Treatment of non-tuberculous mycobacterial cervicofacial lymphadenitis in children: critical appraisal of the literature

Long-term outcome of nonsurgical treatment of nontuberculous mycobacterial cervicofacial lymphadenitis in children

OBJECTIVE

Chronic cervicofacial lymphadenitis in children is often caused by nontuberculous mycobacteria (NTM). Children with NTM infection who were not surgically treated were evaluated for long-term outcome with a follow-up of at least 10 years.

RESULTS

Among the 117 nonsurgically treated children, the median age was 46 months (range, 9-155 months), 56 were male (47.9%), and 61 were female (52.1%). Of the overall group, 75 received antibiotic therapy consisting of clarithromycin and rifabutin (64.1%), and for 54, observation (a wait-and-see approach) was chosen (46.2%). In 100 patients, treatment was considered successful (85%), with a median resolution of 24 (range, 11-134) weeks in the antibiotic group compared to 44.5 (range, 18-130) weeks in the wait-and-see group (P < .05). After 6 months, 58 patients in the antibiotic group were successfully treated (77%), whereas 42 patients of the wait-and-see group demonstrated complete resolution after a median observation time of 44.5 weeks (100%). In 10 patients who experienced complete resolution of the lymphadenitis, infection recurrence developed years later (10%).

CONCLUSION

Nonsurgical treatment of NTM infection can be considered an alternative in advanced and surgically challenging cases. However, healing will take months to years, and late recurrences are possible.

Clinical features and outcomes of lymphadenopathy in a tertiary children's hospital

AIM

The aim of the present study is to describe the clinical features and outcomes of childhood lymphadenopathy and to define factors able to predict neoplastic aetiology or may improve its prognosis.

METHODS

All children evaluated for lymphadenopathy in our tertiary children's hospital and who underwent their first examination between 1 January, 2015 and 31 December, 2017 were enrolled in this retrospective observational study. Data were analysed using SPSS.Statistics, 24.0.

RESULTS

A total of 322 children, aged between 0 and 18 years (median 4.5; interquartile range 2.5-9), were enrolled. A specific diagnosis was achieved in almost half of the cases (n = 159, 49.4%) by using one or more methods, including serological, microbiological, biomolecular or histological investigations on surgical samples. Epstein Barr virus and non-tuberculous mycobacteria were the most common etiological agents among acute/sub-acute and chronic lymphadenopathy, respectively. At the end of the study period, two-thirds (210, 65.2%) of enrolled patients were successfully treated. Malignancies and non-tuberculous mycobacteria infections had the longest time to resolution.

CONCLUSIONS

Our data suggest that lymphadenopathy is a benign condition in most cases. Of note in our study, 2.5% of lymphadenopathy cases were found to be due to oncologic conditions. The most frequent infective causes were Epstein Barr virus, bacteria and non-tuberculous mycobacteria infections. No haematic or ultrasonographic features were independently able to provide sufficient evidence for a conclusive diagnosis. However, utilising these findings alongside evaluation for clinical criteria can guide decision-making for physicians. Lymphadenectomy is the most appropriate process to follow in the event of chronic lymphadenopathy with undefined diagnosis.

[Cervical lymphadenitis caused by non-tuberculous mycobacteria in children with different residence]

OBJECTIVE

Atypical mycobacteria form a heterogeneous group. Although more than 140 species have been identified, only 25 of them are considered responsible for infection in humans. The most frequent manifestation of the disease in immunocompetent children is the cervical lymphadenitis. Aims of this study were to identify a correlation of the location of residence with patients' demographics and disease characteristics, to evaluate the ultrasonographic findings and the different operative treatments modalities and to develop an algorithm for the diagnosis and treatment.

MATERIALS AND METHODS

Cases were identified by using the hospital's correspondence, microbiology and pathology databases. Demographic and clinical data were collected. A statistical analysis of the results was performed.

RESULTS

32 patients were included. Our data revealed no significant correlation between area of residence and disease characteristics. Hypoechoic lymph nodes with intraglandular necrosis and low vascularity were observed in the majority of patients. Surgical treatment included abscess incision with biopsy, lymphadenectomy, selective neck dissection and partial parotidectomy. A recurrent disease was significantly more frequent after abscess incision.

CONCLUSIONS

Further studies with prospective design are required, in order to confidently identify the correlation between area of residence and disease characteristics. Similar ultrasonographic findings suggest a constant constellation of changes that facilitate diagnostic evaluation. Complete surgical excision offers an effective management option as it combines definitive treatment and histological confirmation with low risk of complications.

Surgical treatment of non-tuberculous mycobacterial lymphadenitis in children: Our experience and a narrative review

Non-tuberculous mycobacterial lymphadenitis (NTML) accounts for about 95% of the cases of head-and-neck mycobacterial lymphadenitis, and its prevalence has been increasing in the Western world. The diagnostic work-up can be challenging, and differential diagnoses such as tuberculous and suppurative lymphadenitis need to be considered. It may, therefore, not be diagnosed until the disease is in a late stage, by which time it becomes locally destructive and is characterized by a chronically discharging sinus. The treatment options include a medical approach, a wait-and-see policy, and surgery, with the last being considered the treatment of choice despite the high risk of iatrogenic nerve lesions. The aim of this article is to provide an overview of pediatric, head-and-neck NTML based on the literature and our own experience, with particular emphasis on the impact and limitations of surgery.

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.

Diseases caused by nontuberculous mycobacteria in Asia

 The isolation rate of nontuberculous mycobacteria (NTM) species and the prevalence of NTM-associated diseases are on the rise in Asian, as well as in Western countries; however, the species distribution of NTM isolates and the types of diseases caused by NTM species vary from region to region. In this review, we present an update on the epidemiology of NTM in Asia. We demonstrate that the distribution of NTM species varies within Asia and differs from that in North America and Europe. In addition, the clinical manifestations of NTM diseases include respiratory tract infections, disseminated infections, skin and soft tissue infections, lymphadenitis, empyema, ocular infections, CNS infections and genitourinary infections. Finally, the rate of adaptive resistance of anti-NTM antimicrobial agents remains high and may be associated with a poor outcome for patients with NTM diseases.

Cervical Lymphadenitis by Mycobacterium triplex in an Immunocompetent Child: Case Report and Review

Mycobacterium triplex was first described in 1996. This nontuberculous Mycobacterium causes a severe pulmonary disease in immunocompromised patients but it can involve also healthy patients. A literature search was made on the PubMed database and it produced only few cases of children with cervical lymphadenitis due to this Mycobacterium Triplex. We are describing a case of M. triplex cervical lymphadenitis in an immunocompetent child.

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.

Management of cervicofacial nontuberculous lymphadenitis in children

PURPOSE OF REVIEW

To review the body of literature on the treatment options for nontuberculous cervicofacial lymphadenitis in children, focusing on the most recent reports describing outcomes utilizing either observation alone, medical therapy or various forms of surgical intervention.

RECENT FINDINGS

Large studies have defined the time course of the disease and the safety and efficacy in treating nontuberculosis cervicofacial lymphadenitis with a wait-and-see approach.

SUMMARY

Nontuberculosis cervicofacial lymphadenitis is a disease with several stages that provides for various treatment options. All treatment regimens--wait-and-see approach, medical therapy, and surgical excision--have their risks and benefits. The current body of literature allows the otolaryngologist an assortment of treatment choices that permits him to tailor the treatment with an individualized approach for each family's preferences.

High recurrence rate of lymphadenitis due to nontuberculous mycobacteria and its association with concurrent Salmonella infection in Taiwan

BACKGROUND

The objective of this study is to investigate the clinical characteristics of lymphadenitis due to nontuberculous mycobacteria (NTM) in Taiwan.

METHODS

We retrospectively reviewed the medical records of all patients who presented to the National Taiwan University Hospital with culture-positive NTM lymphadenitis during the period 2000-2010. Patients with concurrent extranodal involvement were excluded.

RESULTS

From 2000 to 2010, 15 patients with lymphadenitis caused by nontuberculous mycobacteria were identified. Most patients (80%, n = 12) were infected with rapidly growing mycobacteria. Mycobacterium abscessus was the most common infective species (n = 8). Recurrence of infection involving multiple organs occurred 2-7 years after the completion of treatment in 11 (73%) patients. Five (33.3%) patients had concurrent Salmonella infections (4 patients with bacteremia and 1 patient with empyema thoracis) during the course of the disease.

CONCLUSION

In Taiwanese patients, we found a high recurrence rate of NTM lymphadenitis that was closely associated with Salmonella infections. We also noted that the clinical and epidemiological manifestations of NTM lymphadenitis in Taiwan differed from their manifestations in western countries.

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.

Nerve dysfunction following surgical treatment of cervical non-tuberculous mycobacterial lymphadenitis in children

AIM

To present our experience of nerve dysfunction following surgical treatment among 126 children with microbiologically verified non-tuberculous mycobacterial (NTM) lymphadenitis.

METHODS

We retrieved data from medical records, and a questionnaire with an invitation to a clinical follow-up was returned by 88 families.

RESULTS

The time from onset of symptoms to diagnosis was more than 3 months in 24% of subjects. Mycobacterium avium complex was isolated from 105, Mycobacterium malmoense from 12 and Mycobacterium scrofulaceum from one cervical lymph node. A total of 89% of the children underwent surgery and were examined in particular with regard to cranial motor nerve functions. Major persisting nerve dysfunction occurred in 3/51 (6%) children who underwent radical surgery, and minor dysfunction in seven (14%). In nine children, the marginal mandibular branch of the facial nerve was affected, and the accessory nerve was affected in one child. There were no neurological signs in 25 children treated with incision and drainage alone or in 12 followed with observation alone. Healing took >6 months in 2/76 (3%) surgically treated and 3/12 (25%) non-surgically treated children.

CONCLUSION

Considering the risk of nerve dysfunction following extirpation, incision with drainage and observation alone should both be included among the management options for cervical NTM lymphadenitis in children.