Nontuberculous mycobacterial lymphadenitis in children

Nontuberculous mycobacterial infection in Wisconsin children and adolescents

Background

The epidemiology of nontuberculous mycobacteria (NTM) infections in the pediatric population is not well described. We estimated the incidence of NTM infection in Wisconsin children and adolescents, and the frequency and type of infection caused by different NTM pathogens. Associations between NTM infection and race/ethnicity and social disadvantage, respectively, were also investigated.

Methods

This retrospective cohort study evaluated reports of NTM infection in Wisconsin residents under 18 years of age submitted to a state-wide database between 2011 and 2018. Demographics of the cohort, including a social disadvantage score (Area Deprivation Index (ADI)), are described. Specimen type and NTM species are enumerated for reported isolates.

Results

There were 224 NTM isolates from 212 children and adolescents. Median age of participants was 3 years; 55 % were female. Cumulative incidence did not vary significantly between the larger racial groups or for the various ADI score groups. Compared to white participants (157), there was a significantly lower cumulative incidence of NTM infection in multiracial individuals (2). Mycobacterium avium complex (MAC) was the most frequently isolated organism (69 %). The majority of isolates (52 %) were from skin and soft tissue, which included lymph node specimens. Annual incidence did not vary significantly over the study period.

Conclusions

The epidemiology of pediatric NTM infections in this cohort is consistent with previous pediatric reports of higher rate of infection in females and predominance of skin and soft tissue infections. Disparities in disease burden across racial/ethnic and socio-economic groups were not demonstrated, but these factors should be further explored in larger pediatric studies of diverse U.S. populations.

Surgical management of parotid non-tuberculous mycobacteria lymphadenitis in children: A pediatric tertiary-care hospital's experience

OBJECTIVE

Non-tuberculous mycobacteria (NTM) represents an important etiology of cervicofacial lymphadenitis (CFL) and skin/soft tissue infections in children. It can also affect the salivary glands, including the parotid gland, which is unique due to the presence of intra-salivary lymph nodes. There are no established guidelines for treatment of NTM CFL. NTM lymphadenitis was historically surgically treated; recently the literature supports initial medical treatment. Treatment decisions have been dependent on the extent of disease, preference of providers, and risk of surgical complications. The goal is to report our experience in surgical outcomes of NTM CFL with involvement of the parotid gland after pre-operative medical management.

METHODS

A retrospective case series of patients with NTM affecting the parotid gland at a tertiary care pediatric hospital between 2004 and 2020.

RESULTS

Seventy-two patients were referred for surgical evaluation of possible parotid NTM. Thirty-three patients underwent surgical excision. Fifteen patients were identified with presumed NTM infection involving the parotid gland. There were twelve females and three males with a mean age of 2.0 years (SD 1.55; range 1-6 days) at the time of surgery. All underwent surgical excision with parotidectomy. The most common pre-operative antimycobacterial therapy used was a combination of clarithromycin and rifampin. All 15 patients had pathological findings consistent with NTM infection (granulomatous lymphadenitis). Forty percent (n = 6) of patients had positive stains with acid-fast bacilli (AFB), with Mycobacterium avium as the most common species (n = 5). The majority of patients, 86.67% (n = 13), had complete resolution of infection after surgery. Clarithromycin and rifampin were the most common post-operative antimycobacterial treatment (mean 81.5 days, SD 110.14, range 2-411 days). The most common complication experienced was acute (<3 months) lower facial nerve paresis (40%, n = 6), but no patient had permanent facial paralysis.

CONCLUSION AND RELEVANCE

Parotidectomy is a safe and efficacious treatment in patients with NTM CFL affecting the parotid gland after incomplete resolution with antimycobacterial therapy. Further investigation to optimize duration of antimycobacterial treatment is necessary. We highlight the experience of a high-volume tertiary care pediatric hospital with surgical management of this disease.

Management of Infectious Lymphadenitis in Children

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.

The Epidemiology of Extrapulmonary Non-tuberculous Mycobacterial Infection in a Pediatric Population

BACKGROUND

Nontuberculous mycobacteria (NTM) are ubiquitous in the environment and a well-known cause of lymphadenitis, skin and soft tissue infections. The aim of this study was to evaluate the epidemiology of extrapulmonary pediatric NTM infections occurring from 2000 to 2017 in Queensland, Australia.

METHODS

All cases of NTM and TB are notifiable under the Queensland Public Health Act (2005) and associated regulations (2005). Data from 2000 to 2017 inclusive was collected from the Notifiable Conditions Database, a laboratory based notification system that covers private and public laboratory systems. Pediatric population demographic data were obtained from the Australian Bureau of Statistics by researching the number of children 0-14 years of age in Queensland from 2000 to 2017; both annual and averaged population was determined. The statistical software SPSS and Tableau was used for analysis.

RESULTS

The mean age of diagnosis was 2.5 years with a majority of the cohort being women. Mycobacterium avium was the most commonly diagnosed pathogen. Geographic regions with the highest numbers of cases were predominantly tropical and coastal areas. M. haemophilum emerged as a more common pathogen from 2011 following a period of major flooding.

CONCLUSION

Characteristics of the cohort of children susceptible to NTM disease appears consistent with previous reports. However, changes in the epidemiology of NTM infection (such as incidence, species, and geographic distribution) in children may be linked to environmental and weather factors.

Submandibular lymphadenitis due to Mycobacterium malmoense: first reported case from Greece

An 8-year-old girl with subacute submandibular lymphadenitis and no other complaints is described. After failure of parenteral antistaphylococcal therapy, she underwent incision and drainage of the involved lymph node. The responsible pathogen was identified as Mycobacterium malmoense by GenoType CM assay and sequencing of the 16S ribosomalRNA (rRNA) gene. The patient remains healthy, 11 months after surgery, even though it took approximately 4 months for the surgical incision to heal completely. While M. malmoense is a relatively common cause of non-tuberculous mycobacteria (NTM) lymphadenitis in Northern Europe, this is the first reported case from Greece. We conclude that in a young child with lymphadenitis without systemic symptoms, the microbiology laboratory should be notified in advance in order to extend the duration of mycobacterial cultures. Application of molecular methods will increase the number of reported cases of rare NTM in the future.

Lymphadenitis by non-tuberculous mycobacteria in children

BACKGROUND

Non-tuberculous mycobacteria (NTM) constitute an important cause of cervical lymphadenitis in immunocompetent children. The aims of this study were to estimate the incidence of lymphadenitis due to NTM in children in Cyprus and to describe the characteristics, diagnostic approach, management and outcome of such infections.

METHODS

Children aged 1-5 years old, evaluated at Archbishop Makarios III Hospital, Nicosia, Cyprus, from 1 January 2007 to 31 December 2016 for lymphadenopathy, were included in the study. All children had positive lymph node culture for NTM.

RESULTS

A total of 22 cases of culture-positive lymphadenitis caused by NTM were reviewed. Patient age ranged from 16 to 55 months. Tuberculin skin test produced an induration in 81.0% of cases (diameter, 4-17 mm). Mycobacterium avium was isolated in 17 cases (77.3%), M. intracellulare in three (13.6%), M. paraffinicum in one (4.5%) and M. kansasii in one case (4.5%). All 22 patients underwent surgical excision of affected nodes. Additional anti-mycobacterial treatment was given when complete excision was not achieved or for post-surgical recurrence. Complications were few and included scar in three children and one case of transient facial nerve palsy.

CONCLUSION

Surgical excision of NTM-infected lymph nodes is an effective diagnostic and therapeutic approach. When total surgical excision is not feasible, a combination of partial excision with a clarithromycin-including drug regimen appears safe, effective and causes milder and fewer complications than surgery alone.

Diagnosis and Management of Children With Mycobacterium abscessus Infections in the Head and Neck

PURPOSE

Controversy exists regarding the most appropriate treatment strategy for children with nontuberculous mycobacterial (NTM) cervical lymphadenitis. Mycobacterium abscessus (MAB) is an uncommon cause of NTM cervical lymphadenitis. The purpose of the present study was to evaluate diagnosis, management, and treatment outcomes in children with MAB-associated cervical lymphadenitis resulting from a pulpotomy.

MATERIALS AND METHODS

This was a retrospective chart review of children with NTM lymphadenitis of the head and neck caused by MAB treated at Children's Healthcare of Atlanta hospitals (Atlanta, GA). The predictor variables were patient demographics, dental history, clinical presentation, imaging characteristics, laboratory findings, histopathologic examination, treatment, and complications. The outcome variable was disease resolution or persistence.

RESULTS

Twenty-two patients (mean age, 6.5 yr) met the inclusion criteria. All patients had pulpotomy at 1 dental practice. The mean time from dental procedure to symptom onset was 43.1 days (range, 3 to 180 days). Children presented with cervical or submandibular swelling, facial swelling, gingival erythema, and skin erythema. Radiographic findings were submandibular or cervical lymphadenitis, maxillary or mandibular osteolysis, subcutaneous abscess, and pulmonary nodules. All children had confirmed or probable MAB infection diagnosed on the pathologic specimen. There were 2 distinct patient presentations that guided surgical management: isolated noninflammatory cervical lymphadenitis, which was partly or completely excised (n = 11), and adjacent extension or disseminated infection requiring subtotal lymph node excision, bone debridement, and postoperative antibiotics (n = 11). Most children required multiple surgical interventions to remove infected tissues. All achieved clinical resolution.

CONCLUSION

In this cohort, treatment of NTM lymphadenitis caused by MAB depended on extent of disease and virulence of bacteria. When complete surgical excision was possible, disease resolution was achieved. However, in cases with adjacent extension or dissemination infection, postoperative antibiotics were necessary.

[Lymphadenitis due to non-tuberculous mycobacteria: Experience over 15 years]

OBJECTIVE

To study the epidemiology, clinical features, diagnosis, therapeutic management, and outcome of non-tuberculous mycobacterial lymphadenitis in a paediatric population of Aragón (Spain).

MATERIAL AND METHODS

A retrospective study was conducted on patients under 15 years-old diagnosed with non-tuberculous mycobacterial lymphadenitis between the years 2000 and 2015.

INCLUSION CRITERIA

patients with lymphadenitis and positive culture. Quantitative values are shown as mean, rank, and standard deviation, and qualitative data as frequencies.

RESULTS

Twenty-seven cases were registered, with a mean age of presentation of 39.9 months (range 10 months-8 years). The mean time between the symptoms onset and first consultation was 1.7±1.1 months. The most frequent location was sub-maxilar in 17/27 cases (63%), on the right side in 59.3%, and size 2.96±1.26cm. Fistulae were observed in 16/27 cases. Tuberculin test was greater than 10mm in 7/24 (29.1%). Microbiological cultures were positive for Mycobacterium avium in 14/27 (51.9%), Mycobacterium intracellulare 3/27 (11.1%), and Mycobacterium lentiflavum 3/27 (11.1%). Combined treatment of antibiotics and surgery was given in 16/27 cases (59.8%), medical treatment only in7/27 (25.9%), and surgical exeresis alone in 4/27 (14.8%). Two patients required a new surgery, and one showed severe neutropenia secondary to rifabutin. Only one case (3.7%) suffered from temporary facial palsy as sequel.

CONCLUSIONS

The most frequent treatment was the combination of antibiotics and surgery. Delay in diagnosis seemed to be responsible for the limited number of exeresis as first option, only one for every seven patients.

Nontuberculous Mycobacterial Disease in Children - Epidemiology, Diagnosis & Management at a Tertiary Center

Background

There are limited data on the epidemiology, diagnosis and optimal management of nontuberculous mycobacterial (NTM) disease in children.

Methods

Retrospective cohort study of NTM cases over a 10-year-period at a tertiary referral hospital in Australia.

Results

A total of 140 children with NTM disease, including 107 with lymphadenitis and 25 with skin and soft tissue infections (SSTIs), were identified. The estimated incidence of NTM disease was 0.6–1.6 cases / 100,000 children / year; no increasing trend was observed over the study period. Temporal analyses revealed a seasonal incidence cycle around 12 months, with peaks in late winter/spring and troughs in autumn. Mycobacterium-avium-complex accounted for most cases (77.8%), followed by Mycobacterium ulcerans (14.4%) and Mycobacterium marinum (3.3%). Polymerase chain reaction testing had higher sensitivity than culture and microscopy for acid-fast bacilli (92.0%, 67.2% and 35.7%, respectively). The majority of lymphadenitis cases underwent surgical excision (97.2%); multiple recurrences in this group were less common in cases treated with clarithromycin and rifampicin compared with clarithromycin alone or no anti-mycobacterial drugs (0% versus 7.1%; OR:0.73). SSTI recurrences were also less common in cases treated with two anti-mycobacterial drugs compared with one or none (10.5% versus 33.3%; OR:0.23).

Conclusions

There was seasonal variation in the incidence of NTM disease, analogous to recently published observations in tuberculosis, which have been linked to seasonal variation in vitamin D. Our finding that anti-mycobacterial combination therapy was associated with a reduced risk of recurrences in patients with NTM lymphadenitis or SSTI requires further confirmation in prospective trials.

The management of non-tuberculous cervicofacial lymphadenitis in children: A systematic review and meta-analysis

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.

Bacterial pathogens

Bacterial infections are frequent complications among patients treated for cancer. The type, severity, and treatment of bacterial infections vary and depend upon the specific malignancy, associated chemotherapies, and transplantation. This chapter discusses commonly encountered bacterial pathogens as well as Nocardia and mycobacteria in patients with cancer and addresses the clinical syndromes and management. Drug-resistant bacteria are becoming an increasingly recognized problem in patients with cancer. Antimicrobial resistance in select gram-positive and gram-negative bacteria are discussed along with the mechanisms of resistance and recommended therapies.

Current trends in nontuberculous mycobacteria infections in Canadian children: A pediatric investigators collaborative network on infections in Canada (PICNIC) study

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.

Predicting Surgical Outcomes in Pediatric Cervicofacial Nontuberculous Mycobacterial Lymphadenitis

Objectives:

We examined surgical outcomes in children with cervicofacial nontuberculous mycobacterial lymphadenitis and attempted to identify predictors of complications.

Methods:

A retrospective chart review from 2 tertiary pediatric centers was used to identify 11 presentation or operative variables (age at surgery, gender, symptom duration, pain, violaceous skin changes, skin breakdown, fluctuance, purified protein derivative positivity, operative procedure, use of nerve integrity monitoring, and use of skin flap advancement) and to compare these to 5 postoperative complications (facial nerve dysfunction [paresis or paralysis], poor scarring, recurrence, wound infection, and wound dehiscence without infection).

Results:

The 45 patients analyzed for presentation or operative variables (28 female, 17 male; average age, 31.2 months) typically presented with painless masses averaging 8.2 weeks in duration, along with violaceous skin changes in 29 of the 45 cases (64%) and skin breakdown in 9 cases (20%). The surgical procedures included parotidectomy with or without selective lymphadenectomy in 38 of the 45 cases (84%) and lymphadenectomy alone in 7 cases (16%). Skin resection and cervicofacial advancement flap reconstruction was performed in 20 cases (44%). Nerve integrity monitoring was utilized in 32 cases (71%). In the 44 patients analyzed for postoperative complications, we found facial nerve paresis in 14 (31.8%), poor scarring in 9 (20.5%), wound infection in 6 (13.6%), recurrence in 4 (9.1%), and facial nerve paralysis in 2 (4.5%). Nine of the 14 cases (64.3%) of initial facial nerve paresis resolved. At final follow-up, facial nerve paresis persisted in 5 of the 14 children (35.7%) with initial postoperative paresis and in 1 of the 2 children (50.0%) with initial postoperative paralysis. Facial nerve paralysis persisted in the other child with initial postoperative paralysis. Overall, 6 of these 7 patients (85.7%) with persistent facial nerve dysfunction had follow-up of less than 1 month. All transient and permanent facial nerve dysfunction was in the distribution of the marginal mandibular nerve only. No statistically significant predictors of complications were identified.

Conclusions:

We report acceptable but not insignificant rates of marginal mandibular distribution facial nerve injury, poor scarring, wound infection, and recurrence following resection of cervicofacial nontuberculous mycobacterial lymphade nitis in children that must be discussed with patients and parents before operation. No presentation or operative variables predicted the complications.

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.

Nontuberculous lymphadenopathy in children: using the evidence to plan optimal management

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.

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.

Surgical Excision versus Antibiotic Treatment for Nontuberculous Mycobacterial Cervicofacial Lymphadenitis in Children: A Multicenter, Randomized, Controlled Trial

BACKGROUND

The optimal treatment of nontuberculosis mycobacterial cervical lymphadenitis in children has not been established. Until recently, surgical excision was the standard treatment, but the number of reports of successful antibiotic treatment is increasing, which questions whether surgery is the preferred treatment. In this randomized, multicenter trial, we compared surgical excision with antibiotic treatment.

METHODS

One hundred children with microbiologically proven nontuberculous mycobacterial cervicofacial lymphadenitis were randomly assigned to undergo surgical excision of the involved lymph nodes or to receive antibiotic therapy with clarithromycin and rifabutin for at least 12 weeks. The primary end point was cure, defined as regression of the lymph node enlargement by at least 75%, with cure of the fistula and total skin closure without local recurrence or de novo lesions after 6 months, as assessed by clinical and ultrasound evaluation. Secondary end points included complications of surgery and adverse effects of antibiotic therapy.

RESULTS

Intention-to-treat analysis revealed that surgical excision was more effective than antibiotic therapy (cure rates, 96% and 66%, respectively; 95% confidence interval for the difference, 16%-44%). Treatment failures were explained neither by noncompliance nor by baseline or acquired in vitro resistance to clarithromycin or rifabutin. Surgical complications were seen in 14 (28%) of 50 patients; staphylococcal wound infection occurred in 6 patients, and a permanent grade 2 facial marginal branch dysfunction occurred in 1 patient. The vast majority of patients who were allocated to antibiotic therapy reported adverse effects (39 [78%] of 50 patients), including 4 patients who had to discontinue treatment.

CONCLUSIONS

Surgical excision is more effective than antibiotic treatment for children with nontuberculous mycobacterial cervicofacial lymphadenitis.

Mycobacterium simiae cervical lymphadenitis

Mycobacterium simiae, a multidrug-resistant, opportunistic acid-fast bacillus, usually causes infection in immunocompromised hosts. We describe a previously healthy child with M. simiae necrotizing granulomatous cervical lymphadenitis. Cure was achieved with excision of the affected nodes and adjunctive antimicrobial therapy.

Adenitis por micobacterias no tuberculosas

OBJECTIVE

To study the clinical features, epidemiology and outcome of nontuberculous mycobacterial lymphadenitis (NTML).

METHODS

A retrospective study was performed on 54 patients under 14 years old diagnosed with atypical mycobacterial lymphadenitis between 1987 and 2004. Inclusion criteria were: (i) positive polymerase chain reaction (PCR) test or culture; (ii) positive sensitin skin test 6 mm above Mantoux; (iii) histopathologic features compatible with mycobacterial infection and/or positive direct smear for acid-fast bacilli, Mantoux reaction less than 15 mm, a normal chest radiograph, absence of exposure to an adult with tuberculosis, negative Mantoux test reactions in family members, and exclusion of other causes of granulomatous adenitis.

RESULTS

Fifty-four patients were included in the study. The number of NTML cases increased notably from 1996, coinciding with a decrease in cases of tuberculous adenitis. The mean age was 35 months (range: 14 months-6 years). Submandibular nodes were involved in 22 of 63 cases of adenitis (34.9%) and cervical nodes were involved in 21 (33.3%). In 8/42 patients (19%) the tuberculin skin test was larger than 10 mm. Cultures were positive in 52.9% of the cases (18/34) and PCR in 53.3% (8/15). The most frequently isolated mycobacteria was Mycobacterium avium (61%). Therapy failed in 8/21 patients receiving antibiotics (38%), in 10/13 patients with drainage alone (77%) and in none of the patients who underwent surgery (8/8).

CONCLUSIONS

Nontuberculous mycobacterial adenitis has become more frequent in our hospital since 1996. Cultures do not always allow isolation of mycobacteria and the Mantoux test frequently yields false positive results, thus hampering diagnosis. The most effective treatment was surgical excision. Nevertheless, when the surgical approach is difficult or there is postoperative recurrence, pharmacological treatment can be useful.

Tuberculin skin testing is useful in the screening for nontuberculous mycobacterial cervicofacial lymphadenitis in children

BACKGROUND

We evaluated the diagnostic usefulness of tuberculin skin testing in the screening for nontuberculous mycobacterial (NTM) infection in children.

METHODS

We enrolled 180 children who had chronic cervicofacial lymphadenitis in our study. Skin testing was done using antigens of Mycobacterium tuberculosis, Mycobacterium avium, Mycobacterium kansasii, and Mycobacterium scrophulaceum. The reference standard for NTM infection was a positive culture result, identification by PCR, or both. Receiver operating characteristic analysis was used to identify the optimal cutoff point in skin induration for the detection of NTM infection. Accuracy of the mycobacterial skin tests was quantified using sensitivity and specificity rates and positive and negative predictive values at the optimal skin induration cutoff.

RESULTS

A total of 112 NTM infections were identified, of which 83 were caused by M. avium, 21 by Mycobacterium haemophilum, and 8 by other NTM species. At the optimal cutoff for a positive test (5 mm), tuberculin skin testing had a sensitivity and specificity of 70% and 98%, respectively, and a positive predictive value and a negative predictive value of 98% and 64%, respectively, compared with a sensitivity and a specificity of 93% and 97%, respectively; M. avium sensitin, the best-performing skin test, had positive and negative predictive values of 98% and 90%, respectively.

CONCLUSION

Tuberculin skin testing could be valuable as a first step in the diagnostic analysis of cervicofacial lymphadenitis in children without a history of TB exposure or bacille Calmette-Guérin vaccination.

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.

Peripheral tuberculous lymphadenitis: epidemiology, diagnosis, treatment, and outcome

We reviewed 106 patients referred to our institution for treatment of peripheral tuberculous adenitis to establish the epidemiologic, clinical, and pathologic manifestations of this disease. Tuberculous lymphadenitis occurred predominantly in young, foreign-born women a mean of 5 years after arrival in the United States. Tuberculin skin tests were positive in 94% of cases. Lymphadenopathy occurred most frequently in the neck (57%) or supraclavicular area (26%) and involved 1-3 nodes. Forty (38%) patients had an abnormal chest radiograph consistent with granulomatous infection. Culture-positive pulmonary tuberculosis was diagnosed in 41% of those patients with abnormal chest radiographs. Fine needle aspiration was an essential step in the evaluation and diagnosis of tuberculous lymphadenitis. Granulomas were seen in 61% of fine needle aspirates and 88% of surgical biopsies. Positive cultures for Mycobacterium tuberculosis were obtained from 62% of fine needle aspirate samples and 71% of excisional biopsies. The presence of necrosis and/or neutrophilic inflammation in tissue samples correlated with culture positivity. Given the high yield of positive cultures from fine needle aspirates, surgery was rarely indicated as an initial step in immunocompetent adults. In this cohort, 101 patients received a final diagnosis of peripheral tuberculous lymphadenitis. Eighty-two percent received their entire therapy under direct observation, and response to antituberculous therapy was uniformly successful. Paradoxical expansion of adenopathy was seen in 20% of all patients and was more commonly noted in human immunodeficiency virus-seropositive patients. We present a diagnostic algorithm based on our experience.

[Pediatric infections caused by nontuberculous mycobacteria]

During the last few years, nontuberculous mycobacteria (NTM) have been isolated with increasing frequency in our environment. However, there are only a few reports of pediatric NTM infections in Spain (13 articles since 1990). This article presents an update of the epidemiology, diagnostic methods, and treatment of these infections in children. The most frequent clinical syndromes caused by NTM include lymphadenitis, pulmonary and disseminated infections in immunocompromised children. NTM cervical adenitis usually causes chronic infection associated with sinus tract formation and scarring. The treatment of choice is surgical excision of the involved node. Incision and drainage of the enlarged node should be avoided because it can lead to chronic drainage or sinus tract formation. Medical treatment with azithromycin or clarithromycin associated with rifabutin, ethambutol or ciprofloxacin should be reserved for cases in which the family refuses surgery, a recurrence occurs or complete excision is impossible. Pulmonary disease caused by NTM is relatively rare in immunocompetent children, but is increasingly reported in children with cystic fibrosis. In these patients, the clinical significance of the presence of NTM in the sputum is unclear. The persistence of positive cultures, especially if bacilloscopy is positive and the patient shows clinical evidence of pulmonary disease exacerbation, is an indication to start treatment. Disseminated infection caused by NTM can appear in patients with severe immunodepression, especially in HIV-infected children with CD4 cell counts of less than 100 cells/mm3. Early antibiotic therapy with at least three drugs including a macrolide, and immune recovery with aggressive antiretroviral therapy are the keys to improving quality of life and survival in these patients.

Mycobacterial Cervical Lymphadenitis

Cervical lymphadenitis is the most common head and neck manifestation of mycobacterial infections. The incidence of mycobacterial cervical lymphadenitis has increased. It may be the manifestation of a systemic tuberculous disease or a unique clinical entity localized to neck. It remains a diagnostic and therapeutic challenge because it mimics other pathologic processes and yields inconsistent physical and laboratory findings. A high index of suspicion is needed for the diagnosis of mycobacterial cervical lymphadenitis. A unilateral single or multiple painless lump, mostly located in posterior cervical or supraclavicular region can occur. A thorough history and physical examination, tuberculin test, staining for acid-fast bacilli, radiologic examination, fine-needle aspiration and PCR will be instrumental in arriving at an early diagnosis early institution of treatment before a final diagnosis can be made by biopsy and culture. It is important to differentiate tuberculous from nontuberculous mycobacterial cervical lymphadenitis because their treatment protocols are different. Tuberculous adenitis is best treated as a systemic disease with antituberculosis medication. Atypical infections can be addressed as local infections and are amenable to surgical therapy.

Mycobacterium lentiflavum as an emerging causative agent of cervical lymphadenitis

A lymph node excision was performed on a 45-year-old woman with left cervical swelling. The disorder which developed after the patient had undergone oral surgery for a severe periodontal disease failed to respond to antimicrobial chemotherapy. A mycobacterial strain subsequently identified by high-performance liquid chromatography analysis of cell wall mycolic acids as Mycobacterium lentiflavum grew from the excised specimen. This case and previously published reports highlight the relevance of M. lentiflavum as an emerging causative agent of mycobacterial cervical lymphadenitis.

Nontuberculous mycobacterial infection in children: a 2-year prospective surveillance study in the Netherlands

We performed a prospective, 2-year nationwide study to assess incidence and disease characteristics of suspected infections with nontuberculous mycobacteria (NTM) in children, via the Netherlands Pediatric Surveillance Unit. Data for 61 children were reported (median age, 31 months; interquartile range, 22-50 months; female sex, 37 subjects); 2 subjects had an underlying disease. Most children (53 [87%] of 61) had cervical lymph node enlargement, with abscess in 25 (47%) and fistula in 11 (21%). The estimated annual incidence of NTM infection was 77 cases per 100,000 children. In 16 children, the diagnosis was based solely on the results of skin tests with mycobacterial antigens. Cultures were performed in 36 cases and yielded mycobacteria in 27 (75%); Mycobacterium avium was isolated from 18 cultures. Children with a culture positive for mycobacteria did not differ in presentation, complications, or treatment from those whose cultures showed no growth. Thirty children underwent surgery, and chemotherapy was the single treatment in 24 (39%) of the cases. The treatment of localized NTM infection in immunocompetent children by antimycobacterial drugs should be evaluated further.

Nontuberculous mycobacterial cervical adenitis: a ten-year retrospective review

OBJECTIVE

To review the authors' institutional experience with nontuberculous mycobacterial cervical adenitis in children over a 10-year period.

STUDY DESIGN

Retrospective chart review.

METHODS

The case histories of 79 children with nontuberculous mycobacterial lymphadenitis who presented to a large tertiary care referral center from 1989 to 1999 were retrospectively analyzed, and the demographics, clinical presentation, methods of diagnosis, and types of surgical intervention they underwent were reported.

RESULTS

The mean age at presentation was 3.6 years. The male-to-female ratio was 1:2, and the frequency of presentation was highest in the winter and spring months. The diagnosis was not immediately apparent to most primary health care physicians because there was a delay between the appearance of the lump and referral for treatment, which was in excess of 8 weeks. Involved nodes were mainly treated surgically. The recurrence rate of complete surgical resection was less than 1%.

CONCLUSION

The study highlights the fact that a high index of clinical suspicion is needed to make an early diagnosis of nontuberculous mycobacterial lymphadenitis and lends further weight to the already existing evidence that surgical excision remains the mainstay of successful treatment for lymphadenitis caused by nontuberculous mycobacteria.

Mycobacterial cervical lymphadenitis in children: clinical and laboratory factors of importance for differential diagnosis

The role of epidemiological and clinical features for the early differential diagnosis between Mycobacterium tuberculosis (MTB) complex and non-tuberculous mycobacterial (NTM) cervical lymphadenitis in children was examined in this study. From 1982 to 1997, 24 MTB complex cases and 26 NTM cases were diagnosed, of which 75% and 25%, respectively, presented during the first half of the study period. Epidemiological and lymph-node features and anatomical areas were not helpful in the differential diagnosis between the 2 groups. Fulfilment of 2 out of 3 criteria (positive tuberculin skin test reaction, abnormal chest radiograph, contact with a person with infectious tuberculosis) was associated with 92% sensitivity for the diagnosis of MTB lymphadenitis. 37.5% of the MTB cases and 88.5% of the NTM cases were culture-confirmed; all inconclusive cultures concerned patients with spontaneous drainage and fistula. Surgical intervention was required in 67% of the MTB cases. All NTM cases were managed by surgery alone. Fistulae or cheloids occurred in all patients in whom incision and drainage were applied instead of total excision. Excellent aesthetic results were achieved in patients who presented within 1 month following the onset of lymphadenitis. The spectrum of mycobacterial cervical lymphadenitis in children in Greece has changed during the 1990s. Early and prompt treatment contributes to the diagnosis and response.

Skin indurations in response to tuberculin testing in patients with nontuberculous mycobacterial lymphadenitis

Mantoux results were examined for 29 children with culture-proven nontuberculous mycobacterial lymphadenitis, and 4 species were isolated: Mycobacterium avium-intracellulare complex (from 14 patients [48%]), Mycobacterium haemophilum (from 12 [41%]), Mycobacterium simiae (from 2 [7%]), and Mycobacterium scrofulaceum (from 1 [3%]); the median indurations for each species were 15.5 mm, 14.5 mm, 20 mm, and 23 mm, respectively, and in 17 cases (59%), they were > or =15 mm. In regions with a low incidence of tuberculosis, lymphadenitis thought to be due to nontuberculous mycobacteria should be managed as such, regardless of Mantoux results, thereby avoiding antituberculosis treatment.

Surgery required to verify atypical mycobacterial infections

To estimate the incidence and distribution of nontuberculuous mycobacterial surgery, a retrospective case record study of 42 children operated for cervicofacial atypical mycobacterial infections in Oslo from 1990 to 2000 was performed. Mean age at diagnosis was 41 months and mean duration of the disease was 40 weeks from symptom onset to remission. All presented with localized and unilateral disease without increased hematological parameters. The majority of children had one lesion localized in the submandibular region characterized by changes in the overlying skin color, but without necrosis or fistula formation. Children below three significantly more often presented with only one lesion and the referring physician more frequently suspected neoplasm and bacterial adenitis than reactive adenopathy in this group. Compared to older children, there was a tendency for shorter symptom duration prior to outpatient treatment (mean 4 and 13 weeks for children up to 3 and above 3 years, respectively, t=-1.6, P=0.11). Furthermore, mycobacterial cultures and histopathology from surgical specimens was needed to diagnose the disease correctly. Fine-needle aspiration biopsy was unsuccessful in 27% (n=8) of the patients, due to non-cooperative patients (n=2) or inconclusive material (n=6), and mycobacterial growth was not obtained in any of the samples. Intradermal mycobacteria skin testing yielded 29% (n=10) false negatives. Although mycobacteria was correctly diagnosed in the remaining patients, correct specimen was found in only 31% (n=11) of the 25 cases.