Treatment of nontuberculous mycobacterial lymphadenitis with clarithromycin plus rifabutin

[Non-tuberculous mycobacterial cervical adenitis in children: 2 cases]

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.

Surgical treatment for chronic cervical lymphadenitis in children. Experience from a tertiary care paediatric centre on non-tuberculous mycobacterial infections

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.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

[Lymphadenitis due to non-tuberculous mycobacteria: Experience over 15 years]

OBJECTIVE

To study the epidemiology, clinical features, diagnosis, therapeutic management, and outcome of non-tuberculous mycobacterial lymphadenitis in a paediatric population of Aragón (Spain).

MATERIAL AND METHODS

A retrospective study was conducted on patients under 15 years-old diagnosed with non-tuberculous mycobacterial lymphadenitis between the years 2000 and 2015.

INCLUSION CRITERIA

patients with lymphadenitis and positive culture. Quantitative values are shown as mean, rank, and standard deviation, and qualitative data as frequencies.

RESULTS

Twenty-seven cases were registered, with a mean age of presentation of 39.9 months (range 10 months-8 years). The mean time between the symptoms onset and first consultation was 1.7±1.1 months. The most frequent location was sub-maxilar in 17/27 cases (63%), on the right side in 59.3%, and size 2.96±1.26cm. Fistulae were observed in 16/27 cases. Tuberculin test was greater than 10mm in 7/24 (29.1%). Microbiological cultures were positive for Mycobacterium avium in 14/27 (51.9%), Mycobacterium intracellulare 3/27 (11.1%), and Mycobacterium lentiflavum 3/27 (11.1%). Combined treatment of antibiotics and surgery was given in 16/27 cases (59.8%), medical treatment only in7/27 (25.9%), and surgical exeresis alone in 4/27 (14.8%). Two patients required a new surgery, and one showed severe neutropenia secondary to rifabutin. Only one case (3.7%) suffered from temporary facial palsy as sequel.

CONCLUSIONS

The most frequent treatment was the combination of antibiotics and surgery. Delay in diagnosis seemed to be responsible for the limited number of exeresis as first option, only one for every seven patients.

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

OBJECTIVES/HYPOTHESIS

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

STUDY DESIGN

Retrospective cohort.

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

4 Laryngoscope, 126:1677-1680, 2016.

The management of non-tuberculous cervicofacial lymphadenitis in children: A systematic review and meta-analysis

OBJECTIVES

Cervicofacial lymphadenitis is the most common manifestation of infection with non-tuberculous mycobacteria (NTM) in immunocompetent children. Although complete excision is considered standard management, the optimal treatment remains controversial. This study reviews the evidence for different management options for NTM lymphadenitis.

METHODS

A systematic literature review and meta-analysis were performed including 1951 children from sixty publications. Generalised linear mixed model regressions were used to compare treatment modalities.

RESULTS

The adjusted mean cure rate was 98% (95% CI 97.0-99.5%) for complete excision, 73.1% (95% CI 49.6-88.3%) for anti-mycobacterial antibiotics, and 70.4% (95% CI 49.6-88.3%) for 'no intervention'. Compared to 'no intervention', only complete excision was significantly associated with cure (OR 33.1; 95% CI 10.8-102.9; p < 0.001). Complete excision was associated with a 10% risk of facial nerve palsy (2% permanent). 'No intervention' was associated with delayed resolution.

CONCLUSIONS

Complete excision is associated with the highest cure rate in NTM cervicofacial lymphadenitis, but also had the highest risk of facial nerve palsy. In the absence of large, well-designed RCTs, the choice between surgical excision, anti-mycobacterial antibiotics and 'no intervention' should be based on the location and extent of the disease, and acceptability of prolonged time to resolution.

Sarcoidosis: Role of non-tuberculosis mycobacteria and Mycobacterium tuberculosis

Sarcoidosis is a granulomatous inflammatory disease that is induced by unknown antigen(s) in a genetically susceptible host. Although the direct link between Mycobacterium tuberculosis (MTB) infection and sarcoidosis can be excluded on the basis of current knowledge, non-infectious mechanisms may explain the causative role of mycobacterial antigens. Ever since sarcoidosis was first described, its relationship with tuberculosis (TB) has been under-investigated. Whereas some researchers consider sarcoidosis and TB as two examples of the same disease process, others have rejected mycobacteria as playing any causative role in sarcoidosis. Whether they are linked causally or not, clinical evidence makes a differential diagnosis between the two conditions very challenging, particularly in countries with high burden of TB. The present study analyzes the relationship between sarcoidosis and TB and its implications in clinical practice. The coincidence of TB and sarcoidosis and the higher incidence of mycobacterial DNA in biological samples of sarcoid patients have been reported by many authors. In addition, new evidence of a similarity in MTB phenotype in sarcoidosis is provided. Overall, these observations suggest that TB and sarcoidosis may not only share the same etiology, but may even be different aspects of one disease.

Management of cervicofacial nontuberculous lymphadenitis in children

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Nontuberculous lymphadenopathy in children: using the evidence to plan optimal management

There is no evidence that drug treatment improves healing more rapidly or is associated with an improved cosmetic outcome compared to spontaneous resolution, and no studies have related therapy and outcome to mycobacterial species and susceptibility. It is interesting that widespread and accepted use of drug treatment has developed with no good evidence that drugs facilitate healing[36]. It is therefore essential, given spontaneous healing will occur, that any future studies compare drug treatment with spontaneous resolution.In conclusion there is good evidence that excision of nontuberculous mycobacterial lymphadenopathy is usually curative and should be performed where possible. Where lesions are too large or too difficult to surgically excise, alternatives could include de-bulking with incision and drainage or curettage, recognising that treated this way lesions will be slow to heal. Until there is evidence about the efficacy of antimycobacterial drug treatment it should not be used routinely, though it may be considered in extensive, complex disease. Also, there is no evidence to suggest that antimycobacterial drugs confer an additional benefit when the lesion is excised.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Conservative wait-and-see therapy versus antibiotic treatment for nontuberculous mycobacterial cervicofacial lymphadenitis in children

BACKGROUND

In this explorative study, 50 children with microbiologically confirmed nontuberculous mycobacterial cervicofacial lymphadenitis were randomized to either receive antibiotic therapy or follow a conservative wait-and-see approach. Our primary objective was to assess the time for all infected lymph nodes to heal in patients after the nonantibiotic, wait-and-see treatment, compared with patients after a 12-week course of clarithromycin and rifabutin.

METHODS

Fifty children (19 boys and 31 girls) with a polymerase chain reaction (PCR)- or culture-confirmed diagnosis of cervicofacial nontuberculous mycobacterial infection were included in our study. Twenty-five children were randomized to receive antibiotic therapy and 25 to be given a wait-and-see approach.

RESULTS

The median age of the children was 35 months (range, 14-114 months). The median time to resolution of the disease for the antibiotic group was 36 weeks, compared with 40 weeks for the wait-and-see group. Adverse effects of antibiotic therapy included gastrointestinal complaints, fever, and reversible extrinsic tooth discoloration.

CONCLUSION

In children with an advanced stage of nontuberculous mycobacterial cervicofacial lymphadenitis, we observed no significant differences in median healing time between the wait-and-see group and the group receiving clarithromycin and rifabutin antibiotic therapy.

Cervicofacial nontuberculous mycobacterium lymphadenitis in children: is surgery always necessary?

INTRODUCTION

The optimal treatment of cervicofacial nontuberculous mycobacterium lymphadenitis (CFNTB) in children is yet to be established. There is a general consensus that surgical excision results in a definitive resolution of the disease. The main aim of surgery is to remove affected nodes so that they do not discharge through the skin. Recently there are some investigators who are reporting successful antibiotic treatment and advocating medical therapy as the first line treatment.

METHODS

16 children consecutively presenting to otolaryngology in a tertiary referral centre over an 8-year period with CFNTB. Inclusion criteria were chronic cervicofacial lymphadenitis with either: (1) a culture positive for atypical mycobacteria (from either a lymph node or fine needle aspirate (FNA) specimen); or (2) acid-fast bacilli identified (from either a lymph node or FNA specimen); or (3) post excision histological findings consistent with mycobacterial infection (i.e. non-caseating granulomas) in the absence of other clinical features suggestive of other granulomatous conditions. Lesions with superficial skin change were treated preferentially with surgery. Children presenting with lymph nodes contained deep to sternocleidmastoid were assessed with FNA cytological and microbiological analysis and MRI or CT, and treated preferentially with antibiotics or watchful waiting.

RESULTS

4 children (2 culture positive, 2 with acid-fast bacilli on needle aspirate) presented with lymphadenopathy deep to sternocleidmastoid and were managed non-surgically. All 4 resolved without cutaneous involvement. 11 children with a clinical presentation of CFNTB underwent complete excision of all involved nodes for superficial lesions (6 were culture positive, and all had granulomatous histology). None recurred. 1 patient presented late with a mature, discharging parotid sinus, which was managed with watchful waiting as the lesion was clinically close to natural resolution.

CONCLUSIONS

Depth at presentation may help decide which patients with CFNTB can be treated non-surgically without cutaneous sequelae. We propose that a watch and wait management is an option for deep nodes.

An unusual case of a cervical mass due to nontuberculous mycobacterium fortuitum infection

Mycobacterium fortuitum, of the class of nontuberculous mycobacteria, rarely causes cervical lymphadenopathy and head and neck masses. However, we treated a woman with a neck mass that was indeed caused by a mycobacterial infection. Our case is unique in that prompt recognition of the infection and treatment with antimicrobials averted surgery. Generally, both antibiotics and surgery are recommended, and in rare instances, infections can resolve with antibiotics alone. Nontuberculous M fortuitum infection should be included in the differential diagnosis of cervical masses, particularly in immunocompromised patients or those for whom standard antibiotics are not effective for treating abscess or lymphadenitis.

Management of nontuberculous mycobacteria-induced cervical lymphadenitis with observation alone

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Non-tuberculous mycobacterial infection of the parotid gland in an immunosuppressed adult

Infections of the parotid gland with non-tuberculous mycobacteria (NTM) are rarely described. Here, we report on an infection of the parotid gland caused by Mycobacterium avium and give a literature-based overview about this entity. In the light of a global increase of mycobacterial infections, unusual manifestations have to be considered and should be included in the differential diagnosis when dealing with solid lesions of uncertain aetiology in the head and neck region.

Atypical mycobacterial infection of the head and neck in children: A 5-year retrospective review

OBJECTIVE: We review the management of 31 cases of atypical mycobacterial lymphadenitis presenting to a tertiary referral pediatric otolaryngology department between February 2002 and February 2007.

STUDY DESIGN: Retrospective case review.

SUBJECTS AND METHODS: Cases were identified by using the hospital's correspondence and pathology databases. Demographic and clinical information was collected. Descriptive and nonparametric inferential statistics (SPSS; SPSS Inc, Chicago, IL) were calculated.

RESULTS: Four patients were treated conservatively with triple-therapy antibiotics. Twenty-seven underwent surgical excision plus 3 months of clarithromycin postoperatively. Thirteen percent developed nodal recurrence; this appeared to be unrelated to the operation performed (χ8 2 = 5.8, P = 0.69) or the management modality used ( P = 0.35). Patients with previous surgery were more likely to have recurrent infection (χ2 2 = 9.3, P = 0.01).

CONCLUSIONS: In our experience, nodal excision plus postoperative clarithromycin remains the best treatment option for most children, although those with limited disease may benefit from combination antibiotic therapy. Previous incision and drainage leads to high recurrence rates after later excision and therefore, heightened awareness of these infections is essential to ensure appropriate early management.

Lymphadenopathy caused by Mycobacterium colombiense

We report the case of a 3-year-old girl with lymphadenopathy caused by the recently described species Mycobacterium colombiense. M. colombiense is a nonpigmented slow grower that is included in the Mycobacterium avium complex. Partial sequencing of the 16S rRNA gene was used for species identification.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Adenitis por micobacterias no tuberculosas

OBJECTIVE

To study the clinical features, epidemiology and outcome of nontuberculous mycobacterial lymphadenitis (NTML).

METHODS

A retrospective study was performed on 54 patients under 14 years old diagnosed with atypical mycobacterial lymphadenitis between 1987 and 2004. Inclusion criteria were: (i) positive polymerase chain reaction (PCR) test or culture; (ii) positive sensitin skin test 6 mm above Mantoux; (iii) histopathologic features compatible with mycobacterial infection and/or positive direct smear for acid-fast bacilli, Mantoux reaction less than 15 mm, a normal chest radiograph, absence of exposure to an adult with tuberculosis, negative Mantoux test reactions in family members, and exclusion of other causes of granulomatous adenitis.

RESULTS

Fifty-four patients were included in the study. The number of NTML cases increased notably from 1996, coinciding with a decrease in cases of tuberculous adenitis. The mean age was 35 months (range: 14 months-6 years). Submandibular nodes were involved in 22 of 63 cases of adenitis (34.9%) and cervical nodes were involved in 21 (33.3%). In 8/42 patients (19%) the tuberculin skin test was larger than 10 mm. Cultures were positive in 52.9% of the cases (18/34) and PCR in 53.3% (8/15). The most frequently isolated mycobacteria was Mycobacterium avium (61%). Therapy failed in 8/21 patients receiving antibiotics (38%), in 10/13 patients with drainage alone (77%) and in none of the patients who underwent surgery (8/8).

CONCLUSIONS

Nontuberculous mycobacterial adenitis has become more frequent in our hospital since 1996. Cultures do not always allow isolation of mycobacteria and the Mantoux test frequently yields false positive results, thus hampering diagnosis. The most effective treatment was surgical excision. Nevertheless, when the surgical approach is difficult or there is postoperative recurrence, pharmacological treatment can be useful.

Nontuberculous mycobacterial adenitis: effectiveness of chemotherapy following incomplete excision

BACKGROUND

Management of lymphadenopathy caused by nontuberculous mycobacteria (NTM) is primarily surgical. Where this cannot achieve sufficient clearance of infected nodes, chemotherapy is often given.

AIM

This study compared results of surgery alone with surgery followed by chemotherapy in instances where there was incomplete surgical removal of diseased tissue.

METHODS

Chemotherapy comprised azithromycin 10 mg/kg and rifabutin 6 mg/kg both given once daily for 6 mo. Ninety-eight children with NTM infection were seen in the period 1990-2004. Sixty-eight cases with adenopathy where "time to healing" (discharge stopped and inflammation settled) was known were available to compare response to treatment.

RESULTS

The median (range) "time to healing" in weeks for 43 patients who had surgery alone was: incision and drainage (I&D)/curettage 6 (1-72) (n = 10); excision 3 (1-28) (n = 22); and from the last operation of multiple (repeat) surgery 3 (1-40) (n = 11). For 25 patients who required chemotherapy in addition to surgery, the median (range) "time to healing" in weeks was I&D/curettage 10 (1-40) (n = 17), excision 14 (8-20) (n = 2) and multiple surgery 29 (2-88) (n = 6).

CONCLUSION

In children with adenitis due to NTM, where surgical resection is followed by continued discharge and inflammation, chemotherapy should be considered before further surgery is undertaken.

Antibiotic therapy for nontuberculous mycobacterial cervicofacial lymphadenitis

OBJECTIVES/HYPOTHESIS

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

STUDY DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

Atypical mycobacterial cervical lymphadenitis with extensive local spread: a surgical disease

Atypical (nontuberculous) mycobacterium is an uncommon cause of cervical lymphadenitis in immunocompetent children. Rarely, this disease progresses to locoregional destruction of the deep structures of the neck including salivary glands. Recent reports suggest medical monotherapy as an effective treatment of this disease. We report three cases of children who experienced progression to locoregional disease while on appropriate antibiotics. We suggest that the patient population to benefit from medical monotherapy has yet to be adequately defined. In our experience, surgical therapy is the only effective treatment for locoregional disease.

[Pediatric infections caused by nontuberculous mycobacteria]

During the last few years, nontuberculous mycobacteria (NTM) have been isolated with increasing frequency in our environment. However, there are only a few reports of pediatric NTM infections in Spain (13 articles since 1990). This article presents an update of the epidemiology, diagnostic methods, and treatment of these infections in children. The most frequent clinical syndromes caused by NTM include lymphadenitis, pulmonary and disseminated infections in immunocompromised children. NTM cervical adenitis usually causes chronic infection associated with sinus tract formation and scarring. The treatment of choice is surgical excision of the involved node. Incision and drainage of the enlarged node should be avoided because it can lead to chronic drainage or sinus tract formation. Medical treatment with azithromycin or clarithromycin associated with rifabutin, ethambutol or ciprofloxacin should be reserved for cases in which the family refuses surgery, a recurrence occurs or complete excision is impossible. Pulmonary disease caused by NTM is relatively rare in immunocompetent children, but is increasingly reported in children with cystic fibrosis. In these patients, the clinical significance of the presence of NTM in the sputum is unclear. The persistence of positive cultures, especially if bacilloscopy is positive and the patient shows clinical evidence of pulmonary disease exacerbation, is an indication to start treatment. Disseminated infection caused by NTM can appear in patients with severe immunodepression, especially in HIV-infected children with CD4 cell counts of less than 100 cells/mm3. Early antibiotic therapy with at least three drugs including a macrolide, and immune recovery with aggressive antiretroviral therapy are the keys to improving quality of life and survival in these patients.

Mycobacterium haemophilum and lymphadenitis in children

Mycobacterium haemophilum is the second most common pathogen in children with mycobacterial lymphadenitis.

Infections associated with Mycobacterium haemophilum are underdiagnosed because specific culture methods required for its recovery are not applied routinely. Using polymerase chain reaction (PCR) technology on fine needle aspirates and biopsied specimens from 89 children with cervicofacial lymphadenitis, we assessed the importance of M. haemophilum. Application of a Mycobacterium genus–specific real-time PCR in combination with amplicon sequencing and a M. haemophilum–specific PCR resulted in the recognition of M. haemophilum as the causative agent in 16 (18%) children with cervicofacial lymphadenitis. Mycobacterium avium was the most frequently found species (56%), and M. haemophilum was the second most commonly recognized pathogen. Real-time PCR results were superior to culture because only 9 (56%) of the 16 diagnosed M. haemophilum infections were positive by culture.

[Usefulness of chemotherapy associated with surgery in the management of nontuberculous mycobacterial adenitis]

BACKGROUND

In recent years, lymphadenitis caused by atypical mycobacteria (also called nontuberculous mycobacteria [NTMB] or, more recently, environmental) have played a significant role in the differential diagnosis of adenitis in non-immunocompromised children.

OBJECTIVES

To describe the clinical and pathological findings in childhood NTMB adenitis and study the possible usefulness of antimicrobial therapy in addition to surgery.

METHODS

We present eight cases of neck lymphadenitis occurring over a 5-year period. All of the children received combined chemotherapy, and six also underwent surgery. Of the two remaining patients, the parents of one child refused surgery and a watchful approach was adopted in the other.

RESULTS

Complete clinical recovery was achieved in all patients except one who did not undergo surgery.

CONCLUSIONS

Prolonged administration of two antibiotics (of which one must be clarithromycin) in addition to surgery was well-tolerated and could be useful in patients with NTMB neck lymphadenitis.

Nontuberculous mycobacteria-induced parotid lymphadenitis successfully limited with clarithromycin and rifabutin

OBJECTIVES/HYPOTHESIS

Nontuberculous mycobacterial adenitis of the parotid gland is often difficult to diagnose. The rarity of these infections in the parotid region and the lack of specific guidelines pose a treatment challenge to the clinician. Three cases of nontuberculous mycobacterial adenitis are presented, with clinical response to antibiotics before surgery.

STUDY DESIGN

Retrospective chart review was made of children up to 18 years of age presenting with a parotid mass diagnosed as nontuberculous mycobacterial infection.

METHODS

Three patients (age range, 15 to 30 mo) with nontuberculous mycobacteria-induced parotid lymphadenitis were treated with a combination antibiotic regimen of clarithromycin and rifabutin or with clarithromycin alone.

RESULTS

All three patients responded clinically to the antibiotic treatment as evidenced by a smaller mass size and resolution of the overlying discoloration. Subsequent parotidectomy or biopsy appeared to be easier to perform because of decreased inflammation and edema and a more readily dissectible facial nerve.

CONCLUSION

Children with nontuberculous mycobacteria-induced parotid lymphadenitis should be started on a trial of antibiotic treatment before surgery. Although surgery remains the definitive treatment modality, a larger study of preoperative antibiotic use against nontuberculous mycobacterial adenitis of the parotid in children is necessary.

Real-time PCR assay using fine-needle aspirates and tissue biopsy specimens for rapid diagnosis of mycobacterial lymphadenitis in children

A real-time PCR assay was developed to diagnose and identify the causative agents of suspected mycobacterial lymphadenitis. Primers and probes for the real-time PCR were designed on the basis of the internal transcribed spacer sequence, enabling the recognition of the genus Mycobacterium and the species Mycobacterium avium and M. tuberculosis. The detection limit for the assay was established at 1,100 CFU/ml of pus, and the specificity tests showed no false-positive reaction with other mycobacterial species and other pathogens causing lymphadenitis. From 67 children with suspected mycobacterial lymphadenitis based on a positive mycobacterial skin test, 102 samples (58 fine-needle aspirates [FNA] and 44 tissue specimens) were obtained. The real-time PCR assay detected a mycobacterial infection in 48 patients (71.6%), whereas auramine staining and culturing were positive for 31 (46.3%) and 28 (41.8%) of the patients. The addition of the real-time PCR assay to conventional diagnostic tests resulted in the recognition of 13 more patients with mycobacterial disease. These results indicate that the real-time PCR is more sensitive than conventional staining and culturing techniques (P = 0.006). The M. avium-specific real-time PCR was positive for 38 patients, and the M. tuberculosis-specific real-time PCR was positive for 1 patient. Analysis of 27 patients from whom FNA and tissue biopsy specimens were collected revealed significantly more positive real-time PCR results for FNA than for tissue biopsy specimens (P = 0.003). Samples from an age-matched control group of 50 patients with PCR-proven cat scratch disease were all found to be negative by the real-time PCR. We conclude that this real-time PCR assay with a sensitivity of 72% for patients with lymphadenitis and a specificity of 100% for the detection of atypical mycobacteria can provide excellent support for clinical decision making in children with lymphadenitis.

Cervicofacial lymphadenitis due to atypical mycobacteria: a surgical disease

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

Nontuberculous mycobacterial infections of the head and neck

Nontuberculous mycobacteria are ubiquitous in the environment. Immunocompetent children are commonly infected by these resilient organisms. Cervical lymphadenitis, the most frequent head and neck manifestation of NTM infection, often presents as chronic, unilateral lymphadenopathy with characteristic violaceous overlying skin changes. Diagnosis is ultimately dependent on culture or histopathologic examination of specimen obtained through excisional lymph node biopsy or FNA. The principal treatment of NTM infection remains the surgical excision of diseased tissue. Antibiotics augment surgical therapy and their potential role as a single-modality therapy continues to be investigated.

Nontuberculous mycobacterial lymphadenitis in children

OBJECTIVES

To describe the clinical and epidemiologic features, management and outcome associated with the development of nontuberculous mycobacterial (NTM) superficial lymphadenitis in children.

METHODS

The medical records of all children 0 to 14 years of age with NTM superficial lymphadenitis who were diagnosed at P. and A. Kyriakou Children's Hospital between January, 1982, and December, 1997, were reviewed.

RESULTS

Forty-seven children were identified, 76.5% during the second half of the study period. Mycobacterium avium complex was the predominant isolate. Children with NTM lymphadenitis noted satisfactory aesthetic results when total excision was performed within 1 month after its onset.

CONCLUSIONS

NTM superficial lymphadenitis in children has been increasingly recognized during the last decade. Prompt total excision of the involved lymph node is required in such patients.

Comparative tolerability of erythromycin and newer macrolide antibacterials in paediatric patients

The macrolides are a well established group of antibacterials frequently used in general practice. The most frequently used macrolides in paediatric patients are erythromycin, a naturally occurring compound, and clarithromycin and azithromycin, recently developed macrolides. Overall adverse effect rates of 7 to 26% for erythromycin, 14 to 26% for clarithromycin, and 6 to 27% for azithromycin have been described in children. Adverse gastrointestinal effects, including nausea, vomiting, diarrhoea and abdominal cramps, are the most common problems in children. Allergic reactions, hepatotoxicity, ototoxicity and adverse effects involving the central and peripheral nervous systems have also been observed in children. Stevens-Johnson, Schonlein-Henoch and Churg-Strauss syndromes have been rarely described in children. Treatment-related laboratory abnormalities have been recorded in 2 to 4% of erythromycin- and in 0 to 1% of both clarithromycin- and azithromycin-treated children. Elevation in liver function tests was the most common abnormality cited. Increased macrolide use in children in recent years has resulted in a growing potential for drug interactions between them and other pharmacologically active agents via the inhibition of cytochrome P450 (CYP) microsomal enzymes. Drug interactions with theophylline, cyclosporin, carbamazepine, terfenadine and warfarin limit erythromycin use. Clarithromycin is a weak inducer of CYP and exhibits fewer drug-drug interactions than erythromycin. However, its use with theophylline, carbamazepine and terfenadine is contraindicated. In contrast, no significant interactions have been reported with azithromycin to date. Macrolides have been proven to be well tolerated in the treatment of upper and lower respiratory tract infections, skin and soft tissue infections, and also in less frequent infections occurring in paediatric patients. In addition, clarithromycin and azithromycin have shown good tolerability profiles in immunocompromised paediatric patients. In conclusion, macrolides antibacterials have proven to be well tolerated in paediatric patients. Although the incidence of adverse effects is similar with the use of erythromycin and the newer macrolides, drug interactions occur significantly less when clarithromycin or azithromycin are administered.

Preoperative diagnosis of Mycobacterium avium lymphadenitis in two immunocompetent children by polymerase chain reaction of gastric aspirates

BACKGROUND

Analysis of gastric aspirates is a routine procedure for detection of Mycobacterium tuberculosis in pediatric pulmonary tuberculosis. However, identification of nontuberculous mycobacteria in gastric aspirates of immunocompetent children is not thought to be clinically significant.

METHODS

A PCR method was devised for the detection of M. avium in clinical specimens. The method is based on the amplification of a M. avium-specific DNA fragment present in the 3'-end of the repetitive element IS1245. Surgically removed lymphatic tissue was analyzed prospectively by microscopy, culture and PCR in 13 children admitted to our hospital with suspected mycobacterial lymphadenitis. In 4 of these children 1 to 4 gastric aspirates were obtained before surgical treatment and submitted to the same analysis.

RESULTS

We report the detection of M. avium in the gastric aspirates of two children with cervical lymphadenitis before surgical intervention by a novel PCR method. The subsequently surgically removed lymph nodes were also positive by PCR and culture. In one child cultures of both sources grew M. avium. The isolates could be identified as the same strain by DNA fingerprinting. The PCR assay was almost twice as sensitive as culture in detecting M. avium.

CONCLUSIONS

Our findings suggest the possibility for noninvasive diagnosis of cervical lymphadenitis caused by nontuberculous mycobacteria before surgery. In addition detection of M. avium in gastric aspirates without evidence of fistula formation provides new insights into the pathogenesis of mycobacterial infection and disease in immunocompetent children.