Atypical cervico-facial mycobacterial infections in childhood

[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.

Tuberculosis: the great imitator in the head and neck - our experience of 24 cases in 22 years

This retrospective study covered over two decades, during which an individual head and neck surgeon treated 24 patients with cervicofacial lymphadenitis that was related to both Mycobacterium tuberculosis complex (n=17, made up of M tuberculosis (n=16) and M bovis (n=1)), and non-tuberculous mycobacteria. The seven cases of non-tuberculous mycobacteria were caused by M avium complex (n=3), M malmoense (n=3), and M kansaii (n=1). By using a tailored management approach, at times selective combined surgical and antimycobacterial treatment, he achieved a success rate of 23/24 cases, with only one recurrence and no major complications. The results suggest that patients with tuberculosis confined to the head and neck rarely develop constitutional symptoms, so the absence of such symptoms may not exclude tuberculosis. There was also a good correlation between predictive variables (immune state, inflammatory markers on admission, causative mycobacterium, and the antimycobacterial regimen used) and time spent under follow-up at the head and neck outpatient clinic.

Granulomatous cervicofacial lymphadenitis in children: a nine-year study in Singapore

INTRODUCTION

Granulomatous cervicofacial lymphadenitis (GCL) is not uncommon in children. Nontuberculous mycobacteria (NTM) seem to be the predominant cause. We sought to study the clinical and microbiological profile of patients with GCL, and identify features that may impact outcome.

METHODS

Children aged < 16 years who presented to KK Women's and Children's Hospital, Singapore, between January 1998 and December 2006, and who had GCL were identified from laboratory records. Clinical and laboratory data was collected and analysed for risk factors for patients with positive lymph node cultures, and for patients with and without recurrence after treatment.

RESULTS

In all, 60 children were identified, with a median age of 56 (interquartile range [IQR] 34-101) months. Median duration of symptoms before presentation was 5 (IQR 4-8) weeks. The majority presented with single (73.3%) or unilateral (96.7%) lymphadenopathy, located in the submandibular, preauricular/parotid or infra-/post-auricular region (76.7%). Out of 51 patients, 26 (51.0%) had a tuberculin skin test reading of ≥ 10 mm. Out of 52 patients, 10 (19.2%) had positive mycobacterial cultures, which included seven isolates of NTM. Out of 34 cases, tuberculous polymerase chain reaction was positive in 11 (32.4%). With regard to recurrence after initial treatment, age < 5 years at presentation was found to be a predictor for recurrence (p = 0.008), while initial complete excision of affected nodes predicted no recurrence (p = 0.003).

CONCLUSION

In our study, younger age was noted to be associated with a higher chance of recurrence, while complete excision of the involved node at initial presentation predicted non-recurrence.

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.

[Primary tuberculosis of the parotid gland: report of two cases]

La localisation isolée de la tuberculose au niveau de la glande parotide est extrêmement rare. Aucun élément clinique, radiologique et biologique ne permet d'affirmer le diagnostic. Nous rapportons deux cas survenus chez un patient âgé de 40 ans, et une femme de 35 ans immunocompétent, opérés pour une tuméfaction parotidienne et le diagnostic de tuberculose reposait sur l'examen histologique. La symptomatologie de la tuberculose de la glande parotide est polymorphe ce qui pose un problème diagnostic, Le diagnostic est surtout anatomopathologique et le traitement repose sur les antibacillaires.

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.

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.

Tuberculous parotitis: report of 3 cases

Tuberculous parotitis, particularly the diffuse form, is rare. I describe here three patients with diffuse tuberculous parotitis, two of whom presented with unilateral parotid swelling while the third had swellings of both glands. All had discharging sinuses. In two of the patients, the parotitis was associated with active pulmonary tuberculosis. In the patient with bilateral parotitis, the disease seemed to be confined to the glands. The diagnosis of tuberculosis was confirmed by the finding of tubercle bacilli in the lesion or the sputum. They all responded well to standard antituberculous drugs.

Fluoroquinolones in paediatrics

Fluoroquinolones have a broad spectrum of activity against gram-positive, gram-negative, and mycobacterial organisms as well as anaerobes, Mycoplasma, Chlamydia, Ureaplasma, and Legionella spp. They have excellent oral bioavailability, with good tissue penetration, and long elimination half-lives. The experience with fluoroquinolones in paediatrics has been limited because of concerns about arthropathy, based on findings in animal models. However, there has not been a definitive fluoroquinolone-associated case of arthropathy described in the literature. We believe that there are a number of specific paediatric infections in which the clinical efficacy and tolerability of the fluoroquinolones should be further investigated. These include patients with cystic fibrosis who have repeated infections with Pseudomonas spp., patients with pseudomonal and other gram-negative infections such as urinary tract infections and osteomyelitis, and febrile neutropenic patients. Meningeal infections caused by multiple drug-resistant Streptococcus pneumoniae and gram-negative organisms, gastroenteritis due to enteric pathogens, and mycobacterial infections are other potential conditions where fluoroquinolones should be studied in paediatric patients.