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Long-term outcome of surgical excision for treatment of cervicofacial granulomatous lymphadenitis in children. Eur Arch Otorhinolaryngol 2020; 277:1785-1792. [PMID: 32144570 PMCID: PMC7222061 DOI: 10.1007/s00405-020-05880-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 02/21/2020] [Indexed: 11/17/2022]
Abstract
Purpose Granulomatous inflammation is a common cause of subacute cervicofacial lymphadenitis in children. Nontuberculous mycobacterial (NTM) infections and cat-scratch disease (CSD) are the most frequent causes. Optimal treatment, which may include surgery, antibiotic treatment or wait-and-see approach, is debatable. The goal of this study was to compare the short- and long-term outcome of various surgical procedures. Methods Case series with a chart review of all children treated by surgical excision of granulomatous lymph nodes in the cervicofacial area from 2000 to 2016 at two tertiary care centers. Results Forty patients were included in this study. The median age at first symptoms was 3.7 years (13 months–14 years). Mean follow-up was 5.8 years (6 months–15.3 years). 25 patients fit with diagnosis of NTM infection, 6 with CSD while diagnosis remained uncertain in 9 patients. The primary surgical procedure consisted of total excision (n = 27), incision/drainage (n = 9) or incomplete excision (n = 4). None of the patients treated by primary complete excision needed further intervention contrary to the group of patients with incomplete surgical procedures where additional surgical management was required in 54%. At follow-up, all patients were healthy without evidence of recurrence. Conclusion We advocate early surgical intervention with complete excision to reach quick resolution and reduce the need for additional surgery. The long-term outcome was favorable.
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Naselli A, Losurdo G, Avanzini S, Tarantino V, Cristina E, Bondi E, Castagnola E. Management of nontuberculous mycobacterial lymphadenitis in a tertiary care children's hospital: A 20year experience. J Pediatr Surg 2017; 52:593-597. [PMID: 27614809 DOI: 10.1016/j.jpedsurg.2016.08.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/27/2016] [Accepted: 08/13/2016] [Indexed: 11/18/2022]
Abstract
PURPOSE Nontuberculous mycobacteria are uncommon cause of chronic cervicofacial lymphadenitis in healthy children. We describe clinical features and management strategies of cervicofacial nontuberculous mycobacterium lymphadenitis in a tertiary pediatric hospital. METHODS Retrospective analysis of medical records of children discharged from 1992 to 2014 with a diagnosis of cervicofacial nontuberculous mycobacterium was made. Diagnosis certainty was based on microhistological investigations. Clinical stage was evaluated according to lymph node size and presence of fistulas. Successful therapy was defined by the regression of the lymph node enlargement (>75%) or complete surgical excision without relapse. RESULTS Cervicofacial nontuberculous mycobacterium was diagnosed in 33 patients. Complete excision was performed in 73% of cases primarily observed in our hospital, while 83% of those referred from other hospitals required further surgical treatment. No case of relapse was observed after one year of follow-up. CONCLUSIONS We recommend surgical approach as the first therapeutic option in the management of cervicofacial nontuberculous mycobacterium lymphadenitis. LEVELS OF EVIDENCE Prognosis and Retrospective Study - Level II.
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Affiliation(s)
- Aldo Naselli
- Infectious Diseases Unit, Istituto Giannina Gaslini, Ospedale Pediatrico IRCCS, Genova, Italy
| | - Giuseppe Losurdo
- Infectious Diseases Unit, Istituto Giannina Gaslini, Ospedale Pediatrico IRCCS, Genova, Italy
| | - Stefano Avanzini
- Pediatric Surgery Unit, Istituto Giannina Gaslini, Ospedale Pediatrico IRCCS, Genova, Italy
| | - Vincenzo Tarantino
- Otorhinolaryngology Unit, Istituto Giannina Gaslini, Ospedale Pediatrico IRCCS, Genova, Italy
| | - Emilio Cristina
- Infectious Diseases Unit, Istituto Giannina Gaslini, Ospedale Pediatrico IRCCS, Genova, Italy
| | - Elisabetta Bondi
- Infectious Diseases Unit, Istituto Giannina Gaslini, Ospedale Pediatrico IRCCS, Genova, Italy
| | - Elio Castagnola
- Infectious Diseases Unit, Istituto Giannina Gaslini, Ospedale Pediatrico IRCCS, Genova, Italy.
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Heraud D, Carr RD, McKee J, Dehority W. Nontuberculous mycobacterial adenitis outside of the head and neck region in children: A case report and systematic review of the literature. Int J Mycobacteriol 2016; 5:351-353. [PMID: 27847024 DOI: 10.1016/j.ijmyco.2016.04.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 04/27/2016] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Diego Heraud
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Richard D Carr
- University of New Mexico Health Sciences Center Health Informatics Center, Albuquerque, NM, USA
| | - Jason McKee
- Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Walter Dehority
- Department of Pediatrics, Division of Infectious Diseases, University of New Mexico Health Sciences Center, Albuquerque, NM, USA.
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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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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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Pham-Huy A, Robinson JL, Tapiéro B, Bernard C, Daniel S, Dobson S, Déry P, Le Saux N, Embree J, Valiquette L, Quach C. Current trends in nontuberculous mycobacteria infections in Canadian children: A pediatric investigators collaborative network on infections in Canada (PICNIC) study. Paediatr Child Health 2013; 15:276-82. [PMID: 21532791 DOI: 10.1093/pch/15.5.276] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2009] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Nontuberculous mycobacteria (NTM) infections appear to be increasing in number and severity in developed countries worldwide. Surgical excision has been considered the standard treatment for NTM lymphadenitis, but the use of medical therapy seems to be increasing. OBJECTIVE To determine the disease characteristics as well as the current therapeutic management of NTM infections in Canadian children. METHODS Cases of definite or probable NTM infections were identified prospectively in children up to 18 years of age seen in 10 Canadian paediatric tertiary care centres from September 2005 to August 2006. Clinical, microbiological and pathological data were collected. RESULTS A total of 60 cases were identified. Data were complete for 45 patients, including 34 cases of lymphadenitis, four cases of skin and soft tissue infection, and seven cases of pulmonary NTM infection. Seventy-nine per cent of children (27 of 34) with lymphadenitis had an unsuccessful course of antibiotics before diagnosis. Sixty-eight per cent of purified protein derivative tests (15 of 22) were positive. NTM was detected in 76% of samples (29 of 38), of which 62% were Mycobacterium avium complex. All patients with lymphadenitis underwent surgical therapy and most patients (74%) also received antimicrobials. CONCLUSIONS Current trends indicate that the majority of the study centres are using medical therapy with variable regimen and duration as an adjunct to surgical excision in the treatment of NTM lymphadenitis. Larger numbers and longer follow-up times are needed to better evaluate the efficacy of medical therapy and outcome of disease. A randomized controlled study comparing surgical therapy alone and chemotherapy for NTM lymphadenitis is required.
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Affiliation(s)
- Anne Pham-Huy
- Infectious Diseases Division, Department of Pediatrics, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec
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Scott CA, Atkinson SH, Sodha A, Tate C, Sadiq J, Lakhoo K, Pollard AJ. Management of lymphadenitis due to non-tuberculous mycobacterial infection in children. Pediatr Surg Int 2012; 28:461-6. [PMID: 22438045 DOI: 10.1007/s00383-012-3068-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2010] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Catherine A Scott
- Department of Paediatrics, Childrens Hospital, University of Oxford, Oxford, OX3 9DU, UK
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Clark JE. Nontuberculous lymphadenopathy in children: using the evidence to plan optimal management. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012; 719:117-21. [PMID: 22125039 DOI: 10.1007/978-1-4614-0204-6_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
There is no evidence that drug treatment improves healing more rapidly or is associated with an improved cosmetic outcome compared to spontaneous resolution, and no studies have related therapy and outcome to mycobacterial species and susceptibility. It is interesting that widespread and accepted use of drug treatment has developed with no good evidence that drugs facilitate healing[36]. It is therefore essential, given spontaneous healing will occur, that any future studies compare drug treatment with spontaneous resolution.In conclusion there is good evidence that excision of nontuberculous mycobacterial lymphadenopathy is usually curative and should be performed where possible. Where lesions are too large or too difficult to surgically excise, alternatives could include de-bulking with incision and drainage or curettage, recognising that treated this way lesions will be slow to heal. Until there is evidence about the efficacy of antimycobacterial drug treatment it should not be used routinely, though it may be considered in extensive, complex disease. Also, there is no evidence to suggest that antimycobacterial drugs confer an additional benefit when the lesion is excised.
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Claesson G, Bennet R, Eriksson M, Petrini B. Nerve dysfunction following surgical treatment of cervical non-tuberculous mycobacterial lymphadenitis in children. Acta Paediatr 2011; 100:299-302. [PMID: 20874782 DOI: 10.1111/j.1651-2227.2010.02030.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To present our experience of nerve dysfunction following surgical treatment among 126 children with microbiologically verified non-tuberculous mycobacterial (NTM) lymphadenitis. METHODS We retrieved data from medical records, and a questionnaire with an invitation to a clinical follow-up was returned by 88 families. RESULTS The time from onset of symptoms to diagnosis was more than 3 months in 24% of subjects. Mycobacterium avium complex was isolated from 105, Mycobacterium malmoense from 12 and Mycobacterium scrofulaceum from one cervical lymph node. A total of 89% of the children underwent surgery and were examined in particular with regard to cranial motor nerve functions. Major persisting nerve dysfunction occurred in 3/51 (6%) children who underwent radical surgery, and minor dysfunction in seven (14%). In nine children, the marginal mandibular branch of the facial nerve was affected, and the accessory nerve was affected in one child. There were no neurological signs in 25 children treated with incision and drainage alone or in 12 followed with observation alone. Healing took >6 months in 2/76 (3%) surgically treated and 3/12 (25%) non-surgically treated children. CONCLUSION Considering the risk of nerve dysfunction following extirpation, incision with drainage and observation alone should both be included among the management options for cervical NTM lymphadenitis in children.
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Freeman AF, Olivier KN, Rubio TT, Bartlett G, Ochi JW, Claypool RJ, Ding L, Kuhns DB, Holland SM. Intrathoracic nontuberculous mycobacterial infections in otherwise healthy children. Pediatr Pulmonol 2009; 44:1051-6. [PMID: 19824053 PMCID: PMC3746060 DOI: 10.1002/ppul.21069] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Nontuberculous mycobacterial (NTM) infection is typically associated with lymphadenitis in immune competent children, and disseminated disease in children with immune deficiencies. Isolated pulmonary NTM disease is seen in cystic fibrosis, and is increasingly recognized in immunocompetent elderly women, where it is associated with an increased incidence of cystic fibrosis transmembrane regulator (CFTR) mutations. Thoracic NTM infection has been reported rarely in otherwise healthy children. We aimed to determine whether otherwise healthy children with pulmonary NTM disease had immunologic abnormalities or CFTR mutations. Clinical presentations of five otherwise healthy children with pulmonary NTM were reviewed. Immunologic studies were performed including a complete blood cell count (CBC), flow cytometric lymphocyte phenotyping and IFN-gamma receptor expression, in vitro cytokine stimulation, and serum immunoglobulin levels. Mutational analysis was performed for CFTR. The children ranged in age from 12 months to 2.5 years at diagnosis. Four presented with new onset wheezing or stridor failing bronchodilator therapy. One child was asymptomatic. Endobronchial lesions and/or hilar lymph nodes causing bronchial obstruction were identified in all patients. Mycobacterium avium complex was cultured from four patients, and Mycobacterium abscessus from one patient. All patients were successfully treated with anti-mycobacterial therapy with or without surgery. No definitive immunologic abnormalities were identified. No clinically significant mutations were found in CFTR. Pulmonary NTM infection should be considered in otherwise healthy young children presenting with refractory stridor or wheezing with endobronchial lesions or hilar lymphadenopathy. It does not appear to be associated with recognized underlying immune deficiency or CFTR mutations.
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