Management of Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis with Intracapsular Tonsillectomy

OBJECTIVE

This study aimed to present 2 children clinically diagnosed with periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome and treated with intracapsular tonsillectomy with adenoidectomy (ITA).

METHODS

We conducted a retrospective analysis of 2 children who were referred for an otolaryngology consultation between 2019 and 2022 for surgical treatment of PFAPA syndrome. Both patients had symptoms strongly suggestive of PFAPA and were at risk for total tonsillectomy (TT) complications. ITA was performed using a microdebrider. Both patients were followed up postoperatively to assess for symptomatic resolution and complications.

RESULTS

Two children exhibited recurrent febrile episodes prior to ITA. The procedure was efficacious in both patients, with neither experiencing postoperative complications or recurring PFAPA symptoms for over 1 year after surgery.

CONCLUSION

Our study reported on the use of ITA as a surgical treatment option for PFAPA. We showed that ITA eliminated febrile attacks and was safely performed without postoperative complications in 2 pediatric patients after 1-year follow-up. Future studies involving larger cohorts of PFAPA patients and lengthier follow-ups will need to be conducted to further evaluate ITA as a surgical option. Laryngoscope, 134:1967-1969, 2024.

Cervical lymphadenitis from Mycobacterium avium complex

We present an instructive case of cervical lymphadenitis in a young man without a history of HIV infection. The patient developed spontaneous left-sided neck swelling that progressed over 4 months. CT imaging demonstrated a necrotic left-sided neck mass within the cervical lymph node chain. He was initially prescribed azithromycin and rifampin for presumed cat scratch disease with improvement but incomplete resolution of symptoms. Blood cultures ordered 2 months later grew Mycobacterium avium complex (MAC) and the patient had an excellent clinical response to MAC therapy. Here, we review the case, including presentation and management, and describe the implications for the immune status of the host and long-term considerations for treatment.

Clinical features of histiocytic necrotizing lymphadenitis in children

Due to its nonspecific clinical characteristics, histiocytic necrotizing lymphadenitis (HNL) is often misdiagnosed as a suppurative cervical lymphadenitis and lymphoma. Thus, this study aimed to investigate the clinical characteristics of HNL in pediatric patients. We retrospectively identified 61 patients with histopathologically confirmed HNL. Clinical and laboratory data, including age, sex, clinical manifestations, laboratory investigations, histological discoveries, treatment, and outcomes, were collected from the medical records to determine associations with extracervical lymph node (LN) involvement. The mean age of patients was 9.7 ± 2.8 years (range, 1.5-14.0 years), and the male-to-female ratio was 2.2:1. The most common systemic symptom was fever in all patients. The median pre-admission and total durations of fever were 13.0 (interquartile range [IQR]: 9.0-22.5 days) and 22.0 days (IQR: 17.0-33.0 days), respectively. Patients with temporary fever (< 2 weeks) had a higher peak temperature and were more likely to undergo LN biopsy after admission than those with a prolonged fever (≥ 2 weeks). Multivariate analysis revealed that peak temperature ≥ 40 °C was significantly associated with a longer fever duration (P = 0.023). Laboratory values showed leukopenia (68.9%), which presented more frequently in solitary cervical LNs than in extracervical LNs (82.4% vs. 52.9%, p = 0.027) in patients with prolonged fever.

CONCLUSIONS

HNL is often misdiagnosed in older children with persistent fever and lymphadenopathy, leading to unnecessary diagnostic tests and evaluations, inappropriate antibiotic administration, and mismanagement. A multidisciplinary team, including primary care providers, rheumatologists, and pathologists, can improve patient outcomes by increasing their awareness of this rare condition.

WHAT IS KNOWN

• Histiocytic necrotizing lymphadenitis (HNL) is characterized by fever, leukopenia, and neck lymphadenopathy with unknown etiology. • The lack of neutrophils or eosinophils in the histology, immunohistochemistry results help distinguish HNL from infectious causes. Although HNL is a self-limiting disease, antibiotics and steroid treatments were used inappropriately.

WHAT IS NEW

• A fever peak ≥ 40 °C was associated with a longer fever duration in HNL patients. Leukopenia presented more frequently in solitary cervical lymph node (LNs) than in extracervical LNs inpatients with prolonged fever. • Steroids are not recommended as a routine treatment, however, in some severe or relapsing cases with persistent symptoms, prednisolone (5 mg twice a day for 2 days) or other steroids (an equivalent dose of prednisolone) responded favorably.

Development and Evaluation of an NTM-IGRA to Guide Pediatric Lymphadenitis Diagnosis

BACKGROUND

Diagnosis of nontuberculous mycobacteria (NTM) infections remains a challenge. In this study, we describe the evaluation of an immunological NTM-interferon (IFN)-γ release assay (IGRA) that we developed using glycopeptidolipids (GPLs) as NTM-specific antigens.

METHODS

We tested the NTM-IGRA in 99 samples from pediatric patients. Seventy-five were patients with lymphadenitis: 25 were NTM confirmed, 45 were of unknown etiology but compatible with mycobacterial infection and 5 had lymphadenitis caused by an etiologic agent other than NTM. The remaining 24 samples were from control individuals without lymphadenitis (latently infected with M. tuberculosis , uninfected controls and active tuberculosis patients). Peripheral blood mononuclear cells were stimulated overnight with GPLs. Detection of IFN-γ producing cells was evaluated by enzyme-linked immunospot assay.

RESULTS

NTM culture-confirmed lymphadenitis patient samples had a significantly higher response to GPLs than the patients with lymphadenitis of unknown etiology but compatible with mycobacterial infection ( P < 0.001) and lymphadenitis not caused by NTM ( P < 0.01). We analyzed the response against GPLs in samples from unknown etiology lymphadenitis but compatible with mycobacterial infection cases according to the tuberculin skin test (TST) response, and although not statistically significant, those with a TST ≥5 mm had a higher response to GPLs when compared with the TST <5 mm group.

CONCLUSIONS

Stimulation with GPLs yielded promising results in detecting NTM infection in pediatric patients with lymphadenitis. Our results indicate that the test could be useful to guide the diagnosis of pediatric lymphadenitis. This new NTM-IGRA could improve the clinical handling of NTM-infected patients and avoid unnecessary misdiagnosis and treatments.

[Recurrent lymphadenitis was Kikuchi-Fujimoto disease]

Kikuchi-Fujimoto disease, or histiocytic necrotizing lymphadenitis, is in most cases a benign disease which affects lymph nodes in the cervical region. Cervical adenopathy and fever are the most common symptoms, and young adults are mostly affected. Lymph node biopsy is the mode of diagnosis with demonstration of paracortical areas of apoptotic necrosis with abundant karyorrhectic debris and a proliferation of histiocytes, plasmacytoid dendritic cells, and CD8+ T cells in the absence of neutrophils. In most cases, the disease is self-limiting but it can be recurrent or evolve to SLE. Treatment varies from symptomatic to more systemic with cortisone and intravenous immunoglobulin.

The diagnosis of nontuberculous cervicofacial lymphadenitis: A systematic review

BACKGROUND

Nontuberculous mycobacterial cervicofacial lymphadenitis (NTMCL) is an uncommon condition detected in young immunocompetent children who typically present with a nontender neck mass. Various tests have been proposed to assist in the work-up of suspected NTMCL, with varying diagnostic utility. This systematic review investigates the sensitivity of the various diagnostic methods used in the work-up of pediatric NTMCL.

METHODS

A systematic review in accordance with PRISMA guidelines was performed using the Pubmed, EMBASE, and Web of Science databases. Searches were filtered for English language studies published prior to 05/10/22. Studies meeting criteria included studies featuring 15+ pediatric patients with confirmed or suspected NTMCL. Studies with any reported diagnostic methodology used in the workup of NTMCL were included.

RESULTS

Of 836 abstracts/articles reviewed, 21 studies met inclusion criteria. Diagnostic methods included culture(n = 11 studies), PPD-Tb(Tuberculin)(n = 12), PPD-Scrofulaceum, -Avium, or -Kansasii(n = 6), staining techniques(n = 4), IGRA(n = 3), and ultrasound(n = 2). All studies had an overall low risk of bias. Among patients confirmed to have NTMCL based on PCR and/or culture, the most sensitive tests were PPD-A(0.94, 95 % CI 0.91 to 0.97; n = 210 patients) and PPD-S(0.75, 95 % CI 0.68 to 0.81; n = 171). Auramine and Ziehl-Neelsen staining techniques had moderately high sensitivity(0.85 and 0.60 respectively), though were limited by low patient numbers(n = 20). PPD-Tb(0.45, 95 % CI 0.39 to 0.50; n = 300) and IGRA(0.02; 95 % CI 0 to 0.06; n = 48) demonstrated poor sensitivity. Among patients suspected to have NTM lymphadenitis based on global assessment, the most sensitive tests included combined PPD-S + A + K(0.92, 95 % CI 0.86 to 0.98; n = 85), PCR(0.82, 95 % CI 0.75 to 0.88; n = 136), and PPD-A(0.72, 95 % CI 0.62 to 0.81; n = 84). Culture showed a sensitivity of 0.54(95 % CI 0.50 to 0.58; n = 494). PPD-K, PPD-S, IGRA, and staining techniques demonstrated lower sensitivity.

CONCLUSIONS

This systematic review is the largest study investigating the sensitivity of the various diagnostic methods used in the work-up of pediatric NTMCL. Patients with clinical suspicion for NTMCL and a positive PPD-Tb should first have tuberculous lymphadenitis ruled out with IGRA. Patients with a positive PPD-Tb and negative IGRA and high clinical suspicion for NTMCL can undergo presumptive surgical intervention. Patients with a negative PPD-Tb can undergo NTM antigen skin testing if available, or if high clinical suspicion exists, surgical intervention to reduce tissue burden and elicit additional tissue data.

Adult-onset Periodic Fever, Aphthous Stomatitis, Pharyngitis and Cervical Adenitis Syndrome Responsive to Colchicine

We herein report a rare case of periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome that occurred in an 18-year-old man. He visited our hospital with recurrent episodes of a fever, pharyngitis and adenitis without suggestive findings of infection. These episodes resolved within 5 days and recurred quite regularly, with an interval of about 30 days. As the febrile episodes significantly impaired his quality of life, he was treated with colchicine (0.5 mg) as prophylaxis. This completely prevented the episodes during six months of follow-up. Colchicine may therefore be effective in cases of adult-onset PFAPA syndrome.

Confused subcutaneous nodules in children: Differential diagnosis of pilomatricoma in children

BACKGROUND

Pilomatricoma is a common but easily misdiagnosed tumor in children.

AIMS

To differentiate pilomatricoma from other common subcutaneous nodules in children.

PATIENTS/METHODS

Misdiagnosed subcutaneous nodules in four children were recorded.

RESULTS

A red mass on a 7-year-old boy's head which had been misdiagnosed pyogenic granuloma was proved to be pilomatricoma. A red mass on an 8-month-old boy's face which had been misdiagnosed infantile hemangioma also turned to be pilomotricoma. A red mass on a 21-month-old girl's breast, which had been misdiagnosed pilomatricoma, was proved to be infantile myofibroma. A subcutaneous nodule under a 13-month-old girl's armpit, which had been misdiagnosed pilomatricoma, turned to be BCG-associated lymphadenitis.

CONCLUSIONS

When a child with a subcutaneous nodule attends, pilomatricoma, vascular tumors, fibrous tumors, and BCG-associated lymphadenitis should be considered.

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.

Gray zone in the spectrum of autoinflammatory diseases: familial Mediterranean fever accompanying periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome: single-center experience

Despite the advanced knowledge concerning autoinflammatory diseases (AID), more data regarding the optimal treatment options and outcomes of the children who met the criteria of more than one AID are required. This study aimed to describe the demographic and clinical characteristics of children from familial Mediterranean fever (FMF)-endemic countries who meet both the FMF and the periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome criteria. Moreover, we aimed to measure the response rates to colchicine and tonsillectomy and evaluate the factors affecting the colchicine response in these patients. The study was conducted at pediatric rheumatology tertiary centre. A total of 131 patients (58 females; 73 males) who met both the modified Marshall and pediatric FMF criteria were included. The median age at onset was 18 months (1-77 months), and the mean age at diagnosis was 47 ± 21.88 months. The median interval between episodes was 21 (7-90) days. The median disease duration was 46 (6-128) months. Consanguineous marriage was detected in 17 (13%) of the patients. The most common clinical finding was fever (100%), followed by exudative pharyngitis (88.5%), abdominal pain (86.3%), arthralgia (61.8%), stomatitis (51.1%), adenitis (42%), myalgia (28.7%), chest pain (16%), maculopapular rash (12.2%), arthritis (8.4%), and erysipelas-like rash (4.6%). MEFV gene variants were identified in 106 (80.9%) patients. The most common variants were M694V heterozygous (29%). We found that patients with tonsillopharyngitis, aphthous stomatitis, and PFAPA family history were more likely to be colchicine-resistant and tonsillectomy responsive, while those with exon 10 MEFV gene mutations were more prone to have a favorable response to colchicine.     Conclusion: PFAPA syndrome patients with exon 10 MEFV gene mutation, showing typical FMF symptoms, should be treated with colchicine, even after tonsillectomy. In multivariate analysis, PFAPA family history and lack of exon 10 MEFV gene mutations were independent risk factors for colchicine resistance. Thus, tonsillectomy may be recommended as a possible treatment option for these patients. It has yet to be clarified when colchicine treatment will be discontinued in patients whose attacks ceased after tonsillectomy that was performed due to colchicine unresponsiveness. What is Known: • A certain number of patients with periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome concomitantly fulfill the familial Mediterranean fever (FMF) criteria. • While colchicine is proposed as a first treatment choice in familial Mediterranean fever (FMF), corticosteroids are recommended as a first-line treatment in PFAPA syndrome patients. What is New: • In patients with concomitant PFAPA syndrome and FMF, PFAPA family history and lack of exon 10 MEFV gene mutation are predictive factors of colchicine resistance. • The presence of exon 10 MEFV gene mutations in patients with concomitant FMF and PFAPA syndrome has a favourable effect on response to colchicine treatment.

Evaluation of the Levels of Blood Cells, Vitamin D, and Inflammatory Factors in Children with PFAPA Syndrome

BACKGROUND

The syndrome of periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA syndrome) is the most common type of recurrent fever in childhood. The aim of this study was evaluation of the levels of blood cells, vitamin D, and inflammatory factors in children with PFAPA syndrome.

METHODS

This retrospective descriptive study was conducted on the recorded information of children with PFAPA syndrome referred to the children's specialty clinic of Imam Khomeini Hospital in Ilam city from March 2021 to February 2022. Complete demographic information, presence of underlying disease, changes in blood cells, vitamin D level and inflammatory factors were obtained from the patients' records. Diagnosis of PFAPA syndrome was performed according to Thomas' criteria.

RESULTS

This study was conducted on 40 children with PFAPA syndrome. The majority of patients were male and in the age range of 3 - 4 years. The results show that the average percentage of neutrophil and lymphocyte cells in the blood of patients was 54.45% and 40.62%, respectively. Also, 6 (15%), 3 (7.5%), and 31 (77.5%) patients had normal neutrophil levels, neutropenia, and neutrophilia, respectively. Regarding lymphocyte cells, 26 (65%), 8 (20%), and 6 (15%) people had normal lymphocyte level, lymphocytosis and lymphopenia, respectively. ESR levels increased in all patients (average percentage: 16.72). CRP level was negative in 9 (22.5%) and +1 in 19 (47.5%) patients, respectively. The results showed that 33 (82.5%) patients were deficient in vitamin D level.

CONCLUSIONS

The etiology and pathogenesis of PFAPA is still unknown; however, the rapid response to corticosteroid therapy is the indication of an immune deregulation. Treatment guidelines for PFAPA syndrome based on controlled studies are needed, as well as a better understanding of the disease itself.

TNFRSF1A-pR92Q variant identifies a subset of patients more similar to systemic undifferentiated recurrent fever than TNF receptor-associated periodic syndrome

OBJECTIVES

To describe the clinical phenotype and response to treatment of autoinflammatory disease (AID) patients with the TNFRSF1A-pR92Q variant compared to patients with tumour necrosis factor receptor-associated periodic syndrome (TRAPS) due to pathogenic mutations in the same gene and patients diagnosed with other recurrent fever syndromes including periodic fever with aphthous stomatitis, pharyngitis, and adenitis (PFAPA) and syndrome of undefined recurrent fever (SURF).

METHODS

Clinical data from pR92Q variant associated AID, classical TRAPS, PFAPA and SURF patients were obtained from the Eurofever registry, an international, multicentre registry enabling retrospective collection of data on AID patients.

RESULTS

In this study, 361 patients were enrolled, including 77 pR92Q variant, 72 classical TRAPS, 152 PFAPA and 60 SURF patients. pR92Q carriers had an older age of disease onset than classical TRAPS and PFAPA patients. Compared to pR92Q variant patients, classical TRAPS patients had more relatives affected and were more likely to have migratory rash and AA-amyloidosis. Despite several differences in disease characteristics and symptoms between pR92Q variant and PFAPA patients, part of the pR92Q variant patients experienced PFAPA-like symptoms. pR92Q variant and SURF patients showed a comparable clinical phenotype. No major differences were observed in response to treatment between the four patient groups. Steroids were most often prescribed and effective in the majority of patients.

CONCLUSIONS

Patients with AID carrying the TNFRSF1A-pR92Q variant behave more like SURF patients and differ from patients diagnosed with classical TRAPS and PFAPA in clinical phenotype. Hence, they should no longer be diagnosed as having TRAPS and management should differ accordingly.

PFAPA syndrome in children

ABSTRACT

Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome is, as the name implies, characterized by an extremely regular cycle of fevers that is accompanied by one or more other symptoms such as oral ulcers, pharyngitis, adenitis, tonsillitis, sore throat, cervical adenopathy, and headache. Originally known as Marshall syndrome, PFAPA is most commonly identified in children younger than age 5 years; however, adults may also present with the disease, though they may report additional symptoms. PFAPA is now understood to be a diagnosis of exclusion. Laboratory studies are typically unremarkable except for increases in acute phase reactants such as C-reactive protein. Treatment is primarily supportive and most frequently uses systemic steroids to suppress the inflammatory response. Acute flares are self-limited, and the syndrome typically resolves on its own as the child reaches age 7 or 8 years.

A classic case of scrofula-cervical tuberculous lymphadenitis

Tuberculosis (TB) is considered a common infection in developing countries and is caused by various strains of mycobacteria, usually Mycobacterium TB. TB remains to be one of the most important health threats. TB can have varied clinical presentations; Pulmonary TB affects the lungs and extrapulmonary TB (EPTB) can affect any part of the body. Cervical tuberculous lymphadenitis (CTL), cervical lymphadenitis, which is also referred to as scrofula is a case of EPTB that most frequently involves the cervical lymph nodes. In our report, a case of a young patient with CTL has been reported. This case's physical examination, evolution, diagnosis, and treatment have been discussed. Our case exemplifies the potential manifestations of an extrapulmonary tubercular lesion of the posterior pharyngeal wall, demonstrating that mycobacteria can infect practically any human organ. A high index of suspicion is critically required for the diagnosis of tuberculous lymphadenitis as mimics a number of pathological conditions.

Extreme Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis (PFAPA): a discrete group of patients

OBJECTIVE

Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is the most common periodic fever syndrome in children; by definition, episodes occur every 2 to 8 weeks. However, in a subset of our patients, we noticed a higher frequency of attacks, of less than 2 weeks, which we refer to as extreme PFAPA (ePFAPA). This group consisted of patients who were extreme upon presentation of PFAPA, and those who became extreme after initiation of abortive corticosteroid treatment. We aimed to characterize demographic and clinical features of ePFAPA, including the two groups, and to compare them to patients with non-extreme PFAPA (nPFAPA).

STUDY DESIGN

The medical records of 365 patients with PFAPA who attended Schneider Children's Medical Center of Israel from March 2014 to April 2021 were reviewed. Patients with concomitant familial Mediterranean fever were excluded. Characteristics of the ePFAPA (including subgroups) and nPFAPA groups were compared using Wilcoxon rank sum, Pearson's chi-squared, and Fisher's exact tests.

RESULTS

Forty-seven patients (12.9%) were identified as having ePFAPA. Among patients with ePFAPA, compared to patients with nPFAPA, the median (interquartile range) age at disease onset was earlier: 1.5 years (0.7-2.5) vs. 2.5 years (1.5-4.0), P < 0.001; and diagnosis was younger: 2.6 years (2.0-3.6) vs. 4.5 years (3.0-6.2), P < 0.001. A higher proportion of patients with ePFAPA than nPFAPA were treated with colchicine prophylaxis (53% vs. 19%, P < 0.001), but symptoms and signs during flares did not differ significantly between these groups. Demographic and clinical characteristics were similar between patients with ePFAPA from presentation of PFAPA (22, 47% of those with ePFAPA) and ePFAPA from after corticosteroid treatment.

CONCLUSION

About half the patients categorized with ePFAPA syndrome already had extreme features upon presentation. Patients with ePFAPA compared to nPFAPA presented and were diagnosed at an earlier age.

Toxoplasmic Lymphadenitis of the Head and Neck Region

OBJECTIVE

We analyzed the clinical characteristics and treatment results in patients with a final diagnosis of toxoplasmic lymphadenitis after surgery.

METHODS

A total of 23 patients with a final diagnosis of toxoplasmic lymphadenitis of the head and neck region after surgery from January 2010 to August 2022 were enrolled.

RESULTS

All patients with toxoplasmic lymphadenitis presented with a neck mass and a mean age of over 40. The most common location of toxoplasma lymphadenitis in the head and neck was neck level II in 9 patients, followed by level I, level V, level III, the parotid gland, and level IV. Three patients had masses in multiple regions of the neck. Preoperative diagnosis (based on imaging tests, physical examination, and fine-needle aspiration cytology results) was benign lymph node enlargement in 11 cases, malignant lymphoma in 8 cases, metastatic carcinoma in 2 cases, and parotid tumors in 2 cases. All patients underwent surgical resection and were diagnosed with toxoplasma lymphadenitis based on the final biopsy. There were no major complications after surgery. A total of 10 patients (43.5%) received additional antibiotics after surgery. There was no recurrence of toxoplasmic lymphadenitis during the follow-up period.

CONCLUSIONS

It is challenging to assess the diagnostic accuracy of preoperative examination in toxoplasma lymphadenitis; hence, surgical resection is necessary to differentiate it from other diseases.

Diagnostic performance of routine blood parameters in periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome

BACKGROUND

We aimed to investigate the difference between PFAPA and streptococcal tonsillitis (Strep Pharyngitis) by using blood parameters. We want to evaluate the relationship between periodic fever, aphthous stomatitis, pharyngitis, adenitis (PFAPA) syndrome, and tonsillitis by using NLR.

METHODS

The data of 141 pediatric patients who had applied to our clinic between October 2016 and March 2019 and were diagnosed with PFAPA syndrome and tonsillitis were reviewed from hospital records. The demographic data of the study group were recorded, as were their WBC, neutrophil, and lymphocyte counts, NLR, and MPV values, which are obtained by proportioning these two counts.

RESULTS

CRP and ESR values were significantly higher in the PFAPA group (p = 0.026 and p < 0.001, respectively). No significant difference was determined between the groups in terms of platelet count or lymphocyte count. Receiver operating curve analyses were calculated. The AUC was 0.713 ± 0.04 according to age, and the CRP was 0.607 ± 0.04 (95% confidence interval). Using a cutoff point of >49 months for age, the sensitivity was 0.71 and the specificity was 0.67.

CONCLUSION

With simple laboratory parameters, PFAPA syndrome can be differentiated from a diagnosis of tonsillitis. This may reduce the costs associated with unnecessary antibiotic use. However, these findings still need to be confirmed by other future studies.

Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Adenitis Syndrome and Syndrome of Unexplained Recurrent Fevers in Children and Adults

Children and adults with autoinflammatory disorders, who often experience recurrent fevers, rashes, cold-induced symptoms, conjunctivitis, lymphadenopathy, recurrent infections, aphthous stomatitis, and abnormal blood cell counts, may present to the allergist/immunologist because the symptoms mimic allergies and disorders of immunity. In recent years, there has been increased recognition of non-monogenic autoinflammatory disorders, including periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome and syndrome of undifferentiated recurrent fevers. For many clinical practitioners, the natural history, diagnostic criteria, differential diagnoses, and preferred therapies remain challenging because of the presumed rarity of patients and the evolving field of autoinflammation. Here, we aim to provide a practical framework for the clinical allergist/immunologist to evaluate and treat this patient population.

Cat-Scratch Lymphadenitis Presenting with Right Upper Arm and Axillary Masses: a Case Report Mimicking Lymphoma and Potential Diagnostic Pitfall

Background

Cat scratch disease (CSD) is an infectious disease caused by a cat's scratch, hard enough to break the skin's surface. Clinical manifestations include inflammatory lymphadenopathy and papular lesions at the site of the injury. However, it may be mistaken for a neoplasm-related process e.g., lymphoma due to its similar clinical presentation.

Objective

To report a CSD case in an Indonesian male presenting with mass-like symptoms in the oncologic ward of our center.

Case report

A 24-year-old male presented with painful and swelling masses in the right upper arm and right armpit for the last 4 months, enlarged progressively, and feverish for two days. Our initial differential diagnosis was lymphoma by history and routine physical examination, however. The patient reported a history of sleeping with his cat and recently experiencing a cat bite. We conducted the ultrasonography and lymph node biopsy to establish the final diagnosis and it was revealed to be related to CSD. The patient was treated with lymphadenectomy and azithromycin 500 mg bd for 7 days. The patient was completely treated with no additional complaints after two weeks of follow-up.

Conclusion

The differential diagnosis for CSD is relatively broad, including active infection, an ongoing inflammatory process, or a metastatic process; hence, thorough diagnostic approaches should be made in approaching CSD cases to avoid the pitfall or mistreatment in advance.

Purulent lymphadenitis due to Halomonas hamiltonii: a case report

Halomonas hamiltonii is a gram-negative rod bacterium isolated from highly saline environments. H. hamiltonii has rarely been reported as a human pathogen. Herein, we present the first case report of a purulent lymphadenitis caused by H. hamiltonii worldwide. The patient was a previously healthy girl aged 1 year who was referred to our hospital for left axillary lymphadenitis. Although oral amoxicillin was administered, lymphadenitis did not improve, and an abscess developed. After incision and drainage, the abscess was reduced. No recurrence of lymphadenitis was observed. The pus culture was negative. However, the 16S ribosomal DNA was amplified by the melting temperature mapping method. The amplified 16S ribosomal DNA sequence revealed 99.7% identity of H. hamiltonii. To the best of our knowledge, this is the first case of H. hamiltonii infection in a lymph node. This pathogen should be considered when diagnosing purulent lymphadenitis in healthy patients with lymphadenopathy of unknown origin.

Challenges in the diagnosis of periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome in developing countries—A decade of experience from North India

Background

Reports of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome from developing countries are sparse. Recognizing PFAPA is often challenging in these regions due to a higher incidence of infectious illnesses and significant resource constraints. Herein, we present our experience from North India regarding the diagnosis and management of PFAPA syndrome.

Methods

We reviewed cases of non-monogenic periodic fever syndrome diagnosed at our center from January 2011 to December 2021. A total of 17 children who fulfilled the Marshall criteria for PFAPA syndrome were included. Data regarding basic clinical features, treatment/outcome, and performance of the recently proposed Eurofever/PRINTO and Takeuchi criteria were analyzed.

Results

Besides recurrent fever, the triad of oral aphthae, pharyngitis, and adenitis was noted in only 18% of patients. Episodes of exudative pharyngitis/tonsillitis were documented in 24%. These figures were lower than the values reported from developed countries. The Takeuchi and Eurofever/PRINTO criteria were fulfilled in 76% and 71% cases, respectively. In addition to antipyretics and supportive care, intermittent steroid therapy was the main treatment modality used. Additional treatment with colchicine (n = 3) and thalidomide (n = 1) was used successfully in a few patients. Before the diagnosis of PFAPA, all patients had received multiple courses of antimicrobials (without microbiological confirmation). These included multiple courses of antibacterials for fever, pharyngotonsillitis, and/or cervical adenitis in all patients and antivirals for fever and aphthous stomatitis in a patient. Empiric antitubercular therapy had also been administered in two patients.

Conclusions

A significant proportion of patients with PFAPA seem to remain undiagnosed in the Indian subcontinent. Increased awareness and improvement in basic healthcare facilities are crucial in enhancing the recognition of PFAPA, which would eliminate the unprecedented scale of undesirable antimicrobial use in such children.

[Clinicopathological Characteristics of Lymphadenitis Caused by Talaromyces marneffei Diagnosed by Core Needle Biopsy]

Objective To analyze the clinicopathological characteristics of lymphadenitis caused by Talaromyces marneffei (TM).Method s The clinical data,pathological features,pathogen examination,and treatment of 15 cases of TM-caused lymphadenitis were analyzed retrospectively.Results The 15 cases included 14 males and 1 females,who were aged 26-67 years,with an average age of (49.1±11.87) years.The 15 cases,including 13 cases of acquired immunodeficiency syndrome and 2 cases of diabetes mellitus,were accompanied by superficial lymph node enlargement in the neck and supraclavicular,axillary,and inguinal regions.The structure of cord-like lymph node tissue punctured by thick needle was completely or partially replaced by inflammatory lesions. Under microscope,8 cases showed mainly diffuse infiltration of phagocytes with pathogens;5 cases presented mainly extensive coagulation necrosis with a small amount of pathogens and nuclear debris;2 cases were characterized by small nodular hyperplasia of fibroblasts,formation of granulomatous structure,and scattered distribution of a few multinucleated giant cells.The pathogens were relatively consistent in size and shape,which were round,oval or sausage-shaped and clustered like mulberry.Diastase periodic acid-Schiff staining and hexamine silver staining highlighted the bacterial structure with transverse septum.TM growth was detected in the blood,alveolar lavage fluid,sputum or lymph node extract fungal culture of the 15 patients.Owing to the adequate antifungal treatment in time,these 15 patients were discharged after their conditions were improved.Conclusion Lymphadenitis is one of the major manifestations of the systemic invasion of TM at the late stage,which is tended to be misdiagnosed.Through core needle biopsy of lymph node,it can be diagnosed as soon as possible to avoid delayed treatment and improve the cure rate.

Mycobacterium mageritense Lymphadenitis in Child

Although human infections caused by Mycobacterium mageritense are rare, there are some case reports involving sinusitis, pneumonia, and hospital-acquired infections in adults. We report a case of lymphadenitis caused by M. mageritense in a child in Spain.

Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome (PFAPA) or recurrent urinary tract infections: a case report

BACKGROUND

Fever is the most frequent reason for medical consultation in children, and makes up 15-25% of all consultations in primary care and emergency departments. In here we report a case of a 13 year-old girl who referred with an unusual presentation of fever and was misdiagnosed with recurrent urinary tract infection for 8 years.

CASE PRESENTATION

This is a Clinical Reasoning Cycle case study. A 13 year-old girl was referred with a chief complaint of recurrent fevers from 8 years. During her first febrile episode, she had a 5-day high-grade fever associated with loss of appetite. Her physical examination at that time was unremarkable. Blood tests showed leukocytosis with a shift to the left and urine examination was in favor of pyuria. The urine culture was positive for bacterial growth. The episodes of fever were repeated every 45 days. Accordingly, the patient was diagnosed as a case of recurrent urinary tract infection. In the intervals between her febrile episodes, the patient was healthy and laboratory tests were normal. Ultrasonography, voiding cystourethrogram and dimercaptosuccinic acid scans were normal. During her last visit, the patient mentioned difficulty in swallowing and on examination cervical lymph nodes, exudative tonsillitis and painful aphthous stomatitis were detected. All antibiotics were stopped and corticosteroids were started. The patient's symptoms were relieved and the interval between her febrile episodes became longer.

CONCLUSIONS

Our study shows that a patient should never be marked, particularly when the symptom and signs aren't completely justifying a patient's condition.

Lingual Tonsillectomy: Successful Treatment of Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Cervical Adenitis Syndrome

BACKGROUND

PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) syndrome is diagnosed clinically. Adult-onset PFAPA syndrome is rare and often has a more diverse clinical presentation that its childhood counterpart. This is the first reported case of adult-onset PFAPA syndrome with complete response to lingual tonsillectomy.

CASE SUMMARY

A 41-year-old man was evaluated for periodic fevers associated with uvulitis, cervical lymphadenitis, pharyngitis, and lower extremity rash. He had a variable response to steroids and was intolerant of colchicine. Laboratory workup revealed intermittent elevation of erythrocyte sedimentation rate and C-reactive protein level. Computed tomography neck and laryngoscopy confirmed adenoidal and lingual tonsillar hypertrophy. He underwent adenoidectomy and lingual tonsillectomy with resolution of symptoms.

CONCLUSIONS

Hypertrophy of the remaining lymphoid structures within Waldeyer's ring may be associated with remote recurrence of PFAPA syndrome after tonsillectomy. Lingual tonsillectomy may be an alternative treatment strategy in select patients with PFAPA, prominent lingual hypertrophy, and incomplete response to steroids.

Acute Inguinal Bacterial Lymphadenitis in Infants Younger Than 1 Year of Age

We examined 17 infants under age 1 year with inguinal bacterial lymphadenitis; 8 had a prior episode of omphalitis or an umbilical procedure, and one-third were afebrile and initially received the misdiagnosis of incarcerated hernia. Our findings suggested a possible association between inguinal bacterial lymphadenitis in infants and umbilical problems.

Cervical adenitis caused by Staphylococcus aureus in a newborn

Cervical acute lymphadenitis is rarely described in neonates. We present the case of a 12-day-old preterm, fed by nasogastric tube, who presented a tender erythematous submandibular swelling. Laboratory data showed neutrophilia and an elevation of C reactive protein and procalcitonin. Ultrasound findings suggested cellulitis and adenitis with abscess. The culture of the drainage material identified methicillin-sensitive Staphylococcus aureus With the administration of the right antibiotic treatment, a good clinical outcome was observed.

Undifferentiated recurrent fevers in pediatrics are clinically distinct from PFAPA syndrome but retain an IL-1 signature

Autoinflammatory disorders of the innate immune system present with recurrent episodes of inflammation often beginning in early childhood. While there are now more than 30 genetically-defined hereditary fever disorders, many patients lack a clear diagnosis. Many pediatric patients are often grouped with patients with periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome despite failing to meet diagnostic criteria. Here, we categorize these patients as syndrome of undifferentiated recurrent fever (SURF), and identify the unique features which distinguish them from the PFAPA syndrome. SURF patients were more likely to report gastrointestinal symptoms of nausea, vomiting and abdominal pain, and experienced inconsistent responses to on-demand steroid therapy compared to PFAPA patients. For this previously undefined cohort, an optimal course of therapy remains uncertain, with medical and surgical therapies largely driven by parental preference. A subset of patients with SURF underwent tonsillectomy with complete resolution. Flow cytometric evaluation demonstrates leukocytic populations distinct from PFAPA patients, with reduced CD3+ T cell numbers. SURF patient tonsils were predominantly characterized by an IL-1 signature compared to PFAPA, even during the afebrile period. Peripheral blood signatures were similar between groups suggesting that PFAPA and SURF patient tonsils have localized, persistent inflammation, without clinical symptoms. These data suggest that SURF is a heterogenous syndrome on the autoinflammatory disease spectrum.

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.

Recurrence of Symptoms Associated with Menstruation in a Patient with a History of Periodic Fevers

BACKGROUND

Periodic fever, aphthous stomatitis, pharyngitis, adenitis (PFAPA) syndrome is a cyclic autoinflammatory disease generally diagnosed in childhood. There have been studies suggesting a relationship between menstruation and other autoinflammatory syndromes such as familial Mediterranean fever (FMF), but not PFAPA specifically.

CASE

This case describes a patient with a diagnosis of PFAPA who experienced complete resolution with tonsillectomy only to have recurrence of symptoms with onset of menstruation. She experienced symptom control with initiation of oral contraceptives.

SUMMARY AND CONCLUSION

Prior to this case report, there had been no evidence in the literature suggesting a relationship between PFAPA and menstruation despite the observed association in other autoinflammatory syndromes. Onset of menses may be a trigger in PFAPA.

; CLINICAL AND LABORATORY CHARACTERISTICS OF ACUTE LYMPHADENITIS IN CHILDREN

The aim of the study is to determine the clinical and laboratory characteristics of acute lymphadenitis in children.; The study was performed using retrograde analysis of diagnosis and treatment of 158 children with acute lymphadenides of nonspecific and specific etiology, different localization (submandibular, cervical, axillary, inguinal and other peripheral localization) who were treated at the inpatient department in the pediatric surgery of MHCF "Local oncologic dispensary of Kramatorsk" from 2015 to 2019. Among the inpatient children there were 86 (54.4%) boys and 72 (45.6%) girls. The age of the patients ranged from 2 months to 18 years. The average age of the patients was 5.8±0.61 years. The surgical procedures were performed in 131 patients (82.9%) while the non-specific nature of the inflammatory process was confirmed in 102 patients (77.9%) taking into account the clinical course of the disease and the results of microbiological analysis. A specific inflammatory process was found out in 29 patients (22.1%). It was clinically detected that 18 children (13.7%) had BCG-lymphadenitis (confirmed by histological examination) and 11 patients (8.4%) had benign lymphoreticulosis (felinosis) among them.; Due to the use of shear wave elastography 62.9% of the children were able to avoid any surgery, extra puncture and they were treated conservatively.

Cluster of Lymphadenitis due to Nontuberculous Mycobacterium in Children and Adolescents 8-15 Years of Age

BACKGROUND

Nontuberculous mycobacteria (NTM) lymphadenitis is an under-recognized entity, and data of the true burden in children are limited. Without a high index of suspicion, diagnosis may be delayed and microbiological detection is challenging. Here, we report a cluster of NTM lymphadenitis experienced in Korean children.

METHODS

Subjects under 19 years of age diagnosed with NTM lymphadenitis during November 2016-April 2017 and April 2018 were included. Electronic medical records were reviewed for clinical, laboratory and pathological findings. Information regarding underlying health conditions and environmental exposure factors was obtained through interview and questionnaires.

RESULTS

A total of ten subjects were diagnosed during 18 months. All subjects were 8-15 years of age, previously healthy, male and had unilateral, nontender, cervicofacial lymphadenitis for more than 3 weeks with no significant systemic symptoms and no response to empirical antibiotics. Lymph nodes involved were submandibular (n = 8), preauricular (n = 6) and submental (n = 1). Five patients had two infected nodes and violaceous discoloration was seen in seven subjects. Biopsy specimens revealed chronic granulomatous inflammation and acid-fast bacteria culture identified Mycobacterium haemophilum in two cases and NTM polymerase chain reaction was positive in two cases. Survey revealed various common exposure sources.

CONCLUSION

NTM lymphadenitis is rare but increasing in detection and it may occur in children and adolescents. Diagnosis requires high index of suspicion and communication between clinicians and the laboratory is essential for identification of NTM.

Periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis in Chinese adult patients

OBJECTIVES

Periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome is a multifactorial autoinflammatory disease (AID), which mainly affects children. There have been hardly any cases reported concerning the Chinese population. We aimed to describe the first cohort of adult PFAPA patients in China.

METHODS

We evaluated all the adult patients suffering from PFAPA syndrome diagnosed in our centre from April 2015 through March 2018. The patients were diagnosed clinically, and whole exome sequencing was performed in each patient to rule out mono-genic AIDs.

RESULTS

During the study period, a total of 9 adult patients (8 men, 1 woman) with PFAPA syndrome were diagnosed. They all had disease onset in adulthood, and the mean age at onset was 25.2±9.5 years. The mean duration of attacks was 4.1±1.0 days, and the mean interval between attacks was 6.2±2.7 weeks. Apart from periodic fever, which was present in all patients, pharyngitis, cervical adenitis and aphthous stomatitis were present in 89%, 67% and 44% patients, respectively. Other common symptoms included fatigue (100%), headache (56%), and myalgia (55%). Inflammatory markers, except ferritin, increased during attacks and returned to normal afterwards. Glucocorticoids given at onset of attacks were effective, while colchicine and tonsillectomy were of no effect.

CONCLUSIONS

Our study is the first to suggest the presence of PFAPA syndrome in the Chinese adult population. Clinicians should take into account PFAPA syndrome when diagnosing patients suffering from recurrent fevers of unknown origin, especially those with pharyngitis, cervical adenopathy and aphthous stomatitis.

A panel of recombinant proteins for the serodiagnosis of caseous lymphadenitis in goats and sheep

Caseous lymphadenitis (CLA) is a small ruminant disease characterized by the development of granulomatous lesions in superficial and internal lymph nodes, as well as in some organs, and causes significant economic losses worldwide. The aetiological agent of CLA is the bacterium Corynebacterium pseudotuberculosis; however, the commercially available diagnostic tools present problems with regard to specificity, which can lead to false-negative results. This study aimed to develop an indirect enzyme-linked immunosorbent assay (ELISA) for the detection of specific immunoglobulins in goats and sheep using recombinant C. pseudotuberculosis PLD, CP40, PknG, DtxR and Grx proteins. For validation of the ELISAs, 130 goat serum samples and 160 sheep serum samples were used. The best ELISA for goats was developed using a combination of PLD and CP40 as antigens at a 1:1 ratio, which presented 96.9% sensitivity and 98.4% specificity. The most effective ELISA for sheep presented 91% sensitivity and 98.7% specificity when recombinant PLD alone was used as the antigen. These ELISAs can be used as highly accurate tools in epidemiological surveys and for the serodiagnosis of C. pseudotuberculosis infection in goats and sheep.

[PFAPA syndrome - An important differential diagnosis in children with recurrent fever]

Periodic Fever, Aphthous Stomatitis, Pharyngitis and Cervical Adenitis (PFAPA) syndrome is the most common autoinflammatory disorder among children in many parts of the world and an important differential diagnosis in children presenting with recurrent fever episodes. Commonly, PFAPA has an onset under the age of 5 years. Fever episodes in PFAPA usually last 3-6 days and are associated with one or more of the cardinal symptoms aphthous stomatitis, pharyngitis and cervical adenitis. The fever episodes typically recur with an interval of 3-6 weeks, often with a striking regularity. During the episodes, the patient has elevated inflammatory variables such as CRP and serum amyloid A (SAA) and may sometimes have additional symptoms such as abdominal pain, nausea and leg pain. Between the fever episodes, the patient is typically free of symptoms with normalized inflammatory variables and grows normally. Awareness and recognition of PFAPA is key to providing the patient with adequate treatment and avoiding misdiagnosis.

[Surgical management of non-tuberculous mycobacterial lymphadenitis in a third level center]

AIM OF STUDY

To describe our experience in the management of non-tuberculosis mycobacterial lymphadenitits (NTML).

METHODS

Retrospective analysis of patients who underwent surgery for NTML in our centre during the period between 2010-2017. Demographic data, diagnostic tests, treatment and follow up information were recovered from medical records.

RESULTS

65 patients (26 male/39 female) with a mean age of 31 months (range 7 months-12 years) were intervened during the period of study. As diagnostic tests, chest X-ray was performed in 92.3% of patients with normal result in all cases, Mantoux test was positive in 20.3%, inconclusive in 12.5% and negative in 67.1%. Preoperative fine needle aspiration was positive for NTML (granulomatous necrotizing lymphadenitis) in 93.7% whereas culture for mycobacteria was only positive in 23.4% of cases, being Mycobacterium lentiflavum the most frequent agent found. Mean preoperative waiting time was 2.5 months with 7.7% of fistulization previous to surgery. Mean hospital stay was 1,1 days and there were no intraoperative complications. Mean follow up time was 5.5 months (range 1-24 months) during which 19 cases of temporal facial paralysis were noted, among which only 2 persisted after one year.

CONCLUSIONS

NTML is a disease with a growing incidence in our country. It is important to make an early diagnosis and surgical treatment in order to avoid complications, as surgery has demonstrated to be safe and effective, with a low rate of complications. We believe the actual protocols should be revised/checked due to low effectiveness of diagnostic tests.

Granulomatous lymphadenitis mimicking metastatic lymphadenopathy in the neck after lymphatic embolization of chyle leakage: A case report

RATIONALE

Lymphatic embolization is a minimally invasive treatment option for managing chyle leakage after nodal dissection in the neck. After the procedure, the embolic material may cause foreign body granulomatous lymphadenitis and can be a diagnostic challenge for radiologists because of sonographic similarity to metastatic lymph node. Herein, we describe a clinical case of granulomatous lymphadenitis due to embolic material mimicking nodal metastasis detected on ultrasonography (US) with cytologic findings in a patient with thyroid cancer who underwent lymphatic embolization to treat chyle leakage after total thyroidectomy and neck dissection. We also review the relevant literature regarding this disease with technical background of the procedure and suggest the importance of clinical suspicion in diagnosing the granulomatous lymphadenitis in patients with a history of lymphatic embolization.

PATIENT CONCERNS

A 40-year-old man who underwent total thyroidectomy and bilateral modified radical neck dissection due to papillary thyroid carcinoma had suspicious cervical lymph node on US after lymphatic embolization of chyle leakage.

DIAGNOSES

The suspicious cervical lymph node proved to be foreign body granulomatous lymphadenitis due to embolic material by US-guided fine-needle aspiration.

INTERVENTIONS

The patient did not undergone additional surgery because the pathologic cervical lymph node was confirmed to be foreign body granulomatous lymphadenitis.

OUTCOMES

The patient is being followed up regularly at the outpatient department.

LESSONS

Clinical awareness of the technical background of lymphatic embolization and possible sonographic features of granulomatous lymphadenitis is important for an accurate diagnosis and the appropriate management in patients who underwent lymphatic embolization.

Mycobacterium orygis Lymphadenitis in New York, USA

We report a case of lymphadenitis caused by Mycobacterium orygis in an immunocompetent person in Stony Brook, New York, USA. Initial real-time PCR assay failed to provide a final subspecies identification within the M. tuberculosis complex, but whole-genome sequencing characterized the isolate as M. orygis.

Emerging and re-emerging infectious disease in otorhinolaryngology

SUMMARY

Emerging and re-emerging infectious disease in otorhinolaryngology (ENT) are an area of growing epidemiological and clinical interest. The aim of this section is to comprehensively report on the epidemiology of key infectious disease in otorhinolaryngology, reporting on their burden at the national and international level, expanding of the need of promoting and implementing preventive interventions, and the rationale of applying evidence-based, effective and cost- effective diagnostic, curative and preventive approaches. In particular, we focus on i) ENT viral infections (HIV, Epstein-Barr virus, Human Papilloma virus), retrieving the available evidence on their oncogenic potential; ii) typical and atypical mycobacteria infections; iii) non-specific granulomatous lymphadenopathy; iv) emerging paediatric ENT infectious diseases and the prevention of their complications; v) the growing burden of antimicrobial resistance in ENT and the strategies for its control in different clinical settings. We conclude by outlining knowledge gaps and action needed in ENT infectious diseases research and clinical practice and we make references to economic analysis in the field of ENT infectious diseases prevention and care.

[Statistical information about the inflammatory processes of the jaw-facial part in children]

OBJECTIVE

Introduction: The acute and chronic inflammatory processes prevail in the structure of the dental surgical diseases in children. Notably, various forms of lymphadenitis, adenophlegmon and odontogenous osteomyelitis dominate in the specialized surgical units; however, it is not possible to resolve a number of organizational problems without clear understanding of the statistical situation. The aim: The paper is aimed at the analysis of the incidence rate of major nosological forms of the acute suppurative inflammations of the maxillofacial area in children for the prospective planning of arrangements to provide them with high-quality specialized care.

PATIENTS AND METHODS

Materials and methods: The paper involves findings of comprehensive examination and treatment of 537children with acute purulent lymphadenitis, adenophlegmon and odontogenous osteomyelitis that was carried out within 6 years.

RESULTS

Results: The resulting clinical data have shown that three abovementioned nosological forms of the disease accounted for 42% of the overall number of the inpatient dental patients and 11% of the total number of children with acute surgical pathology. Out of 537 patients, 240 patients (44.8%) with acute purulent lymphadenitis, 150 (27,9%) patients with adenophlegmon and 147 (27.3%) patients with acute odontogenous osteomyelitis have been observed (318 (59,2%) boys and 219 (40,8%) girls aged from 2 months to 15 years). The study of the past history of the disease has established that in the majority of patients burdened premorbid history and occurrence of concomitant chronic general somatic diseases was presented prior to the onset of acute inflammation.

CONCLUSION

Conclusions: The factors, mentioned above, greatly contributed to increase in protective-adaptive properties of child body and create the prerequisites for the formation of pathological symptomocomplex in children, which can be implemented even in the minimal effect of antigen load on the tissues of maxillofacial area. Such situation requires a balanced multidisciplinary approach to the planning of preventive measures in this category of patients at all stages of the observation.