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Vonasek BJ, Gusland D, Tans-Kersten J, Misch EA, Gibbons-Burgener SN. Nontuberculous mycobacterial infection in Wisconsin children and adolescents. J Clin Tuberc Other Mycobact Dis 2024; 36:100456. [PMID: 38974997 PMCID: PMC11227012 DOI: 10.1016/j.jctube.2024.100456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024] Open
Abstract
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.
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Affiliation(s)
- Bryan J. Vonasek
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Danièle Gusland
- Department of Pediatrics, University of California-San Francisco, San Francisco, CA, USA
| | - Julie Tans-Kersten
- Division of Public Health, WI Department of Health Services, Madison, WI, USA
| | - Elizabeth A. Misch
- Deparment of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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2
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Danis DO, Jamil TL, Levi JR, Scott AR. Regional differences in admissions and surgical management of pediatric nontuberculous mycobacterial cervicofacial lymphadenitis. Int J Pediatr Otorhinolaryngol 2024; 183:112051. [PMID: 39084101 DOI: 10.1016/j.ijporl.2024.112051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 07/20/2024] [Accepted: 07/23/2024] [Indexed: 08/02/2024]
Abstract
OBJECTIVES This study aims to determine the overall incidence of medical and surgical admissions related to non-tuberculous mycobacterial cervicofacial lymphadenitis (NTMCL) and determine if rates vary by geographic region in the US. It also aims to assess if the relative frequency of varying treatment modalities for NTMCL differ among geographic regions. STUDY DESIGN Population-based inpatient registry analysis. SETTING Academic medical center. METHODS The Kids' Inpatient Database (2016 and 2019) was used to determine NTMCL-related admissions and common head and neck procedures performed during these admissions were identified. Analysis was performed on regional differences in demographic factors and procedures performed during NTMCL-related admissions. RESULTS There were 159 weighted admissions (1.31 per 100,000) for NTMCL in 2016 and 2019 in the US, with the Midwest having the highest proportion of NTML-related admissions (1.59:100,000). NTMCL-related admissions were 2.21 times as likely to be elective rather than non-elective in the Midwest when compared to all other geographic regions (p = 0.038). The Midwest was 2.83 times as likely to treat with surgery (p = 0.011), while the Northeast was negatively associated with performing procedures (OR 0.38; p = 0.026). In the Midwest, significantly more excisional surgeries were preformed when compared to other regions, with an OR of 2.98 (p = 0.003). CONCLUSION The Midwest had the highest incidence of pediatric NTMCL-related admissions and was more likely to perform excisional surgery as primary NTMCL treatment. Regions that rarely see pediatric NTMCL have a more inconsistent approach to management.
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Affiliation(s)
- David O'Neil Danis
- Dr. Elie E. Rebeiz Department of Otolaryngology-Head and Neck Surgery, Tufts Medical Center, 860 Washington St Building 1st Floor, Boston, MA, 02111, USA
| | - Taylor Lynn Jamil
- Boston University School of Medicine, 72 East Concord St, Boston, MA, 02118, USA; Boston University School of Public Health, 715 Albany St, Boston, MA, 02118, USA; Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, 12631 East 17th Avenue 3001, Aurora, CO, 80045, USA
| | - Jessica R Levi
- Boston University School of Medicine, 72 East Concord St, Boston, MA, 02118, USA; Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, 830 Harrison Ave, Boston, MA, 02118, USA
| | - Andrew R Scott
- Dr. Elie E. Rebeiz Department of Otolaryngology-Head and Neck Surgery, Tufts Medical Center, 860 Washington St Building 1st Floor, Boston, MA, 02111, USA; Tufts University School of Medicine, 145 Harrison Ave, Boston, MA, 02111, USA; Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, 02114, USA.
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Hoogenkamp MA, Mazurel D, Deutekom-Mulder E, de Soet JJ. The consistent application of hydrogen peroxide controls biofilm growth and removes Vermamoeba vermiformis from multi-kingdom in-vitro dental unit water biofilms. Biofilm 2023; 5:100132. [PMID: 37346320 PMCID: PMC10279787 DOI: 10.1016/j.bioflm.2023.100132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 05/24/2023] [Accepted: 05/24/2023] [Indexed: 06/23/2023] Open
Abstract
The water systems inside a dental unit are known to be contaminated with a multi-kingdom biofilm encompassing bacteria, fungi, viruses and protozoa. Aerosolization of these micro-organisms can potentially create a health hazard for both dental staff and the patient. Very little is known on the efficacy of dental unit disinfection products against amoeba. In this study we have examined the effect of four different treatment regimens, with the hydrogen peroxide (H2O2) containing product Oxygenal, on an in-vitro multi-kingdom dental unit water system (DUWS) biofilm. The treatment efficacy was assessed in time using heterotrophic plate counts, the bacterial 16S rDNA, fungal 18S rDNA gene load and the number of genomic units for Legionella spp. the amoeba Vermamoeba vermiformis. The results indicated that a daily treatment of the DUWS with a low dose H2O2 (0.02% for 5 h), combined with a weekly shock dose (0.25% H2O2, 30 min) is necessary to reduce the heterotrophic plate count of a severely contaminated DUWS (>106 CFU.mL-1) to below 100 CFU.mL-1. A daily treatment with a low dose hydrogen peroxide alone, is sufficient for the statistically significant reduction of the total amount of bacterial 16S rDNA gene, Legionella spp. and Vermamoeba vermiformis load (p < 0.005). Also shown is that even though hydrogen peroxide does not kill the trophozoite nor the cysts of V. vermiformis, it does however result in the detachment of the trophozoite form of this amoeba from the DUWS biofilm and hereby ultimately removing the amoeba from the system.
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Affiliation(s)
- Michel A. Hoogenkamp
- Corresponding author. Gustav Mahlerlaan 3004, 1081 LA, Amsterdam, the Netherlands.
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Pelzer PT, Smit Y, Tiemersma EW, Huong NT, Nhung NV, Cobelens F. Does BCG vaccination protect against infection with M. tuberculosis? Int J Tuberc Lung Dis 2022; 26:529-536. [PMID: 35650705 PMCID: PMC9165740 DOI: 10.5588/ijtld.21.0607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND: Protection against infection by the bacille Calmette-Guérin vaccine against Mycobacterium tuberculosis remains a subject of controversy. We investigated the association between BCG vaccination at birth and infection by M. tuberculosis. MATERIAL AND METHODS: This was a secondary analysis of data from tuberculin skin test (TST) surveys in Vietnamese schoolchildren between 1988 and 2001. We investigated whether a BCG scar was associated with a lower prevalence of TST positivity, adjusting for BCG-induced variation by varying cut-off values for a positive TST. RESULTS: We found a positive association between BCG scar and TST positivity. The strength of the association decreased with increasing TST cut-off values; however, it never inverted significantly, irrespective of geographic region and survey year. CONCLUSION: In Vietnam, BCG vaccination was not associated with reduced M. tuberculosis infection prevalence as measured using TST. This in contrary to a similar study conducted in Tanzania. These contradictory findings may be explained by geographical differences and the relatively high prevalence in Vietnam of the M. tuberculosis Beijing genotype, which is reported to be capable of circumventing BCG-induced immunity.
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Affiliation(s)
- P T Pelzer
- KNCV Tuberculosis foundation, Technical division, The Hague, The Netherlands, Department of Global Health and Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Y Smit
- KNCV Tuberculosis foundation, Technical division, The Hague, The Netherlands
| | - E W Tiemersma
- KNCV Tuberculosis foundation, Technical division, The Hague, The Netherlands
| | - N T Huong
- NTP Vietnam, National Lung Hospital, Hanoi, Viet Nam
| | - N V Nhung
- KNCV Tuberculosis Foundation, Country office in Vietnam, Hanoi, Viet Nam
| | - F Cobelens
- Department of Global Health and Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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Morreale A, Dotta L, Vairo D, Bazzana T, Lougaris V, Soresina A, Plebani A, Giliani SC, Porta F, Matteelli A, Redaelli De Zinis LO, Badolato R. When a Nontuberculous Mycobacterial Infection Reveals an Error of Immunity: A Single Center's Experience. Pediatr Infect Dis J 2022; 41:427-429. [PMID: 35086117 DOI: 10.1097/inf.0000000000003461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We present an algorithm that may be applied in case of a diagnosis of pediatric nontuberculous mycobacterial disease to identify the patients who may require an immunologic assessment to discover a possible underlying immune system defect predisposing to their nontuberculous mycobacterial infections.
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Affiliation(s)
- Alessia Morreale
- From the Department of Pediatrics, ASST Spedali Civili of Brescia, University of Brescia
| | - Laura Dotta
- Department of Pediatrics, Institute for Molecular Medicine A. Nocivelli, ASST Spedali Civili of Brescia
| | - Donatella Vairo
- Department of Molecular and Translational Medicine, Institute for Molecular Medicine A. Nocivelli, University of Brescia
| | - Tullia Bazzana
- Department of Pediatric Otorhinolaryngology, ASST Spedali Civili of Brescia
| | - Vassilios Lougaris
- Department of Pediatrics, Institute for Molecular Medicine A. Nocivelli, Department of Clinical and Experimental Sciences, University of Brescia and ASST Spedali Civili of Brescia
| | | | - Alessandro Plebani
- Department of Pediatrics, Institute for Molecular Medicine A. Nocivelli, Department of Clinical and Experimental Sciences, University of Brescia and ASST Spedali Civili of Brescia
| | - Silvia Clara Giliani
- Institute for Molecular Medicine A. Nocivelli, Department of Pathology, Laboratory of Genetic Disorders of Childhood, Department of Molecular and Translational Medicine, University of Brescia, ASST Spedali Civili of Brescia
| | - Fulvio Porta
- Department of Pediatric Onco-Hematology and BMT, ASST Spedali Civili of Brescia
| | - Alberto Matteelli
- Department of Infectious and Tropical Diseases, WHO Collaborating Centre for TB/human immunodeficiency virus and TB Elimination, University of Brescia and ASST Spedali Civili of Brescia
| | - Luca Oscar Redaelli De Zinis
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Section of Head and Neck Surgery, University of Brescia, Pediatric Otorhinolaryngology Head Neck Surgery Division, Children Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Raffaele Badolato
- Department of Pediatrics, Institute for Molecular Medicine A. Nocivelli, Department of Clinical and Experimental Sciences, University of Brescia and ASST Spedali Civili of Brescia
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Abstract
PURPOSE OF REVIEW The aim of this article is to review the most recent evidences concerning mycobacterial skin infections, limiting the period of literature research to 2020--2021. RECENT FINDINGS Mycobacterial skin infections include a heterogeneous group of cutaneous diseases.Cutaneous tuberculosis is usually the result of hematogenous dissemination or spread from underlying foci and it must be distinguished from tuberculids, resulting from the immunological reaction to Mycobacterium tuberculosis antigens. Leprosy prevalence was drastically reduced after introduction of multidrug therapy in the 1980 s, but cases are still reported due to underdiagnosis, and animal and environmental reservoirs. Recent advances concentrate in the diagnostic field. Specific guidelines for the treatment of nontuberculous mycobacteria skin infections are missing and surgical procedures may be required. Prognosis is better as compared to nontuberculous mycobacteria lung disease. Rapid laboratory-confirmed diagnosis of Buruli ulcer may be achieved by the IS2404 PCR. Among new drugs, telacebec is promising in terms of potency, shorter duration and tolerability in animal studies. A clinical trial in humans is planned. SUMMARY Mycobacterial cutaneous lesions are nonpathognomonic and clinical suspicion must be confirmed by culture or molecular detection. Long-course multidrug treatment is required based on susceptibility tests. Surgical intervention may also be required. Rehabilitation and psychosocial support reduce long-term physical and mental consequences mostly in Buruli ulcer and leprosy.
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Al Bulushi Y, Saint-Martin C, Muthukrishnan N, Maleki F, Reinhold C, Forghani R. Radiomics and machine learning for the diagnosis of pediatric cervical non-tuberculous mycobacterial lymphadenitis. Sci Rep 2022; 12:2962. [PMID: 35194075 PMCID: PMC8863781 DOI: 10.1038/s41598-022-06884-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/09/2022] [Indexed: 01/01/2023] Open
Abstract
Non-tuberculous mycobacterial (NTM) infection is an emerging infectious entity that often presents as lymphadenitis in the pediatric age group. Current practice involves invasive testing and excisional biopsy to diagnose NTM lymphadenitis. In this study, we performed a retrospective analysis of 249 lymph nodes selected from 143 CT scans of pediatric patients presenting with lymphadenopathy at the Montreal Children's Hospital between 2005 and 2018. A Random Forest classifier was trained on the ten most discriminative features from a set of 1231 radiomic features. The model classifying nodes as pyogenic, NTM, reactive, or proliferative lymphadenopathy achieved an accuracy of 72%, a precision of 68%, and a recall of 70%. Between NTM and all other causes of lymphadenopathy, the model achieved an area under the curve (AUC) of 89%. Between NTM and pyogenic lymphadenitis, the model achieved an AUC of 90%. Between NTM and the reactive and proliferative lymphadenopathy groups, the model achieved an AUC of 93%. These results indicate that radiomics can achieve a high accuracy for classification of NTM lymphadenitis. Such a non-invasive highly accurate diagnostic approach has the potential to reduce the need for invasive procedures in the pediatric population.
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Affiliation(s)
- Yarab Al Bulushi
- Augmented Intelligence and Precision Health Laboratory (AIPHL), Department of Radiology and the Research Institute of McGill University Health Centre, 5252 Boulevard de Maisonneuve O, Montréal, QC, H4A 3S9, Canada
- Department of Radiology, McGill University Health Centre, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
- Department of Radiology, Stanford University, Stanford, CA, 94305, USA
| | - Christine Saint-Martin
- Department of Radiology, McGill University Health Centre, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Nikesh Muthukrishnan
- Augmented Intelligence and Precision Health Laboratory (AIPHL), Department of Radiology and the Research Institute of McGill University Health Centre, 5252 Boulevard de Maisonneuve O, Montréal, QC, H4A 3S9, Canada
| | - Farhad Maleki
- Augmented Intelligence and Precision Health Laboratory (AIPHL), Department of Radiology and the Research Institute of McGill University Health Centre, 5252 Boulevard de Maisonneuve O, Montréal, QC, H4A 3S9, Canada
| | - Caroline Reinhold
- Augmented Intelligence and Precision Health Laboratory (AIPHL), Department of Radiology and the Research Institute of McGill University Health Centre, 5252 Boulevard de Maisonneuve O, Montréal, QC, H4A 3S9, Canada
- Department of Radiology, McGill University Health Centre, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Reza Forghani
- Augmented Intelligence and Precision Health Laboratory (AIPHL), Department of Radiology and the Research Institute of McGill University Health Centre, 5252 Boulevard de Maisonneuve O, Montréal, QC, H4A 3S9, Canada.
- Department of Radiology, McGill University Health Centre, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada.
- Radiomics and Augmented Intelligence Laboratory (RAIL), Department of Radiology and Division of Medical Physics, University of Florida, PO Box 100374, Gainesville, FL, 32610-0374, USA.
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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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Ford TJ, Silcock RA, Holland SM. Overview of nontuberculous mycobacterial disease in children. J Paediatr Child Health 2021; 57:15-18. [PMID: 33404128 DOI: 10.1111/jpc.15257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/27/2020] [Accepted: 10/21/2020] [Indexed: 11/27/2022]
Abstract
Nontuberculous mycobacteria (NTM) are ubiquitous organisms in our surrounding environment. Four distinct clinical syndromes associated with NTM infection have been described: skin and soft tissue disease, lymphadenitis, disseminated disease and pulmonary disease. In children, lymphadenitis is the most common NTM clinical entity, particularly affecting those aged 1-5 years who have no known risk factors for disease. Optimal management of NTM lymphadenitis is not entirely clear, although surgical intervention is likely a definitive therapy. Disseminated NTM disease is uncommon and only seen in the setting of immunocompromise. In previously well children, this presentation should always lead to consideration of an underlying immune defect, such as Mendelian susceptibility to mycobacterial disease. Identification of the underlying cause enables more targeted therapy and better prognostic understanding. Pulmonary NTM disease is fundamentally different to the other clinical syndromes, presenting in different hosts, who have different comorbidities, and follow a different clinical course.
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Affiliation(s)
- Timothy J Ford
- Department of Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Robyn A Silcock
- Infection Management and Prevention Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Steven M Holland
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States
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