Cervical lymphadenopathy secondary to atypical mycobacteria in children

Long-term outcome of surgical excision for treatment of cervicofacial granulomatous lymphadenitis in children

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.

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.

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.

Paediatric neck abscesses: microbiology and management

Introduction:

Paediatric neck abscesses remain common problems which are sometimes difficult to manage.

Methods and materials:

We conducted a retrospective study of 64 children who underwent incision and drainage of neck abscesses at Leeds General Infirmary from 1 February 2002 to 31 July 2006. The aim of this study was to identify the presenting symptoms in children, the appropriateness of prescribed antibiotics and the role of atypical mycobacteria in neck infections. The outcome measure was clinical resolution of the abscess.

Results:

The mean presenting age was 44.2 months (3.68 years). The commonest sign and symptom was neck mass (96.9 per cent). The mean period of hospitalisation was 3.7 (± standard deviation of 1.9) days. Staphylococcus aureus (48.4 per cent) was the commonest organism cultured. Atypical mycobacteria were found in only 4.7 per cent of the specimens. Flucloxacillin was the most common antibiotic used (57.8 per cent), often in combination with other antimicrobials. The abscess recurrence rate was 4.7 per cent. No fatalities occurred in this series of patients.

Conclusion:

Appropriately prescribed intravenous antibiotics and surgical drainage remain the central core of treatment. Atypical mycobacterial infection is an important differential diagnosis of a painless, cervico-facial mass. An algorithm for the management of paediatric neck abscesses is proposed.

Mycobacterial infections of the head and neck

Mycobacterial infections are grouped into infections caused by M. tuberculosis and those caused by the atypical mycobacterial organisms. Tuberculosis is a systemic disease, with cervical lymphadenitis of the head and neck being the most common extrapulmonary manifestation of the disease. It is important to use imaging, histopathologic examination, and culture to differentiate tuberculosis from atypical mycobacterial infections, because treatments differ. Tuberculosis is best treated as a systemic disease, with anti-tuberculosis medication. The atypical infections can be addressed as local infections and are amendable to surgical therapy.

Nontuberculous mycobacterial adenitis in children: diagnostic and therapeutic management

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

Nontuberculous mycobacterial adenitis of the head and neck in children: experience from a tertiary care pediatric center

OBJECTIVE

To describe our experience with the diagnosis, surgical treatment, and outcome of nontuberculous mycobacterial (NTM) adenitis of the head and neck in children, and to present a preliminary report about the use of NTM skin tests in our institution.

STUDY DESIGN

Retrospective study.

METHODS

The medical records of all children diagnosed with cervicofacial NTM adenitis were retrospectively reviewed for the period from January 1, 1995, through December 31, 2000. We also examined the use of intradermal skin tests for the diagnosis of NTM infection.

RESULTS

Fifty patients were diagnosed with NTM cervicofacial adenitis. Pertinent demographic information, clinical presentation, investigation, and type of diagnostic procedures were documented. Surgical procedures, complications, and relapses were also noted. One unusual case of retropharyngeal adenitis is illustrated. All patients were treated with complete excision of their lesion at the first operation. No major complications were noted. Only one patient relapsed and required a second operation. Forty-one children were skin-tested with NTM antigens. Of these, 30 patients were dual-tested with Purified Protein Derivative (PPD) also. No adverse reactions were noted with the use of skin tests. Sensitivity of NTM antigens alone is 87%. Sensitivity of dual testing is 78%. No patient had a PPD-dominant reaction.

CONCLUSION

Surgical excision is the treatment of choice of NTM adenitis because of the high cure rate with a single procedure, the excellent cosmetic result, and the low complication rate. NTM skin tests are safe and could be useful in early diagnosis of the infection but further investigation is needed.

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

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

Cervical lymphadenitis due to non-tuberculous mycobacteria: surgical treatment and review

A retrospective study was carried out on 57 children, presenting with non-tuberculous mycobacterial (NTM) lymphadenitis of the head and neck, over a 12 year period. Cultures recovered 56 Mycobacterium avium-intracellulare (MAI), and one Mycobacterium kansasaii. Anti-mycobacterial agents were used in seven patients only. On the basis of the initial operation there were two groups. Group 1 (11 patients) had an excision, and Group 2 (46 patients) had incision and drainage (30 patients), incision and curettage (13 patients), or aspiration (three patients). There was no significant difference in the makeup of these two groups. However, Group 1 had significantly lower number of re-operations than Group 2, P<0.01, and achieved a significantly greater healing rate than Group 2, P<0.001. In Group 2 those who had an excision following failure of the first operation were significantly more likely to heal than those who did not, P<0. 005. Operative excision gives a lower rate of re-operation, and a higher rate of healing than other procedures. The treatment, natural history, clinical presentation, pathogenesis, and diagnosis of NTM cervical lymphadenitis are discussed.

Mycobacterial cervical lymphadenitis: the histological features of non-tuberculous mycobacterial infection

AIMS

The distinction between nontuberculous mycobacterial (NTM) lymphadenitis and other causes of cervical lymphadenitis is critical, as different entities call for different treatments. Despite modern diagnostic techniques for NTM infections their prompt and accurate diagnosis is still difficult. We assessed the value of different histological features in diagnosing clinically suggestive NTM cervical lymphadenitis in cases of granulomatous cervical lymphadenitis.

METHODS AND RESULTS

A retrospective study of 30 patients with a clinical diagnosis of NTM cervical lymphadenitis was carried out. The patients were divided into three subgroups and several histological parameters were examined in each subgroup. A comparison was made with cases of proven tuberculous lymphadenitis. Four histological features (presence of microabscesses, ill-defined granulomas, noncaseating granulomas and a small number of giant cells) were found with significant statistical difference when comparison was made between the NTM group and the tuberculosis group.

CONCLUSIONS

A rapid and accurate diagnostic procedure for NTM lymphadenitis is not yet available. Therefore, in the presence of a suggestive clinical picture for NTM lymphadenitis, we propose four histological features which support this diagnosis, thus allowing prompt therapeutic intervention.

Cervical adenitis due to Mycobacterium fortuitum in patients with acquired immunodeficiency syndrome

Rapidly growing mycobacteria, an infrequent cause of human disease, are increasingly being recognized as human pathogens rather than mere colonizers. Rapidly growing mycobacteria infrequently cause disease in patients with acquired immunodeficiency syndrome (AIDS). It is unclear whether patients with AIDS are more predisposed than others to infection by these organisms. The optimal regimen and duration of treatment is similarly uncertain. Mycobacterium fortuitum is a rare cause of lymphadenitis or neck abscess. We report two cases of M fortuitum neck abscesses in patients with AIDS which were successfully treated with antibiotics after initial drainage. In one of these patients, M fortuitum neck abscess was the AIDS-defining illness. We also present a review of the cases reported in literature. It appears that such infections may be treated with a combination of ciprofloxacin and clarithromycin after incision and drainage of the abscess.