare cause of chronic lymphocutaneous syndrome

We investigated the prevalence of Mycobacterium marinum lymphadenitis and describe 4 children with the disease. The database of the microbiology laboratory of a tertiary pediatric medical center was searched for all cases of nontuberculous mycobacterial lymphadenitis from 1996 to 2016. M. marinum lymphadenitis was defined as isolation of the pathogen from a lymph node or from a skin lesion with an enlarged regional lymph node. M. marinum was isolated from lymph nodes in 2 of 167 patients with nontuberculous mycobacterial lymphadenitis and from skin lesions in 2 children with skin lesions and regional reactive lymphadenitis, yielding a 2.4% prevalence of M. marinum lymphadenitis. All 4 affected children were younger than 7 years and had been referred for evaluation of enlarged lymph nodes. Preauricular/submandibular and inguinal lymph nodes (n = 2 each) were involved. Three patients had skin traumas and visited the same natural spring. The diagnosis was delayed because a history of aquatic exposure was initially missed. Two children were managed with anti-mycobacterial antibiotics and 2 by observation only. All showed good resolution.

CONCLUSION

A detailed history, specifically regarding exposure to spring water sources, in cases of lymphocutaneous syndrome can point to the diagnosis of M. marinum infection. What is Known: • M. marinum can cause chronic nodular or ulcerative skin infections. • Lymphadenitis due to M. marinum has rarely been reported. What is New: • M. marinum infection can present as isolated chronic lymphadenitis; it accounts for about 2.4% of all cases of nontuberculous mycobacterial lymphadenitis and it tends to occur in noncervicofacial regions relative to infections of other nontuberculous mycobacterial species. • Careful history taking including water source exposure, especially in association with skin trauma, can point to the correct diagnosis in children with chronic lymphadenitis.

Nontuberculous mycobacterial adenitis outside of the head and neck region in children: A case report and systematic review of the literature

Nontuberculous mycobacterial (NTM) adenitis of the head and neck region is well-described in healthy children, most commonly presenting under the age of 5years. Extracervicofacial NTM adenitis is less common. We present a case of NTM inguinal adenitis in a 2-year-old girl, followed by a systematic review of the literature.

[Management of atypical cervical mycobacteriosis in childhood]

Atypical mycobacteriosis is a rare cause of cervical lymphadenitis that most frequently affects immunoincompetent children between the ages of 12 months and 5 years. The typical clinical manifestation is a painless unilateral cervical mass. The nonspecific clinical symptoms and laboratory parameters complicate diagnosis and, therefore, therapeutic management. Various therapeutic options, including surgery, antimycobacterial drug therapy and wait-and-scan approaches are discussed in the literature. Complete surgical excision has become the established treatment of choice. However, controlled randomized studies that clearly demonstrate the benefits of a particular type of therapy are lacking.

Management of lymphadenitis due to non-tuberculous mycobacterial infection in children

PURPOSE

Non-tuberculous mycobacterial (NTM) infection is an important cause of cervico-facial lymph node enlargement in young children. The optimal treatment is thought to be early complete excision without chemotherapy. We compared management of patients referred to our centre to this "gold standard" and determined clinical outcomes by type of primary surgical intervention (complete excision vs. incomplete excision).

METHODS

Retrospective study of management and clinical outcomes of all children (<12 years) with NTM lymphadenitis referred to a single UK centre between May 1998 and May 2008.

RESULTS

We identified 43 children. Median time from onset of swelling to operation was 6 weeks. Management was: no operation (n = 1, 2 %), complete excision (n = 20, 47 %), incision and drainage (n = 17, 40 %) and fine needle aspirate (n = 5, 12 %). Children not treated by primary complete excision were more likely to have: re-operation (91 vs. 30 %; χ(2) = 16.48; p < 0.0001); persistent lymphadenitis (77 vs. 30 %; χ(2) = 9.45; p = 0.002); sinus formation (26 vs. 5 %; χ2 = 3.74; p = 0.05).

CONCLUSION

Failure to undertake primary complete excision leads to further morbidity. A high index of suspicion is required for timely appropriate management to avoid unnecessary morbidity and further intervention.

First Canadian Reports of Cervical Adenitis Due to Mycobacterium Malmoense and a 10-year Review of Nontuberculous Mycobacterial Adenitis

The present report reviews a decade of experience with nontuberculous mycobacterial adenitis at a pediatric referral centre, noting that patients are often subjected to multiple ineffective antibiotic courses, and that delays in diagnosis and referral for appropriate therapy are common. Notable clinical features include a mean age of presentation of 3.4 years, a male-to-female ratio of 1:1.5 and a gradual onset of painless, unilateral cervical adenopathy. Fever was absent in most patients (77%), and the disease failed to respond to antistaphylococcal antibiotics. The mean time to correct diagnosis was longer than three months (15 weeks). The clinical features of the disease are highlighted and presented with a practical diagnostic approach to the child with subacute/chronic adenitis. New molecular diagnostic tools and emerging mycobacteria are discussed, including the first reports of Mycobacterium malmoense adenitis in Canada.

Nontuberculous mycobacterial infection in children: a prospective national study

BACKGROUND

The epidemiology and management of nontuberculous mycobacterial (NTM) infection in Australian children is unknown.

METHODS

From July 2004 to June 2007, clinicians identified children with NTM infection as part of a nationwide active surveillance network. Following notification, detailed data were collected.

RESULTS

From 192 reports, data were received on 153 cases (response rate: 79.7%). Of these, 102 met inclusion criteria. The median age was 2.9 years. Predisposing conditions were infrequent and included chronic respiratory disease (n = 12) and immunosuppression (n = 6). Lymphadenitis was the most frequent presentation (n = 68) with pulmonary and disseminated disease infrequent (n = 14 and 3, respectively). NTM was isolated in 68 cases with Mycobacterium avium-intracellulare complex most frequently isolated (33/68; 48.5%). Surgery was performed in 78 cases and 42 children were treated with antimycobacterial therapy. Twenty-five subjects received surgery and antimycobacterial therapy. Follow-up data were available for 77 children with recurrence observed in 18 cases. Complete excision was associated with a higher rate of treatment success when compared with all other therapies (OR: 9.48 [95% CI: 2.00-44.97], P = 0.001). Mycobacterium lentiflavum infection accounted for 4.4% of culture confirmed cases and had a lower rate of treatment success than other species (0% vs. 78.2%; P = 0.016).

CONCLUSIONS

The incidence of NTM infection in Australian children is 0.84 of 100,000 (95% CI: 0.68-1.02). Infection occurs most often in young children without predisposing conditions. Despite therapy, there was recurrence in 23.4% of cases.

Inguinal lymphadenitis caused by mycobacterium haemophilum in an immunocompetent child

Infections caused by Mycobacterium haemophilum in immunocompetent patients are unusual. M. haemophilum have been associated with cervicofacial lymphadenitis in children, but inguinal infections have not yet been described. We present a case of an inguinal lymphadenitis caused by M. haemophilum in an immunocompetent girl.

Nontuberculous mycobacterial adenitis: effectiveness of chemotherapy following incomplete excision

BACKGROUND

Management of lymphadenopathy caused by nontuberculous mycobacteria (NTM) is primarily surgical. Where this cannot achieve sufficient clearance of infected nodes, chemotherapy is often given.

AIM

This study compared results of surgery alone with surgery followed by chemotherapy in instances where there was incomplete surgical removal of diseased tissue.

METHODS

Chemotherapy comprised azithromycin 10 mg/kg and rifabutin 6 mg/kg both given once daily for 6 mo. Ninety-eight children with NTM infection were seen in the period 1990-2004. Sixty-eight cases with adenopathy where "time to healing" (discharge stopped and inflammation settled) was known were available to compare response to treatment.

RESULTS

The median (range) "time to healing" in weeks for 43 patients who had surgery alone was: incision and drainage (I&D)/curettage 6 (1-72) (n = 10); excision 3 (1-28) (n = 22); and from the last operation of multiple (repeat) surgery 3 (1-40) (n = 11). For 25 patients who required chemotherapy in addition to surgery, the median (range) "time to healing" in weeks was I&D/curettage 10 (1-40) (n = 17), excision 14 (8-20) (n = 2) and multiple surgery 29 (2-88) (n = 6).

CONCLUSION

In children with adenitis due to NTM, where surgical resection is followed by continued discharge and inflammation, chemotherapy should be considered before further surgery is undertaken.

Cervicofacial lymphadenitis due to atypical mycobacteria: a surgical disease

Despite the increasing prevalence of cervicofacial lymphadenitis due to atypical mycobacteria (AMB) in children, the true nature of AMB infection in clinical practice is poorly understood. The purpose of our study was to define the most common signs and symptoms, and to establish a workable scheme of diagnosis and treatment. Patients fulfilling the criteria of AMB infection (i.e., clinical signs, positive cultures or polymerase chain reaction, histologic features) were included in the study. All children underwent a standard surgical procedure, depending on pretreatment and the course of the disease. Sixteen infants presented with characteristic unilateral lymphadenopathy predominantly involving the submandibular area (13/16). Eight children had been initially treated at various institutions by fine-needle puncture or incision, and 7 of the 16 patients had received antituberculous multidrug treatment for a varying length of time. Complete excision of the affected lymph nodes was the definitive treatment in all patients. Three children had transient marginal mandibular nerve paralysis that resolved within a few months in all cases. Recognition of the characteristic features of AMB adenitis may permit early diagnosis and appropriate surgical treatment.

Nontuberculous mycobacterial infections of the head and neck

Nontuberculous mycobacteria are ubiquitous in the environment. Immunocompetent children are commonly infected by these resilient organisms. Cervical lymphadenitis, the most frequent head and neck manifestation of NTM infection, often presents as chronic, unilateral lymphadenopathy with characteristic violaceous overlying skin changes. Diagnosis is ultimately dependent on culture or histopathologic examination of specimen obtained through excisional lymph node biopsy or FNA. The principal treatment of NTM infection remains the surgical excision of diseased tissue. Antibiotics augment surgical therapy and their potential role as a single-modality therapy continues to be investigated.