Nontuberculous mycobacterial cervical adenitis

Incidence of an Identifiable Organism in Children Who Underwent a Surgical Procedure for Granulomatous Cervical Lymphadenopathy

Objectives: The incidence of cervical lymphadenopathy due to nontuberculous mycobacteria is rising in the pediatric population. Our goal with this study was to review the number of pediatric patients with granulomatous cervical adenitis and determine the incidence of identification of a specific organism as both healthcare providers and parents are interested in identifying the causative pathogen. Methods: A retrospective chart review was conducted of patients at a high-volume tertiary care children's hospital between 2017 and 2023. Children were included if they underwent a surgical procedure for lymphadenopathy. Pathology, microbiology, and other laboratory reports were reviewed to document the presence of granulomatous cervical adenitis and the incidence of identification of a specific organism. Additional data collected included patient demographics and type of procedure. Results: Of the 1538 charts reviewed, 163 patients underwent an inclusionary procedure. Mean patient age was 10.7 years (range 2.4 months-20 years), 70 (43%) were female, 25 (15%) had granulomatous cervical adenitis, and a specific organism was identified in 9 of these. Conclusion: Despite the availability of a number of ancillary tests, our data demonstrate that the identification of a specific pathogen in cases of granulomatous cervical lymphadenitis is rare. As a result, physicians should be prepared to rely primarily on the history and physical exam findings to determine a working diagnosis as well as a medical and/or surgical treatment plan.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Diagnostic challenges in cervical tuberculous lymphadenitis: A review

Tuberculosis is a very serious disease and incidence is once again on the rise. Lymph node tuberculosis is one of the most common extrapulmonary manifestations of tuberculosis. In differential diagnosis of chronic, painless cervical lymphadenopathy, cervical tuberculous lymphadenitis should be kept in mind. A high index of suspicion is needed for diagnosis of tuberculous lymphadenitis, which is known to mimic a number of pathological conditions. This article reviews epidemiology, clinical manifestations, and diagnostic techniques for cervical tuberculous lymphadenitis.

Complex nontuberculous mycobacterial cervicofacial lymphadenitis: What is the optimal approach?

OBJECTIVES/HYPOTHESIS

Assess the role of combined antimicrobial and surgical therapy for difficult-to-treat nontuberculous mycobacteria (NTM) lesions of the head and neck in children.

STUDY DESIGN

Retrospective cohort.

METHODS

Retrospective review of pediatric head and neck NTM lesions at a tertiary children's hospital from 1999 to 2012.

RESULTS

Seventy-one children were diagnosed with NTM lesions. Age of presentation ranged between 7 and 204 months of age. Most patients (62%) had multiple lesions. Treatments included incision and drainage, curettage, antibiotics, excision, and any combination of surgery and antibiotics. Upon initial presentation, the most common treatment was surgical excision alone (n = 34) with a high complication rate (50%). In 18 cases, patients were initially treated with a combination of antibiotics and surgical excision due to the extent or location of the lesion(s). Complication rate in these patients was also high (67%). The most common complications in surgically excised NTM lesions included temporary or persistent facial nerve dysfunction (24.6%), poor wound healing/scarring (10.8%), and Frey's syndrome (6.2%).

CONCLUSIONS

Surgical excision with or without medical therapy for NTM cervicofacial lymphadenitis in high-risk regions commonly resulted in marginal mandibular nerve dysfunction (24.6%). Postoperative facial nerve weakness generally resolved within a year. High rates of complications and a lack of proven best approaches suggest tailoring the approach to address the potential risks in that particular patient based on location and severity.

LEVEL OF EVIDENCE

4 Laryngoscope, 126:1677-1680, 2016.

The efficacy of the interferon-γ release assay for diagnosing cervical tuberculous lymphadenitis: A prospective controlled study

OBJECTIVES/HYPOTHESIS

The whole-blood interferon (IFN)-γ release assay (IGRA) has been studied mainly for diagnosing latent tuberculosis (TB). We prospectively evaluated its diagnostic usefulness in patients with suspected cervical TB lymphadenitis.

STUDY DESIGN

Prospective cohort study.

METHODS

An IGRA was performed in subjects with suspected TB lymphadenitis. To evaluate the diagnostic performance of the IGRA, we calculated the sensitivity and specificity of culture, radiologic imaging, polymerase chain reaction testing, fine needle aspiration, and excisional biopsy.

RESULT

Of the 271 adult patients with suspected TB lymphadenitis, 42 were diagnosed with the disease. The overall sensitivity and specificity of the IGRA were 78.8% and 95.5%, respectively. When the cutoff value of IFN-γ was set to 0.26 IU/mL, it met the inclusion criteria for suspicious TB lymphadenitis, with sensitivity and specificity of 83.3% and 95.1%, respectively.

CONCLUSIONS

The IGRA is useful in diagnosing TB lymphadenitis, with high sensitivity and specificity.

LEVEL OF EVIDENCE

4.

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.

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.

Predicting Surgical Outcomes in Pediatric Cervicofacial Nontuberculous Mycobacterial Lymphadenitis

Objectives:

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

Methods:

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

Results:

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

Conclusions:

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

Nontuberculous mycobacterial cervicofacial lymphadenitis--a review and proposed classification system

OBJECTIVE

To describe a clinical staging system for nontuberculous mycobacterial (NTM) cervicofacial lymphadenitis that has both diagnostic and therapeutic implications.

METHODS

A Medline database search was performed using key words "nontuberculous mycobacteria". All articles pertaining to nontuberculous mycobacterial cervicofacial lymphadenitis were reviewed for data evaluation regarding diagnosis and treatment methodologies.

RESULTS

Nontuberculous cervicofacial lymphadenitis infections pass through distinctly segmented clinical phases. In Stage I, a painless mass presents with notable increase in vascularity. Stage II is characterized by liquefaction of the affected lymph node, causing the mass to appear fluctuant. Significant skin changes characterize Stage III, whereby overlying skin may develop violaceous discoloration and become notably thinner, or parchment-like, with a "shiny" appearance. During Stage IV, the lesion fistulizes to the skin surface causing a draining wound.

CONCLUSIONS

While nontuberculous mycobacterial cervicofacial lymphadenitis has typically been thought of as a surgical disease, further characterization is warranted. We present a new classification system for appraising the clinical stages of nontuberculous mycobacterial cervicofacial lymphadenitis that may be used as part of a greater approach to disease management: (1) after other causes have been ruled out, the possibility of a tuberculous scrofula must be eliminated, and the degree of diagnostic suspicion must be categorized; (2) the clinical stage of the infection can be determined using the classification system described; and (3) a stage-specific treatment may be chosen based on the individual patient.

Management of nontuberculous mycobacteria-induced cervical lymphadenitis with observation alone

BACKGROUND

Nontuberculous mycobacteria can cause a chronic localized cervicofacial lymphadenitis in immunocompetent children. The recommended treatment is total excision of the affected lymph node. The aim of this study was to describe our experience with an observational approach.

METHODS

Children with chronic nontuberculous mycobacterial (NTM) cervical lymphadenitis, whose parents opted for conservative treatment, were followed at our center from 1990 to 2004. The diagnosis of NTM was based on mycobacterial culture of lymph node specimens obtained by fine needle aspiration. The clinical laboratory and follow-up data were documented.

RESULTS

Ninety-two children with lymph node positive cultures of nontuberculous mycobacterium were included in the study. Mycobacterium avium complex and Mycobacterium hemophilum were isolated in 90% of the cultures. In most cases, the affected lymph nodes underwent violaceous changes with discharge of purulent material for 3-8 weeks. Total resolution was achieved within 6 months in 71% of patients and within 9-12 months in the remainder. At the 2-year follow-up, a skin-colored, flat scar in the region of the drainage was noted. There were no complications.

CONCLUSIONS

We suggest that the observational approach can be effective for managing NTM lymphadenitis in immunocompetent children.

Treatment outcomes for nontuberculous mycobacterial cervicofacial lymphadenitis in children based on the type of surgical intervention

Objective

To report treatment outcomes of nontuberculous mycobacteria (NTM) cervicofacial lymphadenitis.

Study Design

A retrospective study from 1995 to 2006.

Subjects and Methods

Fifty-one patients (mean age, 30.3 months).

Results

All but one patient presented with lymphadenopathy. The mean time from symptoms to diagnosis was 42.3 days. Tuberculin skin testing (TST) was performed on 21 of 51 patients and was positive on 14 of 21 patients. Imaging was ordered in 23; 19 had CT scans. Pathology confirmed caseating granuloma in 45 (88%); cultures grew Mycobacterium avium-intracellulare complex in 46 of 51. Interventions included fine-needle aspiration (5, 10%), incision and drainage ± curettage (24, 46%), and complete excisional biopsy (20, 38%). Of those who underwent complete excisional biopsy initially, 95 percent were cured compared with 32 of 51 (63%) with nonexcisional surgery. Macrolides and rifampin were more likely to be recommended in referred cases and when nonexcisional surgical treatment was not feasible or had failed. The average total duration of antibiotic therapy was 89.1 days.

Conclusion

NTM infections require high levels of suspicion for timely diagnosis, and complete excisional biopsy results in least likelihood of persistent/recurrent disease.

Analysis of the interleukin-12/interferon-gamma pathway in children with non-tuberculous mycobacterial cervical lymphadenitis

Genetic defects along the interleukin (IL)-12/interferon (IFN)-gamma pathway have been found in patients with mendelian susceptibility to mycobacterial disease (MSMD) caused by live BCG vaccine or non-tuberculous Mycobacterium (NTM) species, highlighting the crucial role of this axis in human immunity to Mycobacterium. The aims of this study were to characterize healthy children presenting with cervical lymphadenitis caused by NTM and to investigate their IL-12/IFN-gamma pathway. Epidemiological, clinical, laboratory and pathological findings were reviewed retrospectively. Blood samples from five patients and healthy controls were in vitro activated with BCG, BCG + IL-12 and BCG + IFN-gamma and levels of IL-12p40 and IFN-gamma were measured. Fourteen patients (11 males, median age 24 months, range 12-78 months) were studied. The mean duration of illness before diagnosis was 9.1 weeks. Mycobacterium tuberculosis purified protein derivate (PPD) was positive in all patients (mean 14.5 +/- 9.8 mm). Caseous granuloma was found in all ten patients who underwent excision biopsy. However, acid fast stain was positive in only five children and cultures were positive in only three cases. The amplified M. tuberculosis direct test was negative in all tested cases. No significant differences in IL-12p40 and IFN-gamma levels were found between patients and controls. In spite of the normal response as measured in the screening test, it is still possible that patients might have a monogenic/mendelian disease for which the genetic defect(s) have yet to be elucidated. Alternatively, some single nucleotide polymorphisms along the IL-12/IFN-gamma axis might be associated with an isolated cervical lymph node infection and not a disseminated disease in children.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Mycobacterium fortuitum-induced persistent parotitis: successful therapy with clarithromycin and ciprofloxacin

BACKGROUND

Parotitis caused by nontuberculous mycobacteria, a very rare disease entity, has never been reported to be caused by Mycobacterium fortuitum (M. fortuitum) in the literature.

METHODS AND RESULTS

An 8-year-old girl was seen with painful swelling of the right parotid gland despite antibiotic treatment of more than 1 month. Elevated serum amylase activity and diffuse contrast-enhanced CT of the parotid gland confirmed the diagnosis of parotitis. Histopathological study of specimens taken from the right parotid tail mass showed granulomatous inflammation with acid-fast positive bacilli; culture later confirmed M. fortuitum. After administration of clarithromycin and ciprofloxacin for 9 consecutive months, the parotitis and parotid tail mass were completely resolved at follow-up examination.

CONCLUSION

To our knowledge, this is the first case report of parotitis caused by M. fortuitum and its successful medical treatment.

Antibiotic therapy for nontuberculous mycobacterial cervicofacial lymphadenitis

OBJECTIVES/HYPOTHESIS

To evaluate the efficacy of antibiotic treatment of nontuberculous mycobacterial (NTM) cervicofacial lymphadenitis, both as an alternative and as adjuvant to surgical excision.

STUDY DESIGN

Retrospective chart review of pediatric patients with NTM cervicofacial lymphadenitis treated from January 1993 to November 2003 at an academic tertiary care children's hospital.

METHODS

Fifty-five patients (age range, 15 mo-16 y) with the diagnosis of NTM cervicofacial lymphadenitis by fine-needle aspiration biopsy that had 1) lymph node culture positive for an atypical mycobacteria, 2) histological findings consistent with mycobacterial infection (granulomas) with negative bartonella serological titers, 3) histological stain positive for the presence of acid-fast bacillus in the absence of tuberculous infection, or 4) positive Mantoux tuberculin skin test result with a negative finding on polymerase chain reaction for tuberculous mycobacteria. Clinical response was defined as complete or partial resolution of skin changes and palpable lymphadenopathy in response to antibiotic therapy consisting of macrolide therapy alone or in combination with other anti-mycobacterial pharmaceuticals.

RESULTS

Of the 55 children studied, 45 of 55 (82%) with both single and multiple lesions underwent a trial of medical therapy, and 30 of 45 lesions (67%) ranging in size from 1 x 1 to 6 x 5 cm achieved resolution without surgical excision. Of the other 15 patients treated initially with medical therapy, 6 of 15 (40%) responded well to a course of antibiotic therapy before undergoing surgical excision, and 7 of 15 (47%) patients were nonresponsive to antibiotic therapy and required surgical excision to resolve the neck mass. The remaining 2 of 15 patients (13%) proceeded to surgery only after a course of antibiotics of 3 weeks or less. Ten of the 55 patients (18%) underwent surgical excision initially, with 5 of 10 patients (50%) receiving postoperative antibiotics for treatment of residual disease or prevention of recurrence.

CONCLUSION

Some NTM cervicofacial lymphadenitis infections appear to respond to medical therapy alone. A trial of antibiotic therapy might be considered in patients with NTM cervicofacial lymphadenitis before surgical excision or as an adjuvant to surgical excision.

Species identification of mycobacteria in paraffin-embedded tissues: frequent detection of nontuberculous mycobacteria

Diagnosis of infections caused by mycobacteria, especially nontuberculous mycobacteria still represents a difficult task both in microbiology and pathology. The aim of this study was to determine the frequency of mycobacterial DNA detectable by PCR in formalin-fixed paraffin-embedded tissues showing suspicious granulomatous lesions. A total of 190 archival specimens were analyzed, using a nested PCR protocol, which amplifies a fragment of the mycobacterial 65-kDa heat-shock protein gene. Restriction fragment-length polymorphisms and sequencing were utilized to further analyze the obtained PCR products. Corresponding microbiological culture results were available for 41 cases. We detected mycobacterial DNA in 119 cases (63%), of which 71 (60%) were positive for Mycobacterium tuberculosis complex DNA and 41 (34%) for DNA of nontuberculous mycobacteria. Seven cases (6%) could not be subtyped for technical reasons. The largest group of nontuberculous mycobacteria comprised 29 cases (25% of the 119 positive cases), which were assigned to Mycobacterium fortuitum complex. Mycobacterium avium-intracellulare complex was detected in eight (7%) cases, Mycobacterium gordonae in three (2.5%) and Mycobacterium rhodesiae in a single case (0.8%). All cases of Mycobacterium tuberculosis were unequivocally identified by restriction fragment-length polymorphism analysis. In contrast, sequencing provided a gain of information over restriction fragment-length polymorphism analysis in 37% of the nontuberculous mycobacteria cases (15 of 41). Alignment studies on DNA of nontuberculous mycobacteria showed frequent sequence variations, supporting the existence of sequevars. Comparison of molecular data to available results of microbiological culture assays showed a good concordance of 83%. In conclusion, amplification and sequencing of the mycobacterial 65-kDa heat-shock protein gene is an excellent tool for species identification of mycobacteria, especially nontuberculous mycobacteria, in formalin-fixed paraffin-embedded tissues.

Mycobacterial Cervical Lymphadenitis

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

Cervicofacial lymphadenitis due to atypical mycobacteria: a surgical disease

Despite the increasing prevalence of cervicofacial lymphadenitis due to atypical mycobacteria (AMB) in children, the true nature of AMB infection in clinical practice is poorly understood. The purpose of our study was to define the most common signs and symptoms, and to establish a workable scheme of diagnosis and treatment. Patients fulfilling the criteria of AMB infection (i.e., clinical signs, positive cultures or polymerase chain reaction, histologic features) were included in the study. All children underwent a standard surgical procedure, depending on pretreatment and the course of the disease. Sixteen infants presented with characteristic unilateral lymphadenopathy predominantly involving the submandibular area (13/16). Eight children had been initially treated at various institutions by fine-needle puncture or incision, and 7 of the 16 patients had received antituberculous multidrug treatment for a varying length of time. Complete excision of the affected lymph nodes was the definitive treatment in all patients. Three children had transient marginal mandibular nerve paralysis that resolved within a few months in all cases. Recognition of the characteristic features of AMB adenitis may permit early diagnosis and appropriate surgical treatment.

Nontuberculous mycobacterial adenitis in children: diagnostic and therapeutic management

We reviewed a series of 45 patients affected by nontuberculous mycobacterial adenitis of the neck observed in the Ear, Nose, and Throat Institute of S. Orsola-Malpighi Hospital-Bologna over a 20-year period between 1981 and 2001. The mean age was 5.5 years. Patients were tested by using the differential Mantoux test, which was the principal diagnostic tool in the case of atypical mycobacterial infections. Forty-two patients were surgically treated by total excision of infected nodes, whereas parotidectomy with sparing of facial nerve was performed in those 3 cases with intraparotid nodes involvement. In all cases, the histopathological diagnosis was tubercular granulomatous lymphadenitis. The culture growth of nontuberculous mycobacteria was positive in 13 cases with a marked prevalence of the avium-intracellular germs. The disease was eradicated in all patients. The diagnostic and therapeutic management of nontuberculous mycobacterial adenitis is discussed in this retrospective study.

Nontuberculous mycobacterial cervical adenitis: a ten-year retrospective review

OBJECTIVE

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

STUDY DESIGN

Retrospective chart review.

METHODS

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

RESULTS

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

CONCLUSION

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

Management of non-tuberculous mycobacterial peri-sialadenitis in children: the Sheffield otolaryngology experience

Non-tuberculous mycobacterial infection (NTM) has been recognized as an important cause of infection in the head and neck in children since 1956. It is important to differentiate NTM from the more serious Mycobacterium tuberculosis (TB) since the management differs significantly. The causative organisms of NTM infection are resistant to the most commonly used anti-tuberculous preparations, though they do show sensitivity to the newer antibiotics such as clarithromycin, ciprofloxacin and azithromycin. Between 1986 and 1997, 15 patients with NTM infection involving the major salivary glands were treated at the Sheffield Children's Hospital Department of Otolaryngology. There were 11 girls and four boys. In all patients the onset of symptoms was between September and April. Resolution occurred in two patients without surgery. The remaining 13 underwent formal surgical exploration with excision of the mass, associated nodes and of the overlying skin if necessary. There were nine parotid explorations. There were no long-term facial nerve deficits as a result of surgery and no recurrence of the disease. Co-operation between the Paediatrician and the Otolaryngologist is important for effective management since NTM may also affect the lungs, soft tissues, bones and joints. Diagnosis relies upon culture, histology, chest radiography, purified protein derivative (PPD) testing, clinical features and skin testing. The use of antibiotics such as azithromycin with ciprofloxacin may be justified while waiting for the results of investigations, especially with small, early lesions, as resolution is possible. In patients who have no history of exposure to TB, are not immunocompromised, have a normal chest radiograph and have a Mantoux test with < 15 mm diameter induration, the treatment should be surgical excision rather than prolonged antibiotic therapy.

Lymphadenopathy in children

Lymphadenopathy is a common problem in children and adolescents. A detailed history and physical examination in addition to knowledge of lymph node anatomy is often adequate for diagnosis. The infectious and noninfectious causes of adenopathy are outlined according to location. Medical and surgical evaluation and treatment are discussed, with special attention given to mycobacterial infections, cat scratch disease, and lymphoma.