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Costagliola G, De Marco E, Massei F, Roberti G, Catena F, Casazza G, Consolini R. The Etiologic Landscape of Lymphoproliferation in Childhood: Proposal for a Diagnostic Approach Exploring from Infections to Inborn Errors of Immunity and Metabolic Diseases. Ther Clin Risk Manag 2024; 20:261-274. [PMID: 38770035 PMCID: PMC11104440 DOI: 10.2147/tcrm.s462996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/12/2024] [Indexed: 05/22/2024] Open
Abstract
Lymphoproliferation is defined by lymphadenopathy, splenomegaly, hepatomegaly, or lymphocytic organ and tissue infiltration. The most common etiologies of lymphoproliferation are represented by infectious diseases and lymphoid malignancies. However, it is increasingly recognized that lymphoproliferative features can be the presenting sign of rare conditions, including inborn errors of immunity (IEI) and inborn errors of metabolism (IEM). Among IEI, lymphoproliferation is frequently observed in autoimmune lymphoproliferative syndrome (ALPS) and related disorders, common variable immunodeficiency (CVID), activated phosphoinositide 3-kinase δ syndrome, and Epstein-Barr virus (EBV)-related disorders. Gaucher disease and Niemann-Pick disease are the most common IEMs that can present with isolated lymphoproliferative features. Notably, other rare conditions, such as sarcoidosis, Castleman disease, systemic autoimmune diseases, and autoinflammatory disorders, should be considered in the differential diagnosis of patients with persistent lymphoproliferation when infectious and malignant diseases have been reasonably ruled out. The clinical features of lymphoproliferative diseases, as well as the associated clinical findings and data deriving from imaging and first-level laboratory investigations, could significantly help in providing the correct diagnostic suspicion for the underlying etiology. This paper reviews the most relevant diseases associated with lymphoproliferation, including infectious diseases, hematological malignancies, IEI, and IEM. Moreover, some practical indications to orient the initial diagnostic process are provided, and two diagnostic algorithms are proposed for the first-level assessment and the approach to persistent lymphoproliferation, respectively.
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Affiliation(s)
- Giorgio Costagliola
- Section of Pediatric Hematology and Oncology, Azienda Ospedaliero-Universitaria Pisana, Pisa, 56126, Italy
| | - Emanuela De Marco
- Section of Pediatric Hematology and Oncology, Azienda Ospedaliero-Universitaria Pisana, Pisa, 56126, Italy
| | - Francesco Massei
- Section of Pediatric Hematology and Oncology, Azienda Ospedaliero-Universitaria Pisana, Pisa, 56126, Italy
| | - Giulia Roberti
- Pediatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, 56126, Italy
| | - Fabrizio Catena
- Section of Pediatric Hematology and Oncology, Azienda Ospedaliero-Universitaria Pisana, Pisa, 56126, Italy
| | - Gabriella Casazza
- Section of Pediatric Hematology and Oncology, Azienda Ospedaliero-Universitaria Pisana, Pisa, 56126, Italy
| | - Rita Consolini
- Section of Clinical and Laboratory Immunology, Pediatric Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, 56126, Italy
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Coe J, Puius Y, Jain H, Meyerowitz EA. Cervical lymphadenitis from Mycobacterium avium complex. BMJ Case Rep 2024; 17:e256726. [PMID: 38490710 PMCID: PMC10946343 DOI: 10.1136/bcr-2023-256726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024] Open
Abstract
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.
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Affiliation(s)
- Jared Coe
- Albert Einstein College of Medicine, Bronx, New York, USA
- Montefiore Medical Center, Bronx, New York, USA
| | - Yoram Puius
- Montefiore Medical Center, Bronx, New York, USA
| | - Harsh Jain
- Montefiore Medical Center, Bronx, New York, USA
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Mennes T, Vander Poorten V, Vermeulen F, Hens G. Comparison of treatment modalities for non-tuberculous mycobacterial cervicofacial lymphadenitis in children. Eur Arch Otorhinolaryngol 2024; 281:1463-1471. [PMID: 38085303 DOI: 10.1007/s00405-023-08376-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 11/23/2023] [Indexed: 02/10/2024]
Abstract
PURPOSE We aim to compare the different treatment modalities of non-tuberculous cervicofacial lymphadenitis in children, by means of a retrospective study conducted in the University Hospitals of Leuven of patients treated between 2012 and 2022. METHODS For this retrospective cohort study, data were collected and pseudonimised from 52 patients with non-tuberculous cervicofacial lymphadenitis, who were treated in our hospital between January 2012 and December 2022, either conservatively, antibiotically, surgically, or with a combination of these options. We only included patients who were considered immunocompetent. All of the included patients were below 10 years at time of treatment. We collected data regarding time to resolution and adverse effects, i.e., skin discoloration, excessive scar formation, fistula formation, persistence of adenopathies after treatment, need for additional treatment, facial nerve paresis/paralysis, or systemic side-effects due to antibiotic treatment. RESULTS The mean time to resolution (in days) when looking at primary treatments, was shortest in partial excisions (16), followed by complete excisions (19), antibiotic therapy (129), incision and drainage (153), curettage (240), and finally conservative management (280). Taking into account isolated treatments (i.e., both primary and adjuvant), we also observed consistently faster time to resolution in surgical and antibiotic treatments when compared to conservative treatment. Antibiotic therapy (p = 0.003), incision and drainage (p = 0,004) were associated with a significantly higher need for adjuvant treatment. Curettage was associated with a higher incidence of fistula formation (p = 0,006) and higher number of adjuvant treatments (p = 0,002). CONCLUSIONS This study shows a faster resolution of nontuberculous mycobacterial cervicofacial lymphadenitis in children when treated surgically, more specifically when treated with partial or complete lymph node excision. Antibiotic treatment also leads to faster resolution than conservative management. There was a low rate of complications, and no permanent facial nerve damage was reported.
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Affiliation(s)
- T Mennes
- UZ Leuven, Department of Otorhinolaryngology and Head and Neck Surgery, Leuven, Belgium.
| | - V Vander Poorten
- UZ Leuven, Department of Otorhinolaryngology and Head and Neck Surgery, Leuven, Belgium
| | - F Vermeulen
- UZ Leuven, Department of Paediatrics, Leuven, Belgium
| | - G Hens
- UZ Leuven, Department of Otorhinolaryngology and Head and Neck Surgery, Leuven, Belgium
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Jensen FN, Nielsen AB, Dungu KHS, Poulsen A, Schmidt G, Hjuler T, Zhang H, Vissing NH, Nygaard U. Distinct clinical parameters were associated with shorter spontaneous resolution in children with non-tuberculous mycobacterial lymphadenitis. Acta Paediatr 2024. [PMID: 38226417 DOI: 10.1111/apa.17104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/17/2023] [Accepted: 01/03/2024] [Indexed: 01/17/2024]
Abstract
AIM Non-tuberculous mycobacteria (NTM) lymphadenitis typically resolves spontaneously, yet factors influencing the duration remain explored. We aimed to identify clinical parameters associated with shorter spontaneous resolution. METHODS This cohort study included children with NTM lymphadenitis from 1 January 2015 to 1 March 2021 at Copenhagen University Hospital. Time-to-event analysis assessed clinical parameters associated with the duration of NTM lymphadenitis. RESULTS Sixty children (57% boys) with a median age of 24 months (range 11-84) were included; 13 (22%) received primary surgery, 13 (22%) underwent surgery after a wait-and-see period and 34 (57%) received no intervention. In children without intervention, the median duration was 10 months (range 2-25). Faster resolution was associated with parental-reported lymph node enlargement within 2 weeks (HR 2.3, 95% CI 1.0-5.0; p = 0.044), abscess on ultrasound examination (HR 3.3, 95% CI 1.5-7.3; p = 0.003) and skin discoloration and/or perforation within 3 months of onset (HR 4.3, 95% CI 1.3-14.4; p = 0.017 and HR 3.7, 95% CI 1.5-9.1; p = 0.005). CONCLUSION Knowledge of predictors for shorter spontaneous resolution of NTM lymphadenitis, such as rapid initial lymph node enlargement, abscess on ultrasound examination, and skin discoloration and/or perforation within 3 months of disease onset, may guide clinical management decisions concerning surgery versus a conservative approach.
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Affiliation(s)
- Frederikke Nonboe Jensen
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Copenhagen, Denmark
| | - Allan Bybeck Nielsen
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kia Hee Schultz Dungu
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anja Poulsen
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Copenhagen, Denmark
| | - Grethe Schmidt
- Department of Plastic Surgery and Burns Treatment, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Hjuler
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Otorhinolaryngology and Audiology, University of Copenhagen, Copenhagen, Denmark
| | - He Zhang
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Copenhagen, Denmark
| | - Nadja Hawwa Vissing
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ulrikka Nygaard
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Gallagher ND. 'A sad inheritance of misery': the cultural life of hereditary scrofula in eighteenth-century England. MEDICAL HISTORY 2024; 68:1-21. [PMID: 38486500 PMCID: PMC11046006 DOI: 10.1017/mdh.2023.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
This essay argues that scrofula was one of several disorders, including gout, rickets, and venereal disease, that were 'rebranded' as hereditary in response to broader cultural changes that took place during the Restoration and eighteenth century in England. While the purposes of scrofula's recategorisation were more political than medical, they resulted in this heretofore relatively obscure childhood ailment assuming a new prominence within both medical and popular discourses of the period. Scrofula became both emblem and proof of the links between sexual promiscuity, financial profligacy, and physiological degeneration, its symbolic status reinforced by the legal and moral language used to model processes of hereditary transmission. By likening the inheritance of scrofula to the inheritance of original sin-or, more commonly, to the inheritance of a 'docked entail' or damaged estate-eighteenth-century writers and artists not only made this non-inherited ailment into a sign of catastrophic hereditary decline; they also paved the way for scrofula to be identified as a disease of aristocratic vice, even though its association with crowded, unsanitary living conditions likely made it more common among the poor. By the same token, financial models of disease inheritance facilitated a bias toward paternal transmission, with scrofula often portrayed as passing, like a title or an estate, from father to son rather than from mother to daughter.
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Green K, Denton A, Graves J, Wiedermann J. Late recurrence in surgically managed pediatric atypical mycobacterial lymphadenitis: A case report and review of the literature. World J Otorhinolaryngol Head Neck Surg 2023; 9:357-364. [PMID: 38059148 PMCID: PMC10696275 DOI: 10.1002/wjo2.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 02/03/2023] [Accepted: 02/23/2023] [Indexed: 12/08/2023] Open
Abstract
Objective The purpose of this study is to identify existing literature on recurrent atypical mycobacterial cervicofacial lymphadenitis to augment our understanding of a unique patient who presented to our tertiary-care center 5-years posttreatment with recurrence following curettage. Data Sources OVID Medline, Scopus, and Web of Science. Methods A literature search was conducted yielding 49 original articles which were screened twice by two independent reviewers resulting in 14 studies meeting inclusion criteria for data extraction using Covidence software. Two independent reviewers extracted data on recurrence of atypical mycobacterial cervicofacial lymphadenitis and consensus was reached on data points from all included studies. Results This study illuminated the paucity of recurrence reporting in the literature regarding atypical mycobacterial lymphadenitis. Sixteen studies identified in our review included discussions on recurrence with few elaborating beyond the rate of recurrence to describe their management. Fourteen out of sixteen studies provided recurrence rates for their cohort, 11 out of 14 specified the initial treatment modality, and only five out of eight studies that described initial treatment with surgery differentiated recurrence rates between complete and incomplete excision. The mean length of follow-up in the included studies was 20 months. There was one previously reported case of late recurrence at 5-years. Conclusions We identified few reports that discussed the management of recurrence of atypical mycobacterial cervicofacial lymphadenitis. There was minimal data on recurrence rates between surgical treatment modalities. The case discussed in our study showcases that treatment with curettage has the potential to present with late recurrence.
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Affiliation(s)
- Katerina Green
- Department of Plastic and Reconstructive SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Alexa Denton
- Herbert Wertheim College of MedicineFlorida International UniversityMiamiFloridaUSA
| | | | - Joshua Wiedermann
- Department of Otolaryngology‐Head and Neck SurgeryMayo ClinicRochesterMinnesotaUSA
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Shah KV, Peraza LR, Wiedermann JP. Current management of cervicofacial nontuberculous mycobacterial infections in the pediatric population. Curr Opin Otolaryngol Head Neck Surg 2023; 31:388-396. [PMID: 37712822 DOI: 10.1097/moo.0000000000000927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
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.
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Affiliation(s)
- Keshav V Shah
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lazaro R Peraza
- Department of Otolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Joshua P Wiedermann
- Department of Otolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Omori K, Kitagawa H, Yamaguchi K, Sakamoto S, Horimasu Y, Masuda T, Miyamoto S, Nakashima T, Iwamoto H, Fujitaka K, Hamada H, Tadera K, Nomura T, Shigemoto N, Aoki G, Hattori N, Ohge H. Clinical characteristics of extrapulmonary nontuberculous mycobacteria infections in comparison with pulmonary infections: A single-center, retrospective study in Japan. J Infect Chemother 2023; 29:875-881. [PMID: 37209842 DOI: 10.1016/j.jiac.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 03/23/2023] [Accepted: 05/11/2023] [Indexed: 05/22/2023]
Abstract
INTRODUCTION The prevalence of nontuberculous mycobacteria (NTM) infections is increasing worldwide. Although NTM can affect extrapulmonary organs, studies on the clinical characteristics of extrapulmonary NTM are rare. METHODS We retrospectively analyzed patients who were newly diagnosed with NTM infections at Hiroshima University Hospital between 2001 and 2021 to investigate species distribution, infected sites, and risk factors of extrapulmonary NTM compared to pulmonary NTM. RESULTS Of the 261 NTM infections, 9.6% and 90.4% had extrapulmonary and pulmonary NTM, respectively. The mean ages of patients with extrapulmonary and pulmonary NTM were 53.4 and 69.3 years, 64.0% and 42.8% were male, 36.0% and 9.3% received corticosteroids, 20.0% and 0% had acquired immune deficiency syndrome (AIDS), and 56.0% and 16.1% had any immunosuppressive conditions, respectively. Younger age, corticosteroid use, and AIDS were associated with extrapulmonary NTM. In pulmonary NTM, Mycobacterium avium complex (MAC) accounted for 86.4% of NTM species, followed by M. abscessus complex (4.2%), whereas in extrapulmonary NTM, M. abscessus complex, MAC, M. chelonae, and M. fortuitum accounted for 36.0%, 28.0%, 12.0%, and 8.0%, respectively. Compared to pulmonary NTM, extrapulmonary NTM were significantly more likely to be rapid-growing mycobacteria (RGM) (56.0% vs. 5.5%). The most common sites of infection were the skin and soft tissues (44.0%), followed by the blood (20.0%), tenosynovium, and lymph nodes (12.0%). CONCLUSION Younger age and immunosuppressive conditions are associated with extrapulmonary NTM, with a higher prevalence of RGM in extrapulmonary NTM than in pulmonary NTM. These results provide a better understanding of extrapulmonary NTM.
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Affiliation(s)
- Keitaro Omori
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, Japan; Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Hiroki Kitagawa
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, Japan; Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kakuhiro Yamaguchi
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shinjiro Sakamoto
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yasushi Horimasu
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takeshi Masuda
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shintaro Miyamoto
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Taku Nakashima
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroshi Iwamoto
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazunori Fujitaka
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hironobu Hamada
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kayoko Tadera
- Section of Clinical Laboratory, Department of Clinical Support, Hiroshima University Hospital, Hiroshima, Japan; Division of Clinical Laboratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Toshihito Nomura
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, Japan
| | - Norifumi Shigemoto
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, Japan; Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan; Translational Research Center, Hiroshima University, Hiroshima, Japan
| | - Gaku Aoki
- Department of Biostatistics, Clinical Research Center, Hiroshima University Hospital, Hiroshima, Japan
| | - Noboru Hattori
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroki Ohge
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, Japan
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Leow O, Aoyama R, Loh WS, Shih E, Tay SY, Chew KL, Chew KL, Shen L, Chan SM. Non-Tuberculous Mycobacterial Cervicofacial Lymphadenitis in Children-10-Year Experience in a Tertiary Pediatric Center. J Pediatric Infect Dis Soc 2023; 12:406-412. [PMID: 37310690 DOI: 10.1093/jpids/piad043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 06/10/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Lymphadenitis is the most common manifestation of non-tuberculous mycobacteria (NTM) infection in children. We describe the epidemiology and clinical characteristics of NTM lymphadenitis, determine diagnostic yield from tissue sampling, and review management and outcomes. METHODS This was a 10-year retrospective review of children aged 0-16 years diagnosed with NTM cervicofacial lymphadenitis who were seen in a pediatric infectious disease clinic in a tertiary public hospital. Data relating to patient demographics, clinical features, surgical and antimicrobial treatment, complications, and outcomes were retrieved from patients' electronic medical records and analyzed. RESULTS There were 48 episodes of NTM cervicofacial lymphadenitis in 45 children (17 males and 28 females). Of these episodes, 43.7% manifested as a unilateral single node, mostly parotid (39.6%) and submandibular (29.2%). All patients underwent diagnostic fine-needle aspiration or surgery. Surgical excision more frequently yielded positive histological findings (P = .016). NTM was identified in 22/48 episodes (45.8%) via culture or molecular sequencing. Mycobacterium abscessus was most commonly found (47.8%). Thirty-eight children (79.2%) received antibiotics. Outcomes in 43 episodes revealed full resolution in 69.8%, while 25.6% had de novo disease and 4.6% experienced recurrence at the same site. Overlying skin changes and multiple or bilateral nodal diseases were significantly associated with de novo disease or recurrence (P = .034 and .084, respectively). Complications occurred in 11/70 (15.7%) procedures. Antibiotic-associated adverse effects occurred in 14/38 (36.8%) episodes. CONCLUSIONS NTM lymphadenitis remains a challenging condition. More aggressive management with surgical excision and antibiotics is recommended for those with overlying skin changes and extensive nodal disease.
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Affiliation(s)
- Olivia Leow
- Division of Paediatric Infectious Diseases, Department of Paediatrics, Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore, Singapore
| | - Rie Aoyama
- Division of Paediatric Infectious Diseases, Department of Paediatrics, Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore, Singapore
| | - Woei Shyang Loh
- Department of Otolaryngology-Head and Neck Surgery, National University Health System, Singapore, Singapore
| | - E'Ching Shih
- Department of Otolaryngology-Head and Neck Surgery, National University Health System, Singapore, Singapore
| | - Sok Yan Tay
- Department of Otolaryngology-Head and Neck Surgery, National University Health System, Singapore, Singapore
| | - Ka Lip Chew
- Department of Laboratory Medicine, National University Health System, Singapore, Singapore
| | - Kean Lee Chew
- Department of Laboratory Medicine, National University Health System, Singapore, Singapore
| | - Liang Shen
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Si Min Chan
- Division of Paediatric Infectious Diseases, Department of Paediatrics, Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore, Singapore
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Nurminen J, Heikkinen J, Happonen T, Nyman M, Sirén A, Vierula JP, Velhonoja J, Irjala H, Soukka T, Ivaska L, Mattila K, Hirvonen J. Pictorial Review of MRI Findings in Acute Neck Infections in Children. CHILDREN (BASEL, SWITZERLAND) 2023; 10:967. [PMID: 37371199 DOI: 10.3390/children10060967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 06/29/2023]
Abstract
Pediatric neck infections and their complications, such as abscesses extending to deep neck compartments, are potentially life-threatening acute conditions. Medical imaging aims to verify abscesses and their extensions and exclude other complications. Magnetic resonance imaging (MRI) has proven to be a useful and highly accurate imaging method in acute neck infections in children. Children and adults differ in terms of the types of acute infections and the anatomy and function of the neck. This pictorial review summarizes typical findings in pediatric patients with neck infections and discusses some difficulties related to image interpretation.
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Affiliation(s)
- Janne Nurminen
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Jaakko Heikkinen
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Tatu Happonen
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Mikko Nyman
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Aapo Sirén
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Jari-Pekka Vierula
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Jarno Velhonoja
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Heikki Irjala
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Tero Soukka
- Department of Oral and Maxillofacial Surgery, University of Turku, 20014 Turku, Finland
| | - Lauri Ivaska
- Department of Paediatrics and Adolescent Medicine, InFLAMES Research Flagship Center, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Kimmo Mattila
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Jussi Hirvonen
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
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Roy CF, Balakrishnan K, Boudewyns A, Cheng A, Chun RH, Daniel SJ, Fayoux P, Hart C, Hemansson A, Hewitt R, Hsu WC, Kuo M, Liu C, Maddalozzo J, Messner AH, Pransky S, Rahbar R, Rickert S, Roy S, Russell J, Rutter MJ, Sie KCY, Sidell D, Smith R, Soma M, Spratley J, Watters K, White DR, Wolter N, Zalzal G, Yeung JC. International Pediatric Otolaryngology Group: Consensus guidelines on the diagnosis and management of non-tuberculous mycobacterial cervicofacial lymphadenitis. Int J Pediatr Otorhinolaryngol 2023; 166:111469. [PMID: 36764081 DOI: 10.1016/j.ijporl.2023.111469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/23/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Non-tuberculous mycobacterial (NTM) infection commonly manifests as subacute or chronic cervicofacial lymphadenitis in immunocompetent children. The optimal management of this pathology remains controversial. OBJECTIVES This international consensus guideline aims to understand the practice patterns for NTM cervicofacial lymphadenitis and to address the primary diagnostic and management challenges. METHODS A modified three-iterative Delphi method was used to establish expert recommendations on the diagnostic considerations, expectant or medical management, and operative considerations. The recommendations herein are derived from current expert consensus and critical review of the literature. SETTING Multinational, multi-institutional, tertiary pediatric hospitals. RESULTS Consensus recommendations include diagnostic work-up, goals of treatment and management options including surgery, prolonged antibiotic therapy and observation. CONCLUSION The recommendations formulated in this International Pediatric Otolaryngology Group (IPOG) consensus statement on the diagnosis and management of patients with NTM lymphadenitis are aimed at improving patient care and promoting future hypothesis generation.
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Affiliation(s)
- Catherine F Roy
- Department of Otolaryngology Head & Neck Surgery, McGill University Health Center, Montreal, QC, Canada
| | - Karthik Balakrishnan
- Department of Otolaryngology-Head & Neck Surgery, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - An Boudewyns
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, University of Antwerp, Belgium
| | - Alan Cheng
- Department of Pediatric Otolaryngology, The Sydney Children's Hospital Network-Westmead Campus, The University of Sydney, Sydney, NSW, Australia
| | - Robert H Chun
- Department of Otolaryngology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sam J Daniel
- Department of Otolaryngology Head & Neck Surgery, McGill University Health Center, Montreal, QC, Canada
| | - Pierre Fayoux
- Department of Pediatric Otolaryngology-Head and Neck Surgery, CHU Lille, F-59000, Lille, France
| | - Catherine Hart
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ann Hemansson
- Department of Otorhinolaryngology, Head and Neck Surgery, Lund University Hospital, Lund, Sweden
| | - Richard Hewitt
- Department of Ear, Nose and Throat Surgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Wei-Chung Hsu
- Division of Pediatric Otolaryngology, National Taiwan University College of Medicine and Children's Hospital, Taipei, Taiwan
| | - Michael Kuo
- Department of Pediatric Otolaryngology, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Christopher Liu
- Division of Pediatric Otolaryngology, UT Southwestern Medical Center, Dallas, TX, USA
| | - John Maddalozzo
- Department of Otolaryngology/Head and Neck Surgery, Lurie Children's Hospital, Chicago, IL, USA
| | - Anna H Messner
- Department of Otolaryngology/Head & Neck Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Seth Pransky
- Department of Pediatric Otolaryngology, Rady Children's Hospital, San Diego, CA, USA
| | - Reza Rahbar
- Department of Pediatric Otolaryngology and Communication Enhancement, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott Rickert
- Division of Pediatric Otolaryngology, Hassenfeld Children's Hospital, New York University Langone Health, New York, NY, USA
| | - Soham Roy
- Department of Otolaryngology-Head and Neck Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - John Russell
- Department of Pediatric Otorhinolaryngology, Children's Health Ireland (Crumlin), Dublin, Ireland
| | - Michael J Rutter
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kathleen C Y Sie
- Department of Otolaryngology Head and Neck Surgery, Seattle Children's Hospital, University of Washington, Seattle, USA
| | - Douglas Sidell
- Department of Otolaryngology-Head & Neck Surgery, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Richard Smith
- Department of Otolaryngology-Head & Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Marlene Soma
- Department of Paediatric Otolaryngology, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Jorge Spratley
- Pediatric Otorhinolaryngology, University of Porto Faculty of Medicine, S. Joao Hospital Center, CINTESIS, Porto, Portugal
| | - Karen Watters
- Department of Pediatric Otolaryngology, Rady Children's Hospital, San Diego, CA, USA
| | - David R White
- Division of Pediatric Otolaryngology, MUSC Shawn Jenkins Children's Hospital, Charleston, SC, USA
| | - Nikolaus Wolter
- Department of Otolaryngology - Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - George Zalzal
- Division of Otolaryngology, Children's National Medical Center, George Washington University, Washington, DC, USA
| | - Jeffrey C Yeung
- Department of Otolaryngology Head & Neck Surgery, McGill University Health Center, Montreal, QC, Canada.
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Nguyen T, Marais B, Williams PCM. What is the optimal antibiotic therapy for the treatment of non-tuberculous mycobacterial lymphadenitis in children? Arch Dis Child 2022; 107:1131-1134. [PMID: 36270775 DOI: 10.1136/archdischild-2022-324851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 10/10/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Tran Nguyen
- Paediatric Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Ben Marais
- Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Sydney, New South Wales, Australia.,The WHO Collaborating Centre in Tuberculosis, The University of Sydney, Sydney, New South Wales, Australia
| | - Phoebe C M Williams
- Paediatric Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, New South Wales, Australia.,Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Sydney, New South Wales, Australia.,School of Public Health, Faculty of Medicine, The University of Sydney, Sydney, New South Wales, Australia
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13
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Singh D, Sit S, Singh N. Diagnostic and therapeutic dilemma of cervical adenitis in an adult. BMJ Case Rep 2022. [DOI: 10.1136/bcr-2021-247303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Citrobacter freundii infections have not been previously described as an aetiology for lymphadenitis in healthy adults. Non-tuberculous mycobacteria (NTM) infections typically occur in young children or immunocompromised individuals, with few cases seen in adults. A woman in her 20s presented with lymphadenitis that was subsequently positive for C. freundii and NTM on needle biopsy and was treated with antibiotics. The patient was followed up for 3 months with regular ultrasound scans and is currently asymptomatic. The excisional biopsy was cancelled as a result. This case highlights the complexity of making a diagnosis in some patients with cervical adenopathy, and as such, it is crucial to use the patient’s clinical course to guide treatment modalities. Contamination was a possibility in this case given the number of organisms shown on biopsy and the lack of response to treatment, and we provide an approach to management in this case of uncertainty.
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14
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Non-tuberculous Mycobacterial Infection of the Retropharyngeal Space. Pediatr Infect Dis J 2022; 41:e286-e289. [PMID: 35421046 DOI: 10.1097/inf.0000000000003548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report a case of Mycobacterium avium complex infection of the retropharyngeal space in a 20-month-old girl. We also summarize the published literature on the pathogenesis and management of nontuberculous mycobacterial infections of the retropharynx.
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15
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Rist TM, Baglam T, Pecha PP. A Perplexing Pediatric Parotid Mass. JAMA Otolaryngol Head Neck Surg 2022; 148:277-278. [PMID: 34989767 DOI: 10.1001/jamaoto.2021.3879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Tyler M Rist
- Department of Otolaryngology-Head & Neck Surgery, College of Medicine, Medical University of South Carolina, Charleston
| | - Tekin Baglam
- Department of Otolaryngology-Head & Neck Surgery, College of Medicine, Medical University of South Carolina, Charleston
| | - Phayvanh P Pecha
- Department of Otolaryngology-Head & Neck Surgery, College of Medicine, Medical University of South Carolina, Charleston
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Koo EY, Maksimoski MT, Herron MM, Bhushan B, Reynolds MA, Katz BZ, Johnston DR, Rastatter JC, Maddalozzo J. Surgical management of parotid non-tuberculous mycobacteria lymphadenitis in children: A pediatric tertiary-care hospital's experience. Int J Pediatr Otorhinolaryngol 2021; 151:110960. [PMID: 34736012 DOI: 10.1016/j.ijporl.2021.110960] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 10/04/2021] [Accepted: 10/25/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Non-tuberculous mycobacteria (NTM) represents an important etiology of cervicofacial lymphadenitis (CFL) and skin/soft tissue infections in children. It can also affect the salivary glands, including the parotid gland, which is unique due to the presence of intra-salivary lymph nodes. There are no established guidelines for treatment of NTM CFL. NTM lymphadenitis was historically surgically treated; recently the literature supports initial medical treatment. Treatment decisions have been dependent on the extent of disease, preference of providers, and risk of surgical complications. The goal is to report our experience in surgical outcomes of NTM CFL with involvement of the parotid gland after pre-operative medical management. METHODS A retrospective case series of patients with NTM affecting the parotid gland at a tertiary care pediatric hospital between 2004 and 2020. RESULTS Seventy-two patients were referred for surgical evaluation of possible parotid NTM. Thirty-three patients underwent surgical excision. Fifteen patients were identified with presumed NTM infection involving the parotid gland. There were twelve females and three males with a mean age of 2.0 years (SD 1.55; range 1-6 days) at the time of surgery. All underwent surgical excision with parotidectomy. The most common pre-operative antimycobacterial therapy used was a combination of clarithromycin and rifampin. All 15 patients had pathological findings consistent with NTM infection (granulomatous lymphadenitis). Forty percent (n = 6) of patients had positive stains with acid-fast bacilli (AFB), with Mycobacterium avium as the most common species (n = 5). The majority of patients, 86.67% (n = 13), had complete resolution of infection after surgery. Clarithromycin and rifampin were the most common post-operative antimycobacterial treatment (mean 81.5 days, SD 110.14, range 2-411 days). The most common complication experienced was acute (<3 months) lower facial nerve paresis (40%, n = 6), but no patient had permanent facial paralysis. CONCLUSION AND RELEVANCE Parotidectomy is a safe and efficacious treatment in patients with NTM CFL affecting the parotid gland after incomplete resolution with antimycobacterial therapy. Further investigation to optimize duration of antimycobacterial treatment is necessary. We highlight the experience of a high-volume tertiary care pediatric hospital with surgical management of this disease.
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Affiliation(s)
- Elliot Y Koo
- Department of Otolaryngology - Head & Neck Surgery University of Illinois Chicago, Chicago, IL, USA; Division of Pediatric Otolaryngology Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Matthew T Maksimoski
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Pediatric Otolaryngology Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Monica M Herron
- Division of Pediatric Otolaryngology Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Bharat Bhushan
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Pediatric Otolaryngology Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Meredith A Reynolds
- Division of Pathology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Ben Z Katz
- Division of Infectious Disease, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Douglas R Johnston
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Pediatric Otolaryngology Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jeffrey C Rastatter
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Pediatric Otolaryngology Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - John Maddalozzo
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Pediatric Otolaryngology Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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17
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Bai A, Belda O, Dosanjh A. Pulmonary Nontuberculous Mycobacterial Infection in Infants: A Systematic Review. Pediatric Health Med Ther 2021; 12:551-559. [PMID: 35002357 PMCID: PMC8721029 DOI: 10.2147/phmt.s332434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 11/26/2021] [Indexed: 01/15/2023] Open
Abstract
Limited information and literature exist examining pulmonary infections caused by nontuberculous mycobacterial specifically in an infant population. The objective of our study was to summarize clinical characteristics and outcomes of infant patients with nontuberculous mycobacterial pulmonary infection via systematic literature review to identify common diagnostic and treatment regimens for this infection in infants. A search of MEDLINE and PubMed databases in October 2019 using MeSH search terms “infant,” “NTM,” “pulmonary,” and “Mycobacterium abscessus” yielded 139 articles. Inclusion criteria were i) English-language studies including cases and case series with ii) established nontuberculous mycobacterial pulmonary infection in iii) a patient population of infants no older than 24 months. Patients with cystic fibrosis and any study which did not contain relevant information such as infection and age were excluded. This yielded data on 37 patients extracted from 28 studies analyzed. The most common strain was Mycobacterium avium complex, isolated in 56.8% of patient diagnoses. Bronchoscopy/thoracoscopy with a subsequent culture were the most common diagnostic techniques, utilized in 64.9% of cases. Drug therapeutic treatment was utilized in 86% of cases, with a median of three drugs administered. Notable limitations of this study are the small sample size and its retrospective nature, which relies on information reported in previous case studies. Although there is limited formal clinician consensus on the treatment of NTM pulmonary infection and how it may differ in an infant population, our findings indicate an informal consensus typically involving diagnostic lung specimen culture and antibiotic therapy.
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Affiliation(s)
- Alice Bai
- Brown University, Providence, RI, USA
- Correspondence: Alice Bai Brown University, 69 Brown St. Mail# 5288, Providence, RI, 02912, USATel +1 770 843-2062 Email
| | | | - Amrita Dosanjh
- Pediatric Respiratory, Affiliated Staff Member, Department of Pediatrics, Rady Children’s Hospital, San Diego, CA, USA
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18
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Nielsen NØ, Nørlinger C, Greve T, Klug TE. Cervical suppurative lymphadenitis in children: microbiology, primary sites of infection, and evaluation of antibiotic treatment. Eur Arch Otorhinolaryngol 2021; 279:3053-3062. [PMID: 34623496 DOI: 10.1007/s00405-021-07115-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/29/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE The significant pathogens associated with paediatric cervical suppurative lymphadenitis (CSL) are unclarified, and there is a lack of clinical evaluations of antibiotic regimens in paediatric CSL. We aimed to (1) explore the bacterial findings and the associated primary sites of infection in paediatric cases of CSL and (2) evaluate the clinical outcomes in patients treated with different antibiotic regimens. METHODS All children (< 18 years) treated for non-mycobacterium CSL at the Department of Otorhinolaryngology, Aarhus University Hospital, from 2001 to 2018 were retrospectively evaluated. RESULTS Eighty-five patients were included in the study. The prevalent isolates were S. aureus (57%), S. pyogenes (17%), non-haemolytic streptococci (11%), and F. necrophorum (3%). The primary sites of infection were identified in 30 (35%) patients. The most common sites were the oropharynx (n = 15), the middle ear (n = 10), and the skin (n = 5). All patients were treated with surgical incision and antibiotics. No statistically significant differences were found between patients treated with antibiotics covering streptococci (n = 60) versus antibiotics covering streptococci and S. aureus (n = 25) in terms of duration of hospitalisation (median 4 vs 4 days, p = 0.26), altered antibiotic treatment because of insufficient clinical or biochemical progress (7% vs 12%, p = 0.41), and abscess recurrence (8% vs 12%, p = 0.69). CONCLUSION S. aureus was the predominant pathogen in paediatric CSL at all cervical levels, and even in cases with evidence of primary site infection not normally associated with S. aureus. We were unable to underscore the importance of antibiotic treatment covering S. aureus based on evaluation of the clinical outcomes.
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Affiliation(s)
- Nicolai Østergaard Nielsen
- Department of Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, 8200, Aarhus N, Denmark.
| | - Christian Nørlinger
- Department of Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, 8200, Aarhus N, Denmark
| | - Thomas Greve
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Tejs Ehlers Klug
- Department of Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, 8200, Aarhus N, Denmark
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Pecora F, Abate L, Scavone S, Petrucci I, Costa F, Caminiti C, Argentiero A, Esposito S. Management of Infectious Lymphadenitis in Children. CHILDREN-BASEL 2021; 8:children8100860. [PMID: 34682125 PMCID: PMC8535130 DOI: 10.3390/children8100860] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/22/2021] [Accepted: 09/22/2021] [Indexed: 01/22/2023]
Abstract
Lymphadenopathy is an irregularity in the size and texture of the lymph nodes, which is quite common in childhood. When the enlargement of lymph nodes is caused by inflammatory and infectious processes, it is called lymphadenitis. The main objective of this manuscript is to summarize the common infectious etiologies and presentations of lymphadenitis in children providing a management guide for clinical practice. PubMed was used to search for all of the studies published up to April 2021 using keywords such as "lymphadenitis" and "children". Literature analysis showed that the differential diagnosis for lymphadenitis in pediatrics is broad. Although lymph node enlargement in children is usually benign and self-limited, it is important to exclude malignant etiology. In most cases, history and physical examination allow to identify the correct diagnosis and start a proper treatment with a prompt resolution of the lymphadenopathy. However, particularly in the case of persistent lymphadenitis, determining the cause of lymph node enlargement may be difficult, and the exact etiology may not be identified despite extensive investigations. Further studies should develop and validate an algorithm to assist pediatricians in the diagnosis and timely treatment of lymphadenitis, suggesting situations in which a watchful waiting may be considered a safe approach, those in which empiric antibiotic therapy should be administered, and those requiring a timely diagnostic work-up.
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Affiliation(s)
- Francesco Pecora
- Paediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (F.P.); (L.A.); (S.S.); (I.P.); (F.C.); (A.A.)
| | - Luciana Abate
- Paediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (F.P.); (L.A.); (S.S.); (I.P.); (F.C.); (A.A.)
| | - Sara Scavone
- Paediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (F.P.); (L.A.); (S.S.); (I.P.); (F.C.); (A.A.)
| | - Irene Petrucci
- Paediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (F.P.); (L.A.); (S.S.); (I.P.); (F.C.); (A.A.)
| | - Federico Costa
- Paediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (F.P.); (L.A.); (S.S.); (I.P.); (F.C.); (A.A.)
| | - Caterina Caminiti
- Research an Innovation Unit, University Hospital of Parma, via Gramsci 14, 43126 Parma, Italy;
| | - Alberto Argentiero
- Paediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (F.P.); (L.A.); (S.S.); (I.P.); (F.C.); (A.A.)
| | - Susanna Esposito
- Paediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (F.P.); (L.A.); (S.S.); (I.P.); (F.C.); (A.A.)
- Correspondence: ; Tel.: +39-0521-903-524
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20
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Martínez-Planas A, Baquero-Artigao F, Santiago B, Fortuny C, Méndez-Echevarría A, Del Rosal T, Bustillo-Alonso M, Gale I, Guerrero C, Blázquez-Gamero D, Canet A, Lillo M, Calavia O, Núñez Cuadros E, Falcón-Neyra L, Soriano-Arandes A, Van Ingen J, Tebruegge M, Noguera-Julian A. Interferon-Gamma Release Assays Differentiate between Mycobacterium avium Complex and Tuberculous Lymphadenitis in Children. J Pediatr 2021; 236:211-218.e2. [PMID: 33984332 DOI: 10.1016/j.jpeds.2021.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/24/2021] [Accepted: 05/04/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To assess the performance of interferon-gamma release assays (IGRAs) in the differential diagnosis between Mycobacterium avium complex (MAC) and tuberculosis (TB) in children affected with subacute/chronic submandibular/cervical lymphadenitis. STUDY DESIGN Multicenter observational study comparing children with microbiologically confirmed MAC lymphadenitis from the European NontuberculouS MycoBacterial Lymphadenitis in childrEn study with children with TB lymphadenitis from the Spanish Network for the Study of Pediatric TB database. RESULTS Overall, 78 patients with MAC and 34 with TB lymphadenitis were included. Among MAC cases, 44 out of 74 (59.5%) had positive tuberculin skin test (TST) results at the 5-mm cut-off, compared with 32 out of 33 (97%) TB cases (P < .001); at the 10-mm cut-off TST results were positive in 23 out of 74 (31.1%) vs 26 out of 31 (83.9%), respectively (P < .001). IGRA results were positive in only 1 out of 32 (3.1%) patients with MAC who had undergone IGRA testing, compared with 21 out of 23 (91.3%) TB cases (P < .001). Agreement between TST and IGRA results was poor in MAC (23.3%; κ = 0.017), but good in TB cases (95.6%; κ = 0.646). IGRAs had a specificity of 96.9% (95% CI 84.3%-99.8%), positive predictive value of 95.4% (95% CI 78.2%-99.8%), and negative predictive value of 93.9% (95% CI 80.4%-98.9%) for TB lymphadenitis. CONCLUSIONS In contrast to TST, IGRAs have high specificity, negative predictive value, and positive predictive value for TB lymphadenitis in children with subacute/chronic lymphadenopathy, and consequently can help to discriminate between TB and MAC disease. Therefore, IGRAs are useful tools in the diagnostic work-up of children with lymphadenopathy, particularly when culture and polymerase chain reaction results are negative.
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Affiliation(s)
- Aina Martínez-Planas
- Infectious Diseases and Systemic Inflammatory Response in Pediatrics, Infectious Diseases Unit, Department of Pediatrics, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Fernando Baquero-Artigao
- Pediatrics and Infectious Disease Unit, Hospital Universitario La Paz, Madrid, Spain; Fundación IdiPaz, Madrid, Spain; Translational Research Network of Pediatric Infectious Diseases (RITIP), Madrid, Spain
| | - Begoña Santiago
- Translational Research Network of Pediatric Infectious Diseases (RITIP), Madrid, Spain; Department of Pediatric Infectious Diseases, University Hospital Gregorio Marañón and Gregorio Marañón Research Institute, Madrid, Spain
| | - Clàudia Fortuny
- Infectious Diseases and Systemic Inflammatory Response in Pediatrics, Infectious Diseases Unit, Department of Pediatrics, Institut de Recerca Sant Joan de Déu, Barcelona, Spain; Translational Research Network of Pediatric Infectious Diseases (RITIP), Madrid, Spain; Center for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain; Department of Pediatrics, University of Barcelona, Barcelona, Spain
| | - Ana Méndez-Echevarría
- Pediatrics and Infectious Disease Unit, Hospital Universitario La Paz, Madrid, Spain; Fundación IdiPaz, Madrid, Spain; Translational Research Network of Pediatric Infectious Diseases (RITIP), Madrid, Spain
| | - Teresa Del Rosal
- Pediatrics and Infectious Disease Unit, Hospital Universitario La Paz, Madrid, Spain; Fundación IdiPaz, Madrid, Spain; Translational Research Network of Pediatric Infectious Diseases (RITIP), Madrid, Spain
| | | | - Inés Gale
- Pediatrics Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Carmelo Guerrero
- Pediatrics Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Daniel Blázquez-Gamero
- Translational Research Network of Pediatric Infectious Diseases (RITIP), Madrid, Spain; Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital Universitario 12 de Octubre, Madrid, Spain; Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), Madrid, Spain; Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Madrid, Spain
| | - Anna Canet
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Miguel Lillo
- Pediatrics Department, Hospital General Universitario de Albacete, Albacete, Spain
| | - Olga Calavia
- Pediatrics Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Esmeralda Núñez Cuadros
- Division of Pediatric Rheumatology, Hospital Regional Universitario Materno-Infantil de Málaga, Málaga, Spain
| | - Lola Falcón-Neyra
- Pediatric Infectious Diseases, Rheumatology and Immunology Unit, Hospital Universitario Virgen del Rocío, Institute of Biomedicine, Seville, Spain
| | - Antoni Soriano-Arandes
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Vall d'Hebron Hospital Universitari, Barcelona, Spain; Infection in the Immunocompromissed Child Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Jakko Van Ingen
- Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marc Tebruegge
- Department of Paediatric Infectious Diseases and Immunology, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom; Department of Pediatrics, The University of Melbourne, Parkville, Australia; Department of Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Antoni Noguera-Julian
- Infectious Diseases and Systemic Inflammatory Response in Pediatrics, Infectious Diseases Unit, Department of Pediatrics, Institut de Recerca Sant Joan de Déu, Barcelona, Spain; Translational Research Network of Pediatric Infectious Diseases (RITIP), Madrid, Spain; Center for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain; Department of Pediatrics, University of Barcelona, Barcelona, Spain.
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21
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Sun L, Qi X, Guo Y, Qi H, Li J, Wu X, Yin Q, Guo Y, Xu B, Wang Y, Jin Q, Gao L, Shen A. Tuberculosis infection screening in children with close contact: a hospital-based study. BMC Infect Dis 2021; 21:815. [PMID: 34388985 PMCID: PMC8364055 DOI: 10.1186/s12879-021-06480-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Identifying and prioritizing at-risk populations is critical for pediatric tuberculosis control. We aimed to identify a latent tuberculosis infection (LTBI) screening strategy that is appropriate for the Chinese context among children with different TB exposure levels and to explore its clinical importance. METHODS During 2013-2015, we enrolled hospitalized children with suspected respiratory infectious disease (RID) for LTBI screening using the tuberculin skin test (TST) and interferon-γ release assay (IGRA) T-SPOT.TB as part of a work up for their RID. Participants with confirmed diagnosis were classified into three subgroups according to level of exposure to TB: no reported contact risk, with household contact risk, and with non-household contact risk. RESULTS A total 6202 children (median age: 4.76 years; interquartile range: 1.0-8.0 years) were enrolled. Children with no reported contact risk had the lowest proportions of positive results for the IGRA (0.7%) and TST (3.3%). The proportion of positive results for each test was higher for household contacts than non-household contacts. The TST positive proportion was much higher than that for the IGRA in all three groups. Children with IGRA+/TST+ results had larger indurations than those with IGRA- /TST+ results (15 mm vs. 13 mm, P = 0.02). For IGRA, older age (> 5 years) and non-household or household contact risk were associated with a positive result. CONCLUSIONS Positive IGRA results in children with a contact risk can serve as a critical reference for LTBI management. IGRA can be used, in preference to TST, for Chinese children with a TB exposure risk.
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Affiliation(s)
- Lin Sun
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xue Qi
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.,Department of Respiratory, Qilu Children's Hospital of Shandong University, Jinan, China
| | - Yajie Guo
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Hui Qi
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jieqiong Li
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xirong Wu
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Qingqin Yin
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yan Guo
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Baoping Xu
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yacui Wang
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Qi Jin
- MOH Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, and Centre for Tuberculosis, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lei Gao
- MOH Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, and Centre for Tuberculosis, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Adong Shen
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
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22
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Ford TJ, Silcock RA, Holland SM. Overview of nontuberculous mycobacterial disease in children. J Paediatr Child Health 2021; 57:15-18. [PMID: 33404128 DOI: 10.1111/jpc.15257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/27/2020] [Accepted: 10/21/2020] [Indexed: 11/27/2022]
Abstract
Nontuberculous mycobacteria (NTM) are ubiquitous organisms in our surrounding environment. Four distinct clinical syndromes associated with NTM infection have been described: skin and soft tissue disease, lymphadenitis, disseminated disease and pulmonary disease. In children, lymphadenitis is the most common NTM clinical entity, particularly affecting those aged 1-5 years who have no known risk factors for disease. Optimal management of NTM lymphadenitis is not entirely clear, although surgical intervention is likely a definitive therapy. Disseminated NTM disease is uncommon and only seen in the setting of immunocompromise. In previously well children, this presentation should always lead to consideration of an underlying immune defect, such as Mendelian susceptibility to mycobacterial disease. Identification of the underlying cause enables more targeted therapy and better prognostic understanding. Pulmonary NTM disease is fundamentally different to the other clinical syndromes, presenting in different hosts, who have different comorbidities, and follow a different clinical course.
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Affiliation(s)
- Timothy J Ford
- Department of Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Robyn A Silcock
- Infection Management and Prevention Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Steven M Holland
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States
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23
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Connors J, Taufique Z, Rickert S. Complex mediastinal infection causing bilateral airway obstruction in a young child: Pulmonary mycobacterium avium infection and the role of surgical intervention in the compromised airway. OTOLARYNGOLOGY CASE REPORTS 2020. [DOI: 10.1016/j.xocr.2020.100230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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24
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Le Naour S, Boyer J, Malard O, Guillouzouic A, Aubry A, Launay E, Barbarot S. Adénites cervico-faciales à mycobactéries atypiques de l’enfant : caractéristiques cliniques, microbiologiques et thérapeutiques. Étude rétrospective et revue de la littérature. Ann Dermatol Venereol 2020; 147:618-628. [DOI: 10.1016/j.annder.2020.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 02/06/2020] [Accepted: 06/23/2020] [Indexed: 10/23/2022]
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Venturini E, Grillandini C, Bianchi L, Montagnani C, Chiappini E, Galli L. Clinical features and outcomes of lymphadenopathy in a tertiary children's hospital. J Paediatr Child Health 2020; 56:1277-1282. [PMID: 32436627 DOI: 10.1111/jpc.14922] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/11/2020] [Accepted: 04/14/2020] [Indexed: 02/01/2023]
Abstract
AIM The aim of the present study is to describe the clinical features and outcomes of childhood lymphadenopathy and to define factors able to predict neoplastic aetiology or may improve its prognosis. METHODS All children evaluated for lymphadenopathy in our tertiary children's hospital and who underwent their first examination between 1 January, 2015 and 31 December, 2017 were enrolled in this retrospective observational study. Data were analysed using SPSS.Statistics, 24.0. RESULTS A total of 322 children, aged between 0 and 18 years (median 4.5; interquartile range 2.5-9), were enrolled. A specific diagnosis was achieved in almost half of the cases (n = 159, 49.4%) by using one or more methods, including serological, microbiological, biomolecular or histological investigations on surgical samples. Epstein Barr virus and non-tuberculous mycobacteria were the most common etiological agents among acute/sub-acute and chronic lymphadenopathy, respectively. At the end of the study period, two-thirds (210, 65.2%) of enrolled patients were successfully treated. Malignancies and non-tuberculous mycobacteria infections had the longest time to resolution. CONCLUSIONS Our data suggest that lymphadenopathy is a benign condition in most cases. Of note in our study, 2.5% of lymphadenopathy cases were found to be due to oncologic conditions. The most frequent infective causes were Epstein Barr virus, bacteria and non-tuberculous mycobacteria infections. No haematic or ultrasonographic features were independently able to provide sufficient evidence for a conclusive diagnosis. However, utilising these findings alongside evaluation for clinical criteria can guide decision-making for physicians. Lymphadenectomy is the most appropriate process to follow in the event of chronic lymphadenopathy with undefined diagnosis.
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Affiliation(s)
- Elisabetta Venturini
- Division of Pediatric Infectious Disease, Anna Meyer Children's University Hospital, Florence, Italy.,Department of Health Sciences, University of Florence, Florence, Italy
| | | | - Leila Bianchi
- Division of Pediatric Infectious Disease, Anna Meyer Children's University Hospital, Florence, Italy
| | - Carlotta Montagnani
- Division of Pediatric Infectious Disease, Anna Meyer Children's University Hospital, Florence, Italy
| | - Elena Chiappini
- Division of Pediatric Infectious Disease, Anna Meyer Children's University Hospital, Florence, Italy.,Department of Health Sciences, University of Florence, Florence, Italy
| | - Luisa Galli
- Division of Pediatric Infectious Disease, Anna Meyer Children's University Hospital, Florence, Italy.,Department of Health Sciences, University of Florence, Florence, Italy
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26
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Meoli A, Deolmi M, Iannarella R, Esposito S. Non-Tuberculous Mycobacterial Diseases in Children. Pathogens 2020; 9:pathogens9070553. [PMID: 32660053 PMCID: PMC7400539 DOI: 10.3390/pathogens9070553] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/19/2020] [Accepted: 07/07/2020] [Indexed: 01/19/2023] Open
Abstract
Non-tuberculous mycobacteria (NTMs) are ubiquitous and opportunistic emerging bacteria with the potential to colonize and eventually infect either immunocompromised or immunocompetent individuals. In the last three decades, the prevalence of disease caused by NTMs has increased in several countries. The increased prevalence of NTM infection can be explained by an ageing population with rising comorbidities, HIV infection, the common use of immunosuppressive drugs, and improved diagnostic methods. The aim of this review is to demonstrate the clinical relevance of NTMs in children, describing their features and manifestations, diagnostic tools, and therapeutic approaches. We collected data from the literature about NTM infections in young patients over the past five years (2014–2019) using the keywords “non-tuberculous”, “mycobacteria”, “paediatric”, “NTM”, “cystic fibrosis”, and “children”. Recent literature points out that NTMs are ubiquitous, with several species including both those that are pathogens for humans and those that are not. This means that, if a mycobacterium is isolated from a patient’s specimen, we have to distinguish between a simple colonization and an NTM-related disease. The start of treatment depends on many factors that are necessary to consider, such as clinical and imaging features, patient comorbidity and immunocompetence, drug adverse effects, and compliance with a very long therapy that can last many months. Due to the increasing prevalence and clinical relevance of NTMs, guidelines for their optimal management, especially in the presence of chronic underlying disease, are urgently needed.
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27
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Sharma SK, Sharma R, Singh BK, Upadhyay V, Mani I, Tripathi M, Kumar P. A prospective study of non-tuberculous mycobacterial disease among tuberculosis suspects at a tertiary care centre in north India. Indian J Med Res 2020; 150:458-467. [PMID: 31939389 PMCID: PMC6977370 DOI: 10.4103/ijmr.ijmr_194_19] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background & objectives The burden of non-tuberculous mycobacterial (NTM) disease is increasing worldwide. The disease shares clinicoradiological features with tuberculosis (TB), Nocardia and several fungal diseases, and its diagnosis is frequently delayed. The present study was performed to determine the frequency of NTM disease among TB suspects in a tertiary care centre in north India. Methods In this prospective study, mycobacterial culture isolates from pulmonary and extrapulmonary specimens among TB suspects were tested with immunochromatographic assay (ICA). All ICA-negative isolates were considered as NTM suspects and further subjected to 16S-23S rRNA internal transcribed spacer gene sequencing for confirmation and species identification. Patients with active disease were treated with drug regimen as per the identified NTM species. Follow up of patients was done to determine clinical, radiological and microbiological outcomes. Results Of the 5409 TB suspects, 42 (0.77%) were diagnosed with NTM disease. Patients with active disease consenting for treatment were treated and followed up. Thirty four patients had NTM pulmonary disease (NTM-PD) and the remaining eight had extrapulmonary NTM (EP-NTM) disease. Mycobacterium intracellulare and M. abscessus, respectively, were most frequently isolated from NTM-PD and EP-NTM patients. Fifteen NTM-PD and seven EP-NTM patients successfully completed the treatment. Ten patients died due to unrelated causes, five were lost to follow up and another four declined the treatment. Interpretation & conclusions Our study showed that the frequency of NTM disease was low among TB suspects at a large tertiary care centre in north India and this finding was similar to other Indian studies. More studies need to be done in other parts of the country to know the geographical variation in NTM disease, if any.
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Affiliation(s)
- Surendra Kumar Sharma
- Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rohini Sharma
- Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Binit Kumar Singh
- Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Vishwanath Upadhyay
- Department of Molecular Medicine, Jamia Hamdard Institute of Molecular Medicine, Jamia Hamdard (Deemed to be University), New Delhi, India
| | - Indra Mani
- Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Madhavi Tripathi
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Prahlad Kumar
- National Tuberculosis Institute, Bengaluru, Karnataka, India
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28
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Willemse SH, Karssemakers LHE, Oomens MAEM, Schreuder WH, Lindeboom JA, van Wijk AJ, de Lange J. Cervicofacial non-tuberculous mycobacterial lymphadenitis: clinical determinants of incomplete surgical removal. Int J Oral Maxillofac Surg 2020; 49:1392-1396. [PMID: 32371179 DOI: 10.1016/j.ijom.2020.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/10/2020] [Accepted: 03/31/2020] [Indexed: 10/24/2022]
Abstract
In patients with non-tuberculous mycobacterial cervicofacial lymphadenitis, incomplete surgical removal of infected lymph nodes leads to delayed healing and a higher recurrence rate, with eventual spontaneous drainage through the skin. However, complete surgical removal is not always achievable due to the extent of the infected tissue and proximity to vulnerable structures, such as the facial or accessory nerve. The aim of this study was to identify the clinical determinants of the (in)ability to perform complete surgical removal. The electronic health records of patients aged 0-15 years with bacteriologically proven non-tuberculous mycobacterial cervicofacial lymphadenitis, who underwent surgical treatment and preoperative sonographic imaging, were analysed. This was a case-control study. A total of 103 patients met the inclusion criteria. Most of the infections were unilateral, submandibular, and caused by Mycobacterium avium. Multiple logistic regression analysis revealed that higher age (odds ratio 1.24, 95% confidence interval 1.04-1.47) and fistulization (odds ratio 3.15, 95% confidence interval 1.13-8.75) were significantly associated with a limited ability to surgically remove all infected tissue. However, a larger sonographic lymph node size was not significantly associated. These findings could aid clinicians when informing the parent(s)/guardian(s) of the patient preoperatively and in properly estimating the intraoperative and postoperative course.
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Affiliation(s)
- S H Willemse
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC and Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam, Amsterdam, The Netherlands.
| | - L H E Karssemakers
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC and Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam, Amsterdam, The Netherlands; Department of Head and Neck Oncology and Surgery, Netherlands Cancer Institute/Antoni Van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - M A E M Oomens
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC and Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam, Amsterdam, The Netherlands; Department of Head and Neck Oncology and Surgery, Netherlands Cancer Institute/Antoni Van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - W H Schreuder
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC and Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam, Amsterdam, The Netherlands; Department of Head and Neck Oncology and Surgery, Netherlands Cancer Institute/Antoni Van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - J A Lindeboom
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC and Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam, Amsterdam, The Netherlands; Department of Oral and Maxillofacial Surgery, Amstelland Hospital, Amstelveen, The Netherlands
| | - A J van Wijk
- Department of Social Dentistry, ACTA, University of Amsterdam and Vrije Universiteit, Amsterdam, The Netherlands
| | - J de Lange
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC and Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam, Amsterdam, The Netherlands
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Papatsoutsos E, Aumann V, Vorwerk P, Redlich A, Tammer I, Arens C, Vorwerk U. [Cervical lymphadenitis caused by non-tuberculous mycobacteria in children with different residence]. Laryngorhinootologie 2020; 99:628-636. [PMID: 32268397 DOI: 10.1055/a-1146-3118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Atypical mycobacteria form a heterogeneous group. Although more than 140 species have been identified, only 25 of them are considered responsible for infection in humans. The most frequent manifestation of the disease in immunocompetent children is the cervical lymphadenitis. Aims of this study were to identify a correlation of the location of residence with patients' demographics and disease characteristics, to evaluate the ultrasonographic findings and the different operative treatments modalities and to develop an algorithm for the diagnosis and treatment. MATERIALS AND METHODS Cases were identified by using the hospital's correspondence, microbiology and pathology databases. Demographic and clinical data were collected. A statistical analysis of the results was performed. RESULTS 32 patients were included. Our data revealed no significant correlation between area of residence and disease characteristics. Hypoechoic lymph nodes with intraglandular necrosis and low vascularity were observed in the majority of patients. Surgical treatment included abscess incision with biopsy, lymphadenectomy, selective neck dissection and partial parotidectomy. A recurrent disease was significantly more frequent after abscess incision. CONCLUSIONS Further studies with prospective design are required, in order to confidently identify the correlation between area of residence and disease characteristics. Similar ultrasonographic findings suggest a constant constellation of changes that facilitate diagnostic evaluation. Complete surgical excision offers an effective management option as it combines definitive treatment and histological confirmation with low risk of complications.
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Affiliation(s)
- Efstathios Papatsoutsos
- Universitätsklinik für Hals-, Nasen- und Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Magdeburg, Germany
| | - Volker Aumann
- Pädiatrische Hämatologie und Onkologie, Universitätsklinikum Magdeburg Kinderklinik, Magdeburg, Germany
| | - Peter Vorwerk
- Pädiatrische Hämatologie und Onkologie, Universitätsklinikum Magdeburg Kinderklinik, Magdeburg, Germany
| | - Antje Redlich
- Pädiatrische Hämatologie und Onkologie, Universitätsklinikum Magdeburg Kinderklinik, Magdeburg, Germany
| | - Ina Tammer
- Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Universitätsklinikum Magdeburg, Germany
| | - Christoph Arens
- Universitätsklinik für Hals-, Nasen- und Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Magdeburg, Germany
| | - Ulrich Vorwerk
- Universitätsklinik für Hals-, Nasen- und Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Magdeburg, Germany
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30
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Zhukhovitskaya A, Chang DT, Huoh KC, Pham NS, Singh J, Ahuja GS. Surgical management of atypical mycobacterial cervical lymphadenitis in an outbreak of odontological infection. Int J Pediatr Otorhinolaryngol 2020; 131:109882. [PMID: 31981916 DOI: 10.1016/j.ijporl.2020.109882] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 01/12/2020] [Accepted: 01/13/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION We report on our experience with surgical management of nosocomial Mycobacterium abscessus cervical lymphadenitis in the setting of an epidemic linked to a dental practice in the community. METHODS This is an observational case series of children who required surgical treatment of cervical lymphadenitis as part of multidisciplinary management of nosocomial M. abscessus infections. We describe the criteria for surgical management of cervical lymphadenitis as well as patient characteristics and outcomes. RESULTS Over 1000 children undergoing pulpectomies and pulpotomies at a local dental practice with a contaminated water source were identified as potentially susceptible to atypical mycobacteria infection, identified as M. abscessus. Between August 2016 and May 2017 108 children underwent inpatient evaluation at our institution by general pediatricians and pediatric infectious disease specialists. 90 children required at least 1 surgical intervention by pediatric otolaryngology and/or oral and maxillofacial surgery (OMFS). Children were evaluated by the Pediatric Otolaryngology service if computer tomography (CT) scan of the neck demonstrated lymph nodes of at least 1.5 cm in shortest dimension or lymph nodes with central hypolucencies suspicious for infection with central necrosis. Pediatric Otolaryngology intervened on 11 patients all of whom required selective cervical lymphadenectomy with or without curettage. These patients ranged in age from 3 to 8 years; 8 were male, 6 had concurrent pulmonary nodules. Two patients underwent curettage in addition to lymphadenectomy. Five patients required at least 2 surgical interventions by Pediatric Otolaryngology. CONCLUSION We found M. abscessus to be an aggressive infection requiring early cervical lymphadenectomy in select patients.
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Affiliation(s)
- A Zhukhovitskaya
- University of California - Irvine, Department of Otolaryngology, Orange, CA, USA; CHOC Children's Hospital, Orange, CA, USA.
| | - D T Chang
- CHOC Children's Hospital, Orange, CA, USA
| | - K C Huoh
- CHOC Children's Hospital, Orange, CA, USA
| | - N S Pham
- CHOC Children's Hospital, Orange, CA, USA
| | - J Singh
- CHOC Children's Hospital, Orange, CA, USA
| | - G S Ahuja
- CHOC Children's Hospital, Orange, CA, USA
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31
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Harb JL, Compton RA, Meissner HC, Scott AR. In Response to the Management of Nontuberculous Mycobacterial Cervicofacial Lymphadenitis: A View Beyond Surgery. Laryngoscope 2020; 130:E947-E948. [PMID: 32154910 DOI: 10.1002/lary.28607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 02/10/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Jennifer L Harb
- Department of Otolaryngology-Head and Neck Surgery, Tufts Medical Center, Boston, Massachusetts, U.S.A
| | - Rebecca A Compton
- Department of Otolaryngology-Head and Neck Surgery, Tufts Medical Center, Boston, Massachusetts, U.S.A
| | - H Cody Meissner
- Division of Pediatric Infectious Disease, Floating Hospital for Children at Tufts Medical Center, Boston, Massachusetts, U.S.A
| | - Andrew R Scott
- Department of Otolaryngology-Head and Neck Surgery, Tufts Medical Center, Boston, Massachusetts, U.S.A.,Department of Pediatric Otolaryngology-Head and Neck Surgery and Pediatric Facial Plastic Surgery, Floating Hospital for Children at Tufts Medical Center, Boston, Massachusetts, U.S.A
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32
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Zimmermann P, Ritz N, Curtis N, Tebruegge M. In Reference to The Management of Nontuberculous Mycobacterial Cervicofacial Lymphadenitis: A View Beyond Surgery. Laryngoscope 2020; 130:E945-E946. [PMID: 32154935 DOI: 10.1002/lary.28608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 01/11/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Petra Zimmermann
- Department of Paediatrics, Fribourg Hospital HFR and Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Infectious Diseases Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Nicole Ritz
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Infectious Diseases Unit Basel, University of Basel Children's Hospital, Basel, Switzerland.,Mycobacterial Research Group, Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Nigel Curtis
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Infectious Diseases Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Marc Tebruegge
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Department of Paediatric Infectious Diseases & Immunology, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom.,Department of Infection, Immunity & Inflammation, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
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Long-term outcome of surgical excision for treatment of cervicofacial granulomatous lymphadenitis in children. Eur Arch Otorhinolaryngol 2020; 277:1785-1792. [PMID: 32144570 PMCID: PMC7222061 DOI: 10.1007/s00405-020-05880-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 02/21/2020] [Indexed: 11/17/2022]
Abstract
Purpose Granulomatous inflammation is a common cause of subacute cervicofacial lymphadenitis in children. Nontuberculous mycobacterial (NTM) infections and cat-scratch disease (CSD) are the most frequent causes. Optimal treatment, which may include surgery, antibiotic treatment or wait-and-see approach, is debatable. The goal of this study was to compare the short- and long-term outcome of various surgical procedures. Methods Case series with a chart review of all children treated by surgical excision of granulomatous lymph nodes in the cervicofacial area from 2000 to 2016 at two tertiary care centers. Results Forty patients were included in this study. The median age at first symptoms was 3.7 years (13 months–14 years). Mean follow-up was 5.8 years (6 months–15.3 years). 25 patients fit with diagnosis of NTM infection, 6 with CSD while diagnosis remained uncertain in 9 patients. The primary surgical procedure consisted of total excision (n = 27), incision/drainage (n = 9) or incomplete excision (n = 4). None of the patients treated by primary complete excision needed further intervention contrary to the group of patients with incomplete surgical procedures where additional surgical management was required in 54%. At follow-up, all patients were healthy without evidence of recurrence. Conclusion We advocate early surgical intervention with complete excision to reach quick resolution and reduce the need for additional surgery. The long-term outcome was favorable.
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Childhood nontuberculous mycobacterial lymphadenitis-observation alone is a good alternative to surgery. Int J Pediatr Otorhinolaryngol 2020; 129:109778. [PMID: 31756659 DOI: 10.1016/j.ijporl.2019.109778] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 11/10/2019] [Accepted: 11/10/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Cervicofacial lymphadenitis caused by nontuberculous mycobacteria (NTM) is commonly treated with surgery or antimicrobial therapy. The aim of this study was to analyze the utility of our new blood-based diagnostic method and the treatment protocol, surgery or observation alone, in NTM lymphadenitis in children. METHODS All patients under 16 years of age with cervicofacial NTM lymphadenitis diagnosed and treated at Children's Hospital or at the Department of Otorhinolaryngology, Helsinki University Hospital (Helsinki, Finland) in 2007-2017 were retrospectively reviewed. RESULTS Fifty-two patients, 33 (63%) of whom were girls, were included in the study. The median age at initial presentation of the NTM lymphadenitis was 2.9 years. The novel blood-test had been performed on 49 (94%) of the patients and in all of them it was indicative of NTM infection. A sample for mycobacterial culture was available from 34 patients, and Mycobacterium avium was the most common species detected. Most patients (n = 33, 63%) were treated conservatively with observation alone. Of these, nine patients (27%) did not develop a skin fistula, and the lymphadenitis resolved without drainage. CONCLUSIONS The novel blood test is clinically feasible method for diagnosing childhood cervicofacial NTM lymphadenitis noninvasively. Observation alone is a good alternative to surgery, without the risk of complications.
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Harb JL, Pascal E, Compton RA, Scott AR. What is the optimal management of pediatric nontuberculous mycobacterial cervicofacial lymphadenitis? Laryngoscope 2019; 130:1359-1361. [PMID: 31825090 DOI: 10.1002/lary.28459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 09/25/2019] [Accepted: 11/14/2019] [Indexed: 11/12/2022]
Affiliation(s)
- Jennifer L Harb
- Department of Otolaryngology-Head and Neck Surgery, Tufts Medical Center, Boston, Massachusetts, U.S.A
| | - Emily Pascal
- Tufts University School of Medicine, Boston, Massachusetts, U.S.A
| | - Rebecca A Compton
- Department of Otolaryngology-Head and Neck Surgery, Tufts Medical Center, Boston, Massachusetts, U.S.A
| | - Andrew R Scott
- Department of Otolaryngology-Head and Neck Surgery, Tufts Medical Center, Boston, Massachusetts, U.S.A.,Tufts University School of Medicine, Boston, Massachusetts, U.S.A.,Department of Pediatric Otolaryngology-Head and Neck Surgery and Pediatric Facial Plastic Surgery, Floating Hospital for Children at Tufts Medical Center, Boston, Massachusetts, U.S.A
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Kontturi A, Soini H, Ollgren J, Salo E. Increase in Childhood Nontuberculous Mycobacterial Infections After Bacille Calmette-Guérin Coverage Drop: A Nationwide, Population-Based Retrospective Study, Finland, 1995-2016. Clin Infect Dis 2019; 67:1256-1261. [PMID: 29584893 DOI: 10.1093/cid/ciy241] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 03/22/2018] [Indexed: 01/15/2023] Open
Abstract
Background Epidemiological data on childhood nontuberculous mycobacterial (NTM) disease is scarce and the protective effect of bacille Calmette-Guérin (BCG) vaccination remains debated. In 2006, the BCG policy in Finland changed from universal to selective. We aimed to study the effect of the BCG coverage decrease on the incidence of childhood NTM infections in Finland. Methods We conducted a nationwide, population-based, retrospective study of NTM notifications recorded to the National Infectious Diseases Register between 1995 and 2016 and identified native-born children aged 0-4 years infected with NTM. Poisson log-linear model was used to estimate the change in the incidence rate of cohorts born during universal or selective BCG policy between 1995 and 2015. Results We identified 97 native-born children aged <5 years infected with NTM (median age, 27 months; female-to-male ratio, 2:1). The most common species was Mycobacterium avium (n = 69 [71%]). The estimated incidence rates of NTM in universal-BCG and selective-BCG cohorts were 0.2 and 3.9 per 100000 person-years, respectively. The incidence rate ratio of selective-BCG cohorts compared to universal-BCG cohorts was 19.03 (95% confidence interval, 8.82-41.07; P < .001). Conclusions After infant BCG coverage in Finland decreased, childhood NTM infections increased drastically. As there is no other apparent cause for the increase, this indicates that BCG offers protection against childhood NTM disease. This observation adds to the understanding of childhood NTM epidemiology and might explain why the disease is emerging in some countries.
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Affiliation(s)
- Antti Kontturi
- Doctoral Programme in Population Health, University of Helsinki, Finland.,Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Finland
| | - Hanna Soini
- Department of Health Security, National Institute for Health and Welfare, Finland
| | - Jukka Ollgren
- Department of Health Security, National Institute for Health and Welfare, Finland
| | - Eeva Salo
- Department of Pediatric Infectious Diseases, Children's Hospital, University of Helsinki and Helsinki University Hospital, Finland
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Komorowski AS, Song SI. A politics of the senses: the political role of theKing's-Evil in Richard Wiseman's Severall Chirurgicall Treatises. MEDICAL HUMANITIES 2019; 45:288-294. [PMID: 29970613 DOI: 10.1136/medhum-2017-011390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/05/2018] [Indexed: 06/08/2023]
Abstract
Written by Richard Wiseman, sergeant-surgeon to King Charles II of England, 'A Treatise on the King's-Evil' within his magnum opus Severall Chirurgicall Treatises (1676), acts as a proto-case series which explores the treatment and cure of 91 patients with the King's-Evil. Working within the confines of the English monarch's ability to cure the disease with their miraculous (or thaumaturgic) touch, Wiseman simultaneously elevates and extends the potential to heal to biomedicine. Wiseman's work on the King's-Evil provides an interesting window through which the political expediency of the monarch's thaumaturgic touch may be explored. The dependence of the thaumaturgic touch on liturgy, theatricality and its inherent political economy in Restoration England allowed Wiseman to appropriate the traditionally monarchical role of healer as his own, by drawing attention to a medical ritual of healing that was as reliant, just as the theatrical ritual of monarchical thaumaturgy was, on symbolic binaries of healer-healed, head-body and touch-sight.
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Affiliation(s)
- Adam S Komorowski
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Sang Ik Song
- Department of Psychiatry, McMaster University, Hamilton, Ontario, Canada
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Affiliation(s)
| | | | - David L Goldman
- Department of Pediatrics and Microbiology and Immunology, Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY
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Rapid Identification of Clinically Relevant Mycobacterium Species by Multicolor Melting Curve Analysis. J Clin Microbiol 2019; 57:JCM.01096-18. [PMID: 30333128 DOI: 10.1128/jcm.01096-18] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 10/07/2018] [Indexed: 11/20/2022] Open
Abstract
The sustained increase in the incidence of nontuberculous mycobacterial (NTM) infection and the difficulty in distinguishing these infections from tuberculosis constitute an urgent need for NTM species-level identification. The MeltPro Myco assay is the first diagnostic system that identifies 19 clinically relevant mycobacteria in a single reaction based on multicolor melting curve analysis run on a real-time PCR platform. The assay was comprehensively evaluated regarding its analytical and clinical performances. The MeltPro Myco assay accurately identified 51 reference mycobacterial strains to the species/genus level and showed no cross-reactivity with 16 nonmycobacterial strains. The limit of detection was 300 bacilli/ml, and 1% of the minor species was detected in the case of mixed infections. Clinical studies using 1,163 isolates collected from five geographically distinct health care units showed that the MeltPro Myco assay correctly identified 1,159 (99.7%) samples. Further testing with 94 smear-positive sputum samples showed that all samples were correctly identified. Additionally, the entire assay can be performed within 3 h. The results of this study confirmed the efficacy of this assay in the reliable identification of mycobacteria, suggesting that it might potentially be used as a screening tool in regions endemic for tuberculosis.
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Emergence of Nontuberculous Mycobacterial Lymphadenitis in Children After the Discontinuation of Mandatory Bacillus Calmette and GuÉrin Immunization in France. Pediatr Infect Dis J 2018; 37:e257-e260. [PMID: 29570591 DOI: 10.1097/inf.0000000000001977] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Eighty-five children were diagnosed with culture-confirmed nontuberculous mycobacterial cervical lymphadenitis within the MYCOMED surveillance network from 2004 to 2013. The mean incidence sharply increased from 0.57 to 3.7 per 100,000 children per year, after the discontinuation of mandatory bacillus Calmette and Guérin immunization in 2007. Cases were documented as Mycobacterium avium (62.3%), Mycobacterium intracellulare (15.3%) and Mycobacterium lentiflavum (12.9%). Outcome was favorable in all, with or without surgery or antimycobacterial treatment.
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Willemse SH, Oomens MAEM, De Lange J, Karssemakers LHE. Diagnosing nontuberculous mycobacterial cervicofacial lymphadenitis in children: A systematic review. Int J Pediatr Otorhinolaryngol 2018; 112:48-54. [PMID: 30055739 DOI: 10.1016/j.ijporl.2018.06.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 06/14/2018] [Accepted: 06/15/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Widespread controversy exists regarding correct diagnosing nontuberculous mycobacterial cervicofacial (NTM) lymphadenitis. This study intends to gather the available evidence with respect to diagnosing NTM cervicofacial lymphadenitis. METHODS A review protocol was developed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)-statement (www.prisma-statement.org). A comprehensive search was performed in the bibliographic databases PubMed, Embase.com and Wiley/Cochrane Library. 10 Articles fulfilled the inclusion criteria and were included in the review. Assessing risk of bias of the articles was done using the revised Quality Assessment of Diagnostic Accuracy (QUADAS-2) tool. RESULTS This systematic review shows that diagnostic studies of high methodological quality are scarce. Diagnostic accuracy of polymerase chain reaction (PCR), culture, skin testing, auramine staining, Ziehl-Neelsen staining, and immunodiagnostic assays was studied. Culture sensitivity proved to be 41,8%, while polymerase chain reaction has a sensitivity of 71,6%. Both methods showed a specificity of 100%. Sensitivity of Immunodiagnostic assays ranged between 87,5% and 100% and specificity between 81% and 100%. Overall sensitivity of skin tests containing purified protein derivative (PPD-S) was 70% (95% CI [62%-78%]) with an overall specificity of 94% (95% CI [88%-100%]). CONCLUSIONS In patients with a high clinical suspicion for NTM cervicofacial lymphadenitis, a positive PPD-S skin is indicative for the diagnosis of NTM cervicofacial lymphadenitis. Either PCR or culture is necessary to confirm the diagnosis. Interferon-γ release assays with purified protein derivative stimulation appear to provide good sensitivity and specificity as a non-invasive pre-operative test, but the evidence is weak. More studies of high methodological quality are needed to validate the results of this systematic review.
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Affiliation(s)
- S H Willemse
- Department of Oral and Maxillofacial Surgery, Academic Medical Center, Amsterdam, The Netherlands.
| | - M A E M Oomens
- Department of Oral and Maxillofacial Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - J De Lange
- Department of Oral and Maxillofacial Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - L H E Karssemakers
- Department of Oral and Maxillofacial Surgery, Academic Medical Center, Amsterdam, The Netherlands; Department of Head and Neck Oncology and Surgery, Netherlands Cancer Institute/Antoni Van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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Kavookjian H, Jones JW, Shah S, Escobar H, Swanson D, Nicklaus P. Endobronchial Non-Tuberculosis Mycobacterium Infection Presenting in a Healthy Child. Ann Otol Rhinol Laryngol 2018; 127:726-730. [PMID: 29962232 DOI: 10.1177/0003489418784970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To describe a safe and effective treatment for endobronchial Mycobacterium avium complex. METHODS Case report and literature review. RESULTS We present a case of endobronchial M. avium complex in a healthy child treated with serial carbon-dioxide laser excisions and antibiotic triple therapy using azithromycin, rifampin, and ethambutol. No current guideline for the treatment of these lesions in the pediatric population exists. CONCLUSIONS In patients with airway impingement, serial endoscopic surgical resection combined with antibiotics can provide safe and effective management.
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Affiliation(s)
- Hannah Kavookjian
- 1 Department of Otolaryngology Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Joel W Jones
- 1 Department of Otolaryngology Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Sweeti Shah
- 2 Department of Otolaryngology, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Hugo Escobar
- 3 Department of Pulmonology, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Douglas Swanson
- 4 Department of Infectious Disease, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Pamela Nicklaus
- 2 Department of Otolaryngology, Children's Mercy Hospital, Kansas City, Missouri, USA
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Henkle E, Hedberg K, Schafer SD, Winthrop KL. Surveillance of Extrapulmonary Nontuberculous Mycobacteria Infections, Oregon, USA, 2007-2012. Emerg Infect Dis 2018; 23:1627-1630. [PMID: 28930014 PMCID: PMC5621539 DOI: 10.3201/eid2310.170845] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Limited data are available describing extrapulmonary nontuberculous mycobacteria (NTM) infections in the general population. We describe results from statewide population-based laboratory surveillance in Oregon, USA, during 2007–2012. We defined a case of extrapulmonary NTM infection as >1 isolate from skin/soft tissue, disseminated sites, lymph node, joint, or other sites. The annual incidence of extrapulmonary NTM infection (other than Mycobacterium gordonae) was stable, averaging 1.5 cases/100,000 population. Median age of the 334 patients was 51 years, and 53% of patients were female. Half of cases were caused by M. avium complex, but rapid-growing NTM species accounted for one third of cases. Most extrapulmonary NTM infections are skin/soft tissue. Compared with pulmonary NTM infection, more extrapulmonary infections are caused by rapid-growing NTM species. the designation of NTM as a reportable disease in Oregon in 2014 will result in better detection of changes in the incidence and patterns of disease in the future.
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Sigg N, Bailleul S, Turmel JM, Legrand G, Kettani S, Martin L. [Non-tuberculous mycobacterial cervical adenitis in children: 2 cases]. Ann Dermatol Venereol 2018; 145:505-511. [PMID: 29773279 DOI: 10.1016/j.annder.2018.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 01/07/2018] [Accepted: 02/13/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Cervical lymphadenitis is the most common manifestation of infection with nontuberculous mycobacteria (NTM) in immunocompetent children. Nevertheless, it is poorly known by dermatologists. Its incidence, which is currently increasing since the cessation of BCG vaccination in 2007, raises several issues regarding its pathophysiology, diagnosis and management. PATIENTS AND METHODS We report two cases of NTM adenitis: one in a 2-year-old girl vaccinated with BCG and one in an unvaccinated 22-month-old boy, in whom a misleading presentation led to delayed diagnosis. The condition progressed to fistula formation and the diagnosis was finally made on systematic cultures of lymph node samples. The time to diagnosis was 2 and 4months, respectively. The girl was treated with erythromycin for 3 weeks and with clarithromycin for 3 weeks; the boy received clarithromycin for 7 weeks and underwent complete surgical excision. DISCUSSION NTM adenitis preferentially affects girls under 4 years and occurs more frequently in winter and spring. First, the other differential diagnoses, including tuberculosis, must be ruled out by chest radiography. The diagnosis is oriented by the clinical picture, a positive TST and resistance to conventional antibiotics. However, it is only certified by systematic culture or PCR of lymph node biopsies, with screening for atypical mycobacteria being specified. The decrease in child protection by BCG vaccination coincides with the current increase in NTM infections, of which the most frequent is Mycobacterium avium complex (MAC) for cervical adenitis. The reference treatment is surgery. However, alternative treatments (incomplete excision, antibiotics, watchful waiting, etc.) should be considered where surgery fails or there is excessive risk of injury to a branch of the facial nerve. CONCLUSION Atypical mycobacterial adenitis in immunocompetent children has become an increasingly common infection since the abandonment of BCG vaccination. Improved knowledge of this disease would result in complete surgical excision at an early stage with a lower rate of aesthetic sequelae.
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Affiliation(s)
- N Sigg
- Service de dermatologie, CHU d'Angers, 4, rue Larrey, 49100 Angers, France.
| | - S Bailleul
- Service d'ORL, clinique de l'Anjou, 9, rue de l'Hirondelle, 49000 Angers, France
| | - J-M Turmel
- Service des maladies infectieuses et tropicales, CHU d'Angers, 4, rue Larrey, 49100 Angers, France
| | - G Legrand
- Service d'ORL, clinique de l'Anjou, 9, rue de l'Hirondelle, 49000 Angers, France
| | - S Kettani
- Centre de pathologie de l'Ouest, 2, rue de l'Appentis, 49000 Angers, France
| | - L Martin
- Service de dermatologie, CHU d'Angers, 4, rue Larrey, 49100 Angers, France
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Spinelli G, Mannelli G, Arcuri F, Venturini E, Chiappini E, Galli L. Surgical treatment for chronic cervical lymphadenitis in children. Experience from a tertiary care paediatric centre on non-tuberculous mycobacterial infections. Int J Pediatr Otorhinolaryngol 2018; 108:137-142. [PMID: 29605343 DOI: 10.1016/j.ijporl.2018.02.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 02/08/2018] [Accepted: 02/26/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Non-tuberculous mycobacteria are the most frequent cause of chronic lymphadenitis in children. We reviewed treatment and outcomes of paediatric patients with chronic cervical lymphadenitis, to better understand their differential diagnosis, surgical indication, complication and recover. METHODS A retrospective study was carried out on children who underwent surgery from 2013 to 2016 at Meyer Children's University Hospital, Florence, Italy. Time to cure, type of surgery, and complications rate were determined and etiologic agents were identified and correlated to their clinical presentation. RESULTS 275 children were evaluated. Nearly 98% of the patients were cured regardless of which therapeutic option was used and surgery was necessary in 38.2% of children. Complete excisional biopsy ensured recover in 97.7% of patients compared with the non-excisional surgical group 88.2% (p = 0.06). Re-interventions were needed in the 2.3% of complete excision group and in two cases of the incision and drainage group; all of them developed fistula and were caused by Mycobacterium avium complex. Excision followed by adjunctive antibiotic therapy was favoured in the majority of the patients (80.1%, n = 71). CONCLUSION In cases of non-tuberculous mycobacteria lymphadenitis, surgery is the treatment of choice and it is closely related to a favourable prognosis.
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Affiliation(s)
| | - Giuditta Mannelli
- Clinic of Otorhinolaryngology-Head and Neck Surgery, Department of Surgery and Translational Medicine, University of Florence, AOU-Careggi, Via Largo Palagi 1, 50134, Florence, Italy.
| | | | - Elisabetta Venturini
- Pediatric Infectious Diseases Unit, Meyer Children's Hospital, Department of Pediatrics, University of Florence, Italy
| | - Elena Chiappini
- Pediatric Infectious Diseases Unit, Meyer Children's Hospital, Department of Pediatrics, University of Florence, Italy
| | - Luisa Galli
- Pediatric Infectious Diseases Unit, Meyer Children's Hospital, Department of Pediatrics, University of Florence, Italy
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Cervicofacial lymphadenitis due to Mycobacterium mantenii: rapid and reliable identification by MALDI-TOF MS. New Microbes New Infect 2018; 22:1-3. [PMID: 29348923 PMCID: PMC5767568 DOI: 10.1016/j.nmni.2017.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 11/29/2017] [Accepted: 12/07/2017] [Indexed: 11/20/2022] Open
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Zimmermann P, Curtis N, Tebruegge M. Nontuberculous mycobacterial disease in childhood - update on diagnostic approaches and treatment. J Infect 2018. [PMID: 28646953 DOI: 10.1016/s0163-4453(17)30204-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Recent studies suggest that the incidence of nontuberculous mycobacterial infections in children may be increasing. Nontuberculous mycobacterial lymphadenitis, skin and soft tissue infection, and pulmonary disease each present unique challenges in relation to diagnosis and treatment. In this update, we critically review the recent literature on the epidemiology, clinical features, diagnostic approaches and treatment of nontuberculous mycobacterial disease in children. In addition, we outline key areas warranting further research.
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Affiliation(s)
- Petra Zimmermann
- Infectious Diseases Unit, Royal Children's Hospital Melbourne, Parkville, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Australia; Murdoch Children's Research Institute, Parkville, Australia
| | - Nigel Curtis
- Infectious Diseases Unit, Royal Children's Hospital Melbourne, Parkville, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Australia; Murdoch Children's Research Institute, Parkville, Australia
| | - Marc Tebruegge
- Department of Paediatrics, The University of Melbourne, Parkville, Australia; Academic Unit of Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK; NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Global Health Research Institute, University of Southampton, Southampton, UK; Department of Paediatric Infectious Diseases & Immunology, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK.
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Treatment of infections caused by nontuberculous mycobacteria. Enferm Infecc Microbiol Clin 2017; 36:586-592. [PMID: 29217094 DOI: 10.1016/j.eimc.2017.10.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 10/12/2017] [Indexed: 12/15/2022]
Abstract
Nontuberculous mycobacteria are a heterogeneous group of microorganisms that can often cause human infection, although they may also be considered to be contaminants or colonisers on occasions. The management of these infections must necessarily take into account the identification of isolated species and their in vitro susceptibility testing (although not for all of them), as well as the characteristics of the patient, because these treatments are usually prolonged and must be carried out by experts in the management of these infections. Classically divided into slowly growing mycobacteria and rapidly growing mycobacteria, the treatment regimens and the antibiotics used are different for both groups. In addition, in certain circumstances, this treatment must necessarily be linked to other measures (removal of foreign bodies, surgery) in order to maximise the likelihood of curing the patient.
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Okabe T, Sasahara T, Suzuki J, Onishi T, Komura M, Hagiwara S, Suzuki H, Morisawa Y. Mycobacterium mageritense Parotitis in an Immunocompetent Adult. Indian J Microbiol 2017; 58:28-32. [PMID: 29434394 DOI: 10.1007/s12088-017-0692-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 11/10/2017] [Indexed: 11/29/2022] Open
Abstract
Mycobacterium mageritense, a rapidly growing mycobacterium, is a rare clinical pathogen. Furthermore, parotitis due to non-tuberculosis mycobacterium is very rare in adults. Herein, we report the first case of M. mageritense parotitis in an immunocompetent adult. A 40-year-old man presented with swelling in a left parotid lesion. He was diagnosed with parotitis. The culture from the parotid abscess grew M. mageritense. He was unsuccessfully treated with levofloxacin monotherapy. Trimethoprim-sulfamethoxazole was added, leading to some clinical response; however, the erythema persisted despite 14 months of antibiotic therapy. Subsequently, the skin lesion was surgically removed. The antibiotic treatment was ceased a week after surgery as the postoperative course was uneventful and the lesion had improved. No recurrence was noted at 7 months after surgery. Although extremely rare, M. mageritense can cause parotitis in immunocompetent adults, and may not be sufficiently treated with antibiotics alone.
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Affiliation(s)
- Taro Okabe
- 1Division of Infectious Diseases, Jichi Medical University Hospital, Shimotsuke, Tochigi Japan
| | - Teppei Sasahara
- 1Division of Infectious Diseases, Jichi Medical University Hospital, Shimotsuke, Tochigi Japan.,2Department of Infection and Immunity, School of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498 Japan
| | - Jun Suzuki
- 1Division of Infectious Diseases, Jichi Medical University Hospital, Shimotsuke, Tochigi Japan
| | - Tsubasa Onishi
- 1Division of Infectious Diseases, Jichi Medical University Hospital, Shimotsuke, Tochigi Japan
| | - Masayoshi Komura
- 3Department of Internal Medicine, Saiseikai Utsunomiya Hospital, Utsunomiya, Tochigi Japan
| | - Shigehiro Hagiwara
- 4Department of Clinical Laboratory, Saiseikai Utsunomiya Hospital, Utsunomiya, Tochigi Japan
| | - Hiromichi Suzuki
- 5Clinical Laboratory Center, Dokkyo Medical University Hospital, Mibu, Tochigi Japan
| | - Yuji Morisawa
- 1Division of Infectious Diseases, Jichi Medical University Hospital, Shimotsuke, Tochigi Japan
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Kuntz M, Henneke P. Infektionen durch nichttuberkulöse Mykobakterien im Kindesalter. Monatsschr Kinderheilkd 2017. [DOI: 10.1007/s00112-017-0386-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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