Incidence rate of nontuberculous mycobacterial disease in immunocompetent children: a prospective nationwide surveillance study in Germany

Regional differences in admissions and surgical management of pediatric nontuberculous mycobacterial cervicofacial lymphadenitis

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.

Epidemiological assessment of non-tuberculous mycobacterial cervicofacial lymphadenitis: A PHIS database study

OBJECTIVE

Cervicofacial lymphadenitis caused by non-tubercular mycobacterial (NTM) infections has the highest infection rate in children. Our objective was to assess patient demographics, treatment methods, and the impact of weather and geography on the incidence of disease in patients with NTM cervicofacial lymphadenitis.

METHODS

The Pediatric Health Information System (PHIS) database was queried for data on all patients diagnosed with concurrent cervicofacial lymphadenopathy and NTM infection from 2004 to 2022. We assessed the association between weather patterns and NTM cervicofacial lymphadenitis by collecting monthly weather data from the NOAA National Center for Environmental Information. Incidence rates were calculated by dividing the number of cases by the total hospital discharges during the study period.

RESULTS

Among 47 PHIS hospitals, there were 992 diagnoses of NTM cervicofacial lymphadenitis. The average age at diagnosis was 2 [IQR, 2-4], with 59 % female. Drainage of skin abscesses or lesions was performed for 93 (9.4 %) patients, while 15 (1.5 %) had an excisional procedure of the CPT codes assessed. The most common antibiotics utilized were cephalosporins (28 %), macrolides (27 %), and rifampin (12 %). The most common treatment method was surgery with antibiotics (37 %) followed by no treatment at all (35 %), surgery alone (17 %), and antibiotics alone (10 %). Of the 28 states included in the analysis, Washington (IR: 3.5) and Nebraska (IR: 3.3) had the highest incidence rates (IR) of NTM cervical lymphadenitis. The cases were relatively equally distributed across the different weather seasons within each U.S. geographic region. However, the overall average wind speed was weakly associated with increasing the risk of diagnosis when utilizing a mixed effect zero-inflated negative binomial model (Incidence Ratio: 1.07, 95 % CI: (1.01-1.14), p = 0.035).

CONCLUSIONS

Our results indicate that the most common treatment method utilized in patients within our cohort with NTM cervicofacial lymphadenitis was the concurrent use of surgery and antibiotics. Our results also indicate there may be variation in the incidence rate among different states, but additional studies are needed as our cohort only included approximately 50 % of states within the U.S.

Nontuberculous mycobacterial disease in children: A systematic review and meta-analysis

Background

The prevalence of nontuberculous mycobacterial (NTM) disease in children is increasing worldwide. The clinical manifestations of pediatric NTM patients are significantly different from those of adult patients, but the knowledge of the disease is generally poor.

Methods

English databases (PubMed, Web of Science, Embase, BIOSIS) and Chinese databases (CNKI, Wanfan, VIP) were searched on October 15th, 2022. All the articles of cross-sectional and cohort studies reporting the species composition and lesion site of the NTM disease in children using well-recognized NTM species identification methods were taken into account. Using a random effects model, we assessed the disease lesion sites and the prevalence of different NTM species in pediatric NTM disease. Sources of heterogeneity were analyzed using Cochran's Q and the I2 statistic. All analyses were performed using CMA V3.0.

Results

The prevalence rates of NTM disease in children ranged between 0.6 and 5.36/100,000 in different countries, and Europe reported the highest prevalence rate. The most common clinical lesion site was lymph node, accounting for 71.1 % (55.0 %-83.2 %), followed by lung (19.3 %, 9.8%-34.4 %）and then skin and soft tissue (16.6 %,13.5%-20.3 %). Mycobacterium avium complex (MAC) was the most isolated NTM pathogen in children, accounting for 54.9 % (39.4%-69.6 %). Inconsistent with adult patients, Mycobacterium avium accounted for a dominant proportion in MAC than Mycobacterium intracellulare.

Conclusions

The lymph node was the most affected organ in pediatric NTM disease, while Mycobacterium avium was the most isolated pathogenic species in children.

Prevalence and Characteristics of Non-tuberculous Mycobacteria (NTM) Infection in Recipients of Allogeneic Hematopoietic Stem Cell Transplantation: a Systematic Review and Meta-analysis

PURPOSE

Non-tuberculous mycobacteria (NTM) infections in hematopoietic stem cell transplantation (HSCT) recipients represent a diagnostic and therapeutic challenge. Here, we aimed to review and analyze current literature on incidence, clinical presentation, and outcome of NTM infection after allogeneic HSCT.

METHODS

We performed a systematic review and meta-analysis of available literature regarding NTM infection in children and adults receiving allogeneic HSCT.

RESULTS

We identified 56 articles eligible for the analysis. Among 15 studies, describing 15,798 allogeneic HSCT, we estimated a prevalence of 1.26% (95% CI 0.72, 1.93) of NTM after transplant. Analysis of 175 patients with NTM infection showed a median time of diagnosis of 318 days after HSCT, an increased prevalence in adults (82.9%), and a most frequent pulmonary involvement (44%). Comparison between children and adults revealed an earlier post-transplant disease onset (median 130 days vs 287 days) and most frequent non-pulmonary presentation in children. A vast heterogeneity of therapeutic approach reflected the lack of universal recommendations regarding drug combination and duration of therapy. Overall, NTM-related mortality accounted for 33% in this systematic review.

CONCLUSION

Although rare, NTM infections can complicate post-transplant course with a high mortality rate in children and adults. The lack of prospective studies and guidelines prevents identification of risk factors and therapeutic recommendations.

Current management of cervicofacial nontuberculous mycobacterial infections in the pediatric population

PURPOSE OF REVIEW

The purpose of this review is to analyze and consolidate recently published literature to provide updated guidelines on the diagnosis and management of nontuberculous mycobacterial lymphadenitis (NTM LAD) in the pediatric population and to suggest areas of further research.

RECENT FINDINGS

Diagnosis of NTM LAD relies on a detailed clinical history, physical examination, laboratory tests, and imaging techniques. Treatment strategies vary widely, with a shift towards complete surgical excision being observed due to its higher cure rate, improved aesthetic outcomes, and lower recurrence rates. However, patient-specific factors must be considered. The role of genetic factors, such as Mendelian susceptibility to mycobacterial disease (MSMD), is being increasingly recognized and could lead to targeted therapies.

SUMMARY

Despite strides in the understanding and management of NTM LAD, substantial gaps remain in key areas such as the role of diagnostic imaging, optimal treatment parameters, postoperative care, and surveillance strategies. In this article, we explain our approach to NTM using the most relevant evidence-based medicine while offering directions for future work.

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.

Interferon-Gamma Release Assays Differentiate between Mycobacterium avium Complex and Tuberculous Lymphadenitis in Children

OBJECTIVES

To assess the performance of interferon-gamma release assays (IGRAs) in the differential diagnosis between Mycobacterium avium complex (MAC) and tuberculosis (TB) in children affected with subacute/chronic submandibular/cervical lymphadenitis.

STUDY DESIGN

Multicenter observational study comparing children with microbiologically confirmed MAC lymphadenitis from the European NontuberculouS MycoBacterial Lymphadenitis in childrEn study with children with TB lymphadenitis from the Spanish Network for the Study of Pediatric TB database.

RESULTS

Overall, 78 patients with MAC and 34 with TB lymphadenitis were included. Among MAC cases, 44 out of 74 (59.5%) had positive tuberculin skin test (TST) results at the 5-mm cut-off, compared with 32 out of 33 (97%) TB cases (P < .001); at the 10-mm cut-off TST results were positive in 23 out of 74 (31.1%) vs 26 out of 31 (83.9%), respectively (P < .001). IGRA results were positive in only 1 out of 32 (3.1%) patients with MAC who had undergone IGRA testing, compared with 21 out of 23 (91.3%) TB cases (P < .001). Agreement between TST and IGRA results was poor in MAC (23.3%; κ = 0.017), but good in TB cases (95.6%; κ = 0.646). IGRAs had a specificity of 96.9% (95% CI 84.3%-99.8%), positive predictive value of 95.4% (95% CI 78.2%-99.8%), and negative predictive value of 93.9% (95% CI 80.4%-98.9%) for TB lymphadenitis.

CONCLUSIONS

In contrast to TST, IGRAs have high specificity, negative predictive value, and positive predictive value for TB lymphadenitis in children with subacute/chronic lymphadenopathy, and consequently can help to discriminate between TB and MAC disease. Therefore, IGRAs are useful tools in the diagnostic work-up of children with lymphadenopathy, particularly when culture and polymerase chain reaction results are negative.

Diagnosis of nontuberculous mycobacterial lymphadenitis: the role of fine-needle aspiration

Nontuberculous mycobacterial lymphadenitis often presents a diagnostic challenge. This study aimed to evaluate the role of fine-needle aspiration cytology in the diagnosis of nontuberculous mycobacterial lymphadenitis in children. We conducted a retrospective review of fine-needle aspiration cytology performed in patients < 17 year-old with subacute lymphadenitis from 2003 to 2016 in a tertiary hospital in Spain. Confirmed nontuberculous mycobacterial lymphadenitis (isolation of nontuberculous mycobacterial in culture from fine-needle aspiration cytology or biopsy samples) and probable nontuberculous mycobacterial lymphadenitis ("granulomatous inflammation" in cytopathologic examinations from fine-needle aspiration cytology or biopsy and clinical-epidemiological history compatible with nontuberculous mycobacterial) were selected. Forty-one patients with nontuberculous mycobacterial lymphadenitis were included: 14 confirmed and 27 probable. Fine-needle aspiration cytology was done in all of them. For 34 patients with excised lymphadenopathy, cytopathology from fine-needle aspiration cytology was concordant with biopsy in 100% cases. Culture results were available from 78.0% (32/41) of patients with fine-needle aspiration cytology and from 85.3% (29/34) with excisional biopsy. Among 22 patients with microbiological results from fine-needle aspiration cytology and biopsy, fine-needle aspiration cytology allowed advanced results in concordance with biopsy or with positive isolation not found in biopsy in 90.1% (20/22) of patients. Sensitivity of nontuberculous mycobacterial cultures obtained by fine-needle aspiration cytology compared to biopsy was 45.5% vs. 36.4% (p = 0.07). Two patients with previous skin alterations presented fistulas after fine-needle aspiration cytology (4.9%); no other complications were described.Conclusion: Fine-needle aspiration cytology provides quick cytopathologic information and is an accurate and safe technique for the diagnosis of nontuberculous mycobacterial lymphadenitis, especially in cases with challenging work-up. What is Known: • Nontuberculous mycobacterial (NTM) infection is an important cause of subacute lymphadenitis in children. • Fine-needle aspiration cytology (FNAC) is an available technique for the diagnosis of lymphadenitis of unknown etiology. What is New: • FNAC is an accurate and safe technique for the diagnosis of NTM lymphadenitis in children. • FNAC can provide reliable samples for cytopathological studies and even a better sensitivity for microbiological culture than excisional biopsy in the study of suspected NTM lymphadenitis.

Risk Factors for Complicated Lymphadenitis Caused by Nontuberculous Mycobacteria in Children

Nontuberculous mycobacteria (NTM) are an emerging cause of infections, including chronic lymphadenitis in children. To identify risk factors for NTM lymphadenitis, particularly complicated disease, we collected epidemiologic, clinical, and microbiological data on 138 cases of NTM lymphadenitis in children across 13 centers in Germany and Austria. We assessed lifestyle factors but did not identify specific risk behaviors. We noted that more cases of NTM lymphadenitis occurred during cold months than during warm months. Moreover, we noted female sex and age <5.5 years as potential risk factors. Complete extirpation of the affected lymph node appeared to be the best therapeutic measure. We integrated the study data to develop a simple risk score to predict unfavorable clinical outcomes for NTM lymphadenitis.

General Overview of Nontuberculous Mycobacteria Opportunistic Pathogens: Mycobacterium avium and Mycobacterium abscessus

Nontuberculous mycobacteria (NTM) are emerging human pathogens, causing a wide range of clinical diseases affecting individuals who are immunocompromised and who have underlying health conditions. NTM are ubiquitous in the environment, with certain species causing opportunistic infection in humans, including Mycobacterium avium and Mycobacterium abscessus. The incidence and prevalence of NTM infections are rising globally, especially in developed countries with declining incidence rates of M. tuberculosis infection. Mycobacterium avium, a slow-growing mycobacterium, is associated with Mycobacterium avium complex (MAC) infections that can cause chronic pulmonary disease, disseminated disease, as well as lymphadenitis. M. abscessus infections are considered one of the most antibiotic-resistant mycobacteria and are associated with pulmonary disease, especially cystic fibrosis, as well as contaminated traumatic skin wounds, postsurgical soft tissue infections, and healthcare-associated infections (HAI). Clinical manifestations of diseases depend on the interaction of the host's immune response and the specific mycobacterial species. This review will give a general overview of the general characteristics, vulnerable populations most at risk, pathogenesis, treatment, and prevention for infections caused by Mycobacterium avium, in the context of MAC, and M. abscessus.

Cervicofacial non-tuberculous mycobacterial lymphadenitis: clinical determinants of incomplete surgical removal

In patients with non-tuberculous mycobacterial cervicofacial lymphadenitis, incomplete surgical removal of infected lymph nodes leads to delayed healing and a higher recurrence rate, with eventual spontaneous drainage through the skin. However, complete surgical removal is not always achievable due to the extent of the infected tissue and proximity to vulnerable structures, such as the facial or accessory nerve. The aim of this study was to identify the clinical determinants of the (in)ability to perform complete surgical removal. The electronic health records of patients aged 0-15 years with bacteriologically proven non-tuberculous mycobacterial cervicofacial lymphadenitis, who underwent surgical treatment and preoperative sonographic imaging, were analysed. This was a case-control study. A total of 103 patients met the inclusion criteria. Most of the infections were unilateral, submandibular, and caused by Mycobacterium avium. Multiple logistic regression analysis revealed that higher age (odds ratio 1.24, 95% confidence interval 1.04-1.47) and fistulization (odds ratio 3.15, 95% confidence interval 1.13-8.75) were significantly associated with a limited ability to surgically remove all infected tissue. However, a larger sonographic lymph node size was not significantly associated. These findings could aid clinicians when informing the parent(s)/guardian(s) of the patient preoperatively and in properly estimating the intraoperative and postoperative course.

Nontuberculous mycobacterial infections in a Brazilian pediatric population: a seven-year survey

The aim of this study was to describe the frequency of nontuberculous mycobacteria (NTM) isolation and their related outcomes among pediatric patients of a Brazilian university hospital from 2012 to 2019. NTM were identified in different clinical samples by microbiological culture and molecular-based methods. NTM were isolated from 14 patients, out of whom four (27%) were infected and were treated accordingly. Two were infected with Mycobacterium avium complex (MAC), two with M. abscessus complex (MABSC) and one with M. intracellulare. Two patients had cystic fibrosis-related lung disease and improved after successful NTM eradication. One patient was HIV-positive and died. One patient had severe combined immunodeficiency (SCID)-related pneumonia and is currently being followed-up. We conclude that NTM frequency in our center was low among pediatric patients. Whether this is inherent to Brazilian patients, due to the broad coverage of the Bacille Calmette-Guérin (BCG) vaccine in Brazil, or a result of underdiagnosis remains to be elucidated.

Childhood nontuberculous mycobacterial lymphadenitis-observation alone is a good alternative to surgery

OBJECTIVE

Cervicofacial lymphadenitis caused by nontuberculous mycobacteria (NTM) is commonly treated with surgery or antimicrobial therapy. The aim of this study was to analyze the utility of our new blood-based diagnostic method and the treatment protocol, surgery or observation alone, in NTM lymphadenitis in children.

METHODS

All patients under 16 years of age with cervicofacial NTM lymphadenitis diagnosed and treated at Children's Hospital or at the Department of Otorhinolaryngology, Helsinki University Hospital (Helsinki, Finland) in 2007-2017 were retrospectively reviewed.

RESULTS

Fifty-two patients, 33 (63%) of whom were girls, were included in the study. The median age at initial presentation of the NTM lymphadenitis was 2.9 years. The novel blood-test had been performed on 49 (94%) of the patients and in all of them it was indicative of NTM infection. A sample for mycobacterial culture was available from 34 patients, and Mycobacterium avium was the most common species detected. Most patients (n = 33, 63%) were treated conservatively with observation alone. Of these, nine patients (27%) did not develop a skin fistula, and the lymphadenitis resolved without drainage.

CONCLUSIONS

The novel blood test is clinically feasible method for diagnosing childhood cervicofacial NTM lymphadenitis noninvasively. Observation alone is a good alternative to surgery, without the risk of complications.

Increase in Childhood Nontuberculous Mycobacterial Infections After Bacille Calmette-Guérin Coverage Drop: A Nationwide, Population-Based Retrospective Study, Finland, 1995-2016

Background

Epidemiological data on childhood nontuberculous mycobacterial (NTM) disease is scarce and the protective effect of bacille Calmette-Guérin (BCG) vaccination remains debated. In 2006, the BCG policy in Finland changed from universal to selective. We aimed to study the effect of the BCG coverage decrease on the incidence of childhood NTM infections in Finland.

Methods

We conducted a nationwide, population-based, retrospective study of NTM notifications recorded to the National Infectious Diseases Register between 1995 and 2016 and identified native-born children aged 0-4 years infected with NTM. Poisson log-linear model was used to estimate the change in the incidence rate of cohorts born during universal or selective BCG policy between 1995 and 2015.

Results

We identified 97 native-born children aged <5 years infected with NTM (median age, 27 months; female-to-male ratio, 2:1). The most common species was Mycobacterium avium (n = 69 [71%]). The estimated incidence rates of NTM in universal-BCG and selective-BCG cohorts were 0.2 and 3.9 per 100000 person-years, respectively. The incidence rate ratio of selective-BCG cohorts compared to universal-BCG cohorts was 19.03 (95% confidence interval, 8.82-41.07; P < .001).

Conclusions

After infant BCG coverage in Finland decreased, childhood NTM infections increased drastically. As there is no other apparent cause for the increase, this indicates that BCG offers protection against childhood NTM disease. This observation adds to the understanding of childhood NTM epidemiology and might explain why the disease is emerging in some countries.

Socio-Economic and Environmental Factors Related to Spatial Differences in Human Non-Tuberculous Mycobacterial Diseases in the Czech Republic

Non-tuberculous mycobacteria (NTM) are ubiquitous environmental bacteria that can induce pulmonary and non-pulmonary diseases in susceptible persons. It is reported that the prevalence of NTM diseases is increasing in developed countries, but this differs by regions and countries. NTM species distribution and the rate of diseases caused by NTM vary widely in the historical territories of Moravia and Silesia (Czech Republic). This epidemiologic study of NTM diseases covers the period 2012–2018, reviews isolates obtained from patients with clinical disease and investigates correlations with related socio-economic and environmental factors. Individual NTM patients were included only once during the studied period and results were presented as incidence rate per year. The most frequently isolated NTM meeting the microbiological and clinical criteria in the study were the Mycobacterium avium-intracellulare complex, followed by Mycobacterium kansasii and Mycobacteriumxenopi. A previously described endemic incidence of M.kansasii in the Karviná district and M.xenopi in the Ostrava district was also observed in this study. The incidence of NTM patients in the whole studied territory was 1.10/100,000 inhabitants (1.33/100,000 in men and 0.88/100,000 in women). The annual incidence of lymphadenitis in children (≤5 years of age) was 2.35/100,000 of the population of children during the 7 year period but increased in the year 2018 to 5.95/100,000. The rate of human tuberculosis in the studied area was 1.97/100,000 inhabitants. The incidence of NTM pulmonary diseases correlated with a lower socio-economic status (r = 0.63) and a higher concentration of benzo[a]pyrene pollution in the air (r = 0.64).

Burden of non-tuberculous mycobacterial diseases in Saudi Arabian children: The first nationwide experience

BACKGROUND

Non-tuberculous mycobacteria (NTM) causing pulmonary and extra-pulmonary diseases are increasing worldwide. A large paucity of data related to pediatric NTM diseases exists globally and particularly in Saudi Arabia.

METHODS

The first nationwide exploratory study on existence of NTM diseases among Saudi Arabian children (0-14 years old) has been carried out during 2016-2017. Suspected NTM isolates with clinical and demographical data were enrolled from regional reference laboratories. Species level identification of isolates was carried out by commercial line probe assays and gene sequencing.

RESULTS

In 12 months, 52 culture positive cases with 44(84.6%) confirmed disease incidences were identified. Demographically, Saudi nationals (86.5%) were dominated and 77.3% cases have different comorbid conditions. Lymphadenitis (40.4%) followed by 26.9% of pulmonary cases with 42.8% of confirmed clinical relevance were mainly reported. Species identification showed Mycobacterium simiae (31.8%), M. abscessus (23.1%) and nine other species including rarely encountering M. riyadhense. Ascites caused by M. monacense, pulmonary disease caused by M. riyadhense and M. monacense were rarest clinical events and reported for the first time globally in a pediatric cohort.

CONCLUSIONS

Diverse NTM diseases even in immunocompetent children are an upcoming challenge in Saudi Arabia. Lack of awareness on NTM disease must be addressed with immediate development of management plans.

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.

Diagnosing nontuberculous mycobacterial cervicofacial lymphadenitis in children: A systematic review

OBJECTIVES

Widespread controversy exists regarding correct diagnosing nontuberculous mycobacterial cervicofacial (NTM) lymphadenitis. This study intends to gather the available evidence with respect to diagnosing NTM cervicofacial lymphadenitis.

METHODS

A review protocol was developed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)-statement (www.prisma-statement.org). A comprehensive search was performed in the bibliographic databases PubMed, Embase.com and Wiley/Cochrane Library. 10 Articles fulfilled the inclusion criteria and were included in the review. Assessing risk of bias of the articles was done using the revised Quality Assessment of Diagnostic Accuracy (QUADAS-2) tool.

RESULTS

This systematic review shows that diagnostic studies of high methodological quality are scarce. Diagnostic accuracy of polymerase chain reaction (PCR), culture, skin testing, auramine staining, Ziehl-Neelsen staining, and immunodiagnostic assays was studied. Culture sensitivity proved to be 41,8%, while polymerase chain reaction has a sensitivity of 71,6%. Both methods showed a specificity of 100%. Sensitivity of Immunodiagnostic assays ranged between 87,5% and 100% and specificity between 81% and 100%. Overall sensitivity of skin tests containing purified protein derivative (PPD-S) was 70% (95% CI [62%-78%]) with an overall specificity of 94% (95% CI [88%-100%]).

CONCLUSIONS

In patients with a high clinical suspicion for NTM cervicofacial lymphadenitis, a positive PPD-S skin is indicative for the diagnosis of NTM cervicofacial lymphadenitis. Either PCR or culture is necessary to confirm the diagnosis. Interferon-γ release assays with purified protein derivative stimulation appear to provide good sensitivity and specificity as a non-invasive pre-operative test, but the evidence is weak. More studies of high methodological quality are needed to validate the results of this systematic review.

Mycobacterium abscessus Infections in Children: A Review of Current Literature

There is limited literature on Mycobacterium abscessus infections in children and limited data about its diagnosis and management. The incidence of infections due to M abscessus appears to be increasing in certain populations and can be a significant cause of morbidity and mortality.Management of these infections is challenging and relies on combination antimicrobial therapy and debridement of diseased tissue, depending on the site and extent of disease. Treatment regimens often are difficult to tolerate, and the antimicrobials used can cause significant adverse effects, particularly given the long duration of therapy needed.This review summarizes the literature and includes information from our own institution's experience on pediatric M abscessus infections including the epidemiology, transmission, clinical manifestations, and the management of these infections. Adult data have been used where there are limited pediatric data. Further studies regarding epidemiology and risk factors, clinical presentation, optimal treatment, and outcomes in children are necessary.

Nontuberculous mycobacterial disease in childhood - update on diagnostic approaches and treatment

Recent studies suggest that the incidence of nontuberculous mycobacterial infections in children may be increasing. Nontuberculous mycobacterial lymphadenitis, skin and soft tissue infection, and pulmonary disease each present unique challenges in relation to diagnosis and treatment. In this update, we critically review the recent literature on the epidemiology, clinical features, diagnostic approaches and treatment of nontuberculous mycobacterial disease in children. In addition, we outline key areas warranting further research.

Pinpointing the source of infection of Mycobacterium avium hominissuis in children

Mycobacterium avium hominissuis is the most important causative agent of chronic nontuberculous lymphadenitis in children. Despite a ubiquitous occurrence of the bacteria in the environment, the disease is a rare entity, and so far no source of infection has been formally identified. The current state of knowledge regarding possible sources of M. avium hominissuis, especially where children are concerned, is summarized here. An analysis of the seasonal variation of M. avium lymphadenitis in children leads to a new hypothesis regarding the probable source of infection of M. avium hominissuis, where global trade of alimentary products might be involved.

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.

Osteomyelitis Because of Mycobacterium Xenopi in an Immunocompetent Child

We present the case of a 6-year-old, immunocompetent boy with chronic osteomyelitis of the calcaneus caused by Mycobacterium xenopi. Of note, typical histopathology was not visible on the first biopsy and developed only later over a period of 6 weeks, highlighting the difficult differential diagnosis of osteomyelitis caused by nontuberculous mycobacteria.

[Diagnosis of infectious lymphadenitis]

Adenitis is a common disorder requesting numerous medical specialties. Etiologies are dominated by viral and bacterial infections, and more rarely parasitic, or by neoplastic and inflammatory diseases. Nevertheless, etiology remains often unknown and invasive tests may be required. On nodal tissue sample, histological examination, culture and polymerase chain reaction (PCR) are realized. PCR has revolutionized the diagnostic approach and consequently, knowledge of infectious lymphadenopathy. Previously, staphylococcus, streptococcus and mycobacterium were the main infectious agents identified in lymph nodes. Since its use, new emergent microorganisms responsible of lymphadenitis have been identified. Bartonella henselae, responsible of cat scratch disease, is to date the infectious agent most often encountered in adenitis. Mycobacterium avium subsp. hominisuis has been recently described as responsible of children lymphadenitis. PCR has become an essential tool in the diagnostic process of infectious lymphadenitis. Here, we propose a literature review on infectious adenitis and we emphasize the diagnostic strategy of adenitis.

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.

[Surgical treatment of children with nontuberculous mycobacteria cervical lymphadenitis]

BACKGROUND

Persistent cervical lymphadenopathy is the typical clinical manifestation of nontuberculous mycobacterial (NTM) infection in otherwise healthy children 1-5 years of age. A positive NTM culture or PCR is necessary to proof the diagnosis. In the case of localized disease, cervical lymphadenectomy simultaneously serves both diagnosis and therapy. A typical complication of surgical treatment, i.e. incision, puncture or excision, is the formation of a fistula, which then requires further surgical intervention. In the case of an unconfirmed diagnosis, the extent of the initial surgical intervention remains unclear.

PATIENTS AND METHODS

On the basis of this diagnosis, 17 operations were performed in 10 children under the age of 7 years (8 female, 2 male; age 17 months to 5 years, median 36 months) in the Charité ENT clinics between 2009 and 2012. Clinical course and diagnostics, as well as the results of therapies and treatments were retrospectively analysed.

RESULTS

Duration of anamnesis prior to initial surgery was 2-30 weeks (mean 10.4 weeks). A second intervention was performed in 7 out of 10 patients. No patient developed recurrent disease after selective cervical lymphadenectomy. The clinical course of 1 patient was complicated by a cefuroxime-responsive Staph. aureus superinfection. A second patient experienced transient accessory nerve paresis after lymphadenectomy, which resolved 2 months after the second surgery.

CONCLUSION

In case of persistent cervical lymphadenopathy a complete diagnostic workup is necessary. If lymphadenopathy continues to persist 1 month after a 10-day course of broad-spectrum antibiotics, a selective cervical lymphadenectomy should be performed. In order to avoid the development of fistulae and avoid secondary surgical procedures, incision, drainage and puncture should be deferred.

Abundance of Mycobacterium avium ssp. hominissuis in soil and dust in Germany - implications for the infection route

The nontuberculous mycobacteria (NTM) are a heterogeneous group of bacteria found in soil, water and dust. The spread of NTM infection depends on the exposure to reservoirs with high proportions of mycobacteria, the virulence of the NTM strains, the enhanced sensitivity to infections such as those of immune-compromised hosts and patient risk factors such as Cystic Fibrosis. Since several decades, NTM lung disease has been increasingly observed in slender postmenopausal women. The most important NTM in Germany is Mycobacterium avium ssp. hominissuis (MAH). The routes of MAH infection are in almost all cases unknown, but water is often suspected as source of infection. We wanted to examine this hypothesis by determining the frequency of MAH in environmental samples of water, biofilms, soil and dust originating from Germany. We found MAH in 33% of the dust samples and 20% of the soil samples. No MAH could be isolated from water and biofilm. Dust and soil clearly presented more abundance of MAH in comparison with water and biofilms. Therefore, more attention should be paid to soil and dust in Germany as an important source of Myco. avium infections.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study was conducted to investigate the ecological abundance of the most prominent clinical nontuberculous mycobacteria (NTM) in Germany, the Mycobacterium avium ssp. hominissuis (MAH). Examination of soil, water, dust and biofilm samples revealed that MAH in Germany was predominant in soil and dust. No MAH was identified in water and biofilms. Our finding contributes to the identification of the environmental niche of this opportunistic pathogen and proposes soil and dust as sources of MAH infection in Germany.

Comparison of Mycobacterium lentiflavum and Mycobacterium avium-intracellulare complex lymphadenitis

BACKGROUND

Mycobacterium lentiflavum is considered a rare pathogen causing nontuberculous mycobacterial (NTM) lymphadenitis.

METHODS

A multicenter, retrospective study was performed in immunocompetent children <14 years of age with microbiologically confirmed NTM lymphadenitis treated at 6 hospitals in Madrid, Spain, during 2000-2010. We compared children with M. lentiflavum and Mycobacterium avium-intracellulare complex infection.

RESULTS

Forty-five microbiologically confirmed NTM lymphadenitis patients were identified: 19 (45.2%) caused by M. avium-intracellulare complex, 17 (40.5%) by M. lentiflavum, 1 by both and 5 by other mycobacteria. Out of 17 M. lentiflavum cases, 14 were diagnosed in the past 5 years. Regarding M. lentiflavum cases, median age was 23 months. Submandibular nodes were the most frequently involved (76.5%), with multiple locations seen in 41% of the children and spontaneous drainage in 41% of them. Drug susceptibility tests were performed in 14 isolates and showed a complete susceptibility to clarithromycin and cycloserine, whereas 93% were resistant to rifampin, 33% to quinolones and full resistance to other tested antimycobacterial drugs was detected. All but 1 child required surgery and 11 were treated additionally with various drug combinations. Total resolution was achieved in 50% of children within 6 months.Compared with M. avium-intracellulare complex cases, children were younger and laterocervical nodes were significantly less frequently involved. No statistically significant differences were found related to clinical characteristics, treatment and outcome.

CONCLUSIONS

M. lentiflavum is an emerging pathogen producing NTM lymphadenitis in Madrid.

Interferon-gamma inducible protein 10 as a biomarker for active tuberculosis and latent tuberculosis infection in children: a case-control study

BACKGROUND

Interferon-gamma (IFN-γ) release assays (IGRAs) are suboptimally sensitive to diagnose tuberculosis (TB) and latent TB infection (LTBI) in young children. In this study we compared Mycobacterium tuberculosis antigen-stimulated IFN-γ inducible protein 10 (IP-10) responses in children with active TB and LTBI to responses from children with non-tuberculous mycobacterial (NTM) lymphadenopathy and respiratory tract infection (RTI). We also assessed test agreement between IP-10 and the QuantiFERON(®)-TB Gold In-Tube (QFT-IT) test results, and investigated whether IP-10 release upon mitogen stimulation is associated with age.

METHODS

We recruited 48 children (median age 54 months) diagnosed in Germany with either active TB (n = 11), LTBI (n = 14), NTM lymphadenopathy (n = 8), or common RTI (n = 15). IFN-γ levels were measured using the QFT-IT. These plasma supernatants were used to determine IP-10 concentrations using an in-house enzyme-linked immunosorbent assay (ELISA).

RESULTS

The median antigen-stimulated IP-10 levels in children with active TB, LTBI, NTM lymphadenopathy, and RTI were 12,702 pg/ml, 9109 pg/ml, 97 pg/ml, and 84 pg/ml, respectively. We observed a strong correlation between IP-10 and IFN-γ plasma concentration in children with active TB and LTBI (r(2) = 0.69). Overall agreement between IP-10 and QFT-IT assays was high (kappa = 0.95). IP-10 levels after mitogen stimulation showed no association with age.

CONCLUSIONS

IP-10 and IFN-γ were both induced with antigen stimulation in blood from children in the TB and LTBI groups, in contrast to the NTM and RTI groups. Compared to IFN-γ the IP-10 levels were higher and IP-10 was released independently of age. IP-10 therefore may represent an additional biomarker in the paediatric population.

Blurring the lines in interferon {gamma} receptor deficiency: an infant with near-fatal airway disease

Deficiencies of the interferon γ (IFN-γ) pathway have become a well-recognized cause of nontuberculous mycobacterial infection. We report here a case of autosomal dominant IFN-γ receptor 1 (IFN-γ-R1) deficiency presenting at the unusually young age of 16 months with a severe clinical course. Mycobacterium avium complex was cultured from bronchial washings of a child who presented with primary endobronchial disease after a 4-month history of rhinorrhea, wheeze, and acute lobar consolidation. A maternal history of multifocal Mycobacterium kansasii osteomyelitis and cutaneous M avium complex led to genetic confirmation of IFN-γ-R1 818del4 deletion (a 4 base pair deletion at nucleotide position 818) in both family members. This case demonstrates the link between mycobacterial disease and IFN-γ pathway deficiency, the diagnosis of which facilitates more accurate therapy and genetic counseling. The case also raises questions about the reported distinct presentation, treatment, and prognosis of autosomal dominant and recessive IFN-γ-R1 phenotypes.