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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Tonsillotomy for Periodic Fever Syndrome: A Randomized and Controlled Trial

OBJECTIVE

Tonsillectomy is an effective treatment for periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome. Tonsillotomy has a milder operative risk profile and postoperative morbidity in children than tonsillectomy. We aimed to compare the efficacy of tonsillotomy to observation-only in children with PFAPA syndrome at a 3-month follow-up.

METHODS

This was a randomized multicenter trial with sequential design. Participants were randomized into a tonsillotomy group and a control group that was only observed. The trial started in 1/2017 and was accomplished in 12/2021 with 16 patients (10 boys, six girls, the mean age 4.2 years). The symptoms were monitored with daily symptom diaries.

RESULTS

After the 3-month follow-up, 7/8 patients (87.5%) in the tonsillotomy group and 2/8 (25%) patients in the control group were free from PFAPA symptoms (95% CI 13% to 87%; p = 0.0021). The mean number of days with fever was 2.6 (SD 3.7) in the tonsillotomy group and 8.0 (SD 6.5) days in the control group (n = 8) (p = 0.06). Mean number of fever days compatible with PFAPA syndrome was 0.8 (SD 1.4) in the tonsillotomy group and 6.5 (SD 6.0) in the control group (95%CI -10% to -1%; p = 0.007). Rescue tonsillectomy was needed for all patients in the control group and none of the patients in the tonsillotomy group.

CONCLUSIONS

Tonsillotomy might be an effective treatment option for children with PFAPA syndrome. Further studies are needed to clarify the long-term efficacy of tonsillotomy for treating PFAPA.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:968-972, 2024.

A comparison of ultrasound-guided aspiration with open surgical drainage in the management of pediatric acute suppurative cervical lymphadenitis

OBJECTIVES

Image-guided aspiration has been proposed as an alternative to the traditional open drainage in acute suppurative cervical lymphadenitis, although little evidence comparing these approaches exists. The aim of this study was to compare ultrasound-guided aspiration and open surgical drainage in the management of pediatric acute suppurative cervical lymphadenitis.

METHODS

Patients treated for acute suppurative cervical lymphadenitis at a tertiary referral pediatric hospital over a three-year period were retrospectively analyzed.

RESULTS

Of eighteen patients included, 9 (50 %) underwent aspiration and 9 (50 %) underwent open surgical drainage. None required repeat intervention or readmission over a median follow up of 10.5 weeks. Those undergoing aspiration had a shorter post-operative length of stay (1.67 vs 4.33 days, p = 0.001) compared with open surgical drainage.

CONCLUSION

Ultrasound-guided aspiration of pediatric acute suppurative cervical lymphadenitis is a safe and effective alternative to open drainage.

Current management of cervicofacial nontuberculous mycobacterial infections in the pediatric population

PURPOSE OF REVIEW

The purpose of this review is to analyze and consolidate recently published literature to provide updated guidelines on the diagnosis and management of nontuberculous mycobacterial lymphadenitis (NTM LAD) in the pediatric population and to suggest areas of further research.

RECENT FINDINGS

Diagnosis of NTM LAD relies on a detailed clinical history, physical examination, laboratory tests, and imaging techniques. Treatment strategies vary widely, with a shift towards complete surgical excision being observed due to its higher cure rate, improved aesthetic outcomes, and lower recurrence rates. However, patient-specific factors must be considered. The role of genetic factors, such as Mendelian susceptibility to mycobacterial disease (MSMD), is being increasingly recognized and could lead to targeted therapies.

SUMMARY

Despite strides in the understanding and management of NTM LAD, substantial gaps remain in key areas such as the role of diagnostic imaging, optimal treatment parameters, postoperative care, and surveillance strategies. In this article, we explain our approach to NTM using the most relevant evidence-based medicine while offering directions for future work.

Long-Term Esthetic Outcome of Different Treatment Modalities for Nontuberculous Mycobacterial Cervicofacial Lymphadenitis

BACKGROUND

Nontuberculous mycobacterial (NTM) cervicofacial lymphadenitis is a rare infection which almost exclusively occurs in children, most commonly children 0-5 years old. It can leave scars in highly visible areas. The present study aimed to evaluate the long-term esthetic outcome of different treatment modalities for NTM cervicofacial lymphadenitis.

METHODS

This retrospective cohort study included 92 participants with a history of bacteriologically proven NTM cervicofacial lymphadenitis. All patients were diagnosed at least 10 years prior and were aged >12 years upon enrollment. Based on standardized photographs, the scars were assessed by subjects with the Patient Scar Assessment Scale, and by five independent observers with the revised and weighted Observer Scar Assessment Scale.

RESULTS

The mean age at initial presentation was 3,9 years and the mean follow-up time was 15.24 years. Initial treatments included surgical treatment (n = 53), antibiotic treatment (n = 29) and watchful waiting (n = 10). Subsequent surgery was performed in two patients, due to a recurrence after initial surgical treatment, and in 10 patients initially treated with antibiotic treatment or watchful waiting. Esthetic outcomes were statistically significantly better with initial surgery, compared to initial non-surgical treatment, based on patient scores of scar thickness, and based on observer scores of scar thickness, surface appearance, general appearance and the revised and weighted sum score of all assessment items.

CONCLUSIONS

The long-term esthetic outcome of surgical treatment was superior to non-surgical treatment. These findings could facilitate the process of shared decision making.

LEVEL OF EVIDENCE

Level III.

Toxoplasmic Lymphadenitis of the Head and Neck Region

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Successful treatment with laparoscopic extended posterior sectionectomy for inflammatory pseudotumor in the liver with para-aortic lymphadenitis

Inflammatory pseudotumor (IPT) is a rare disease that requires a differential diagnosis from malignancies. We describe a case of hepatic IPT with para-aortic lymphadenopathy, treated with a stepwise strategy of laparoscopic surgery. A 61-year-old woman was referred with a liver lesion. Computed tomography revealed a 13 cm well-defined lesion in segments VII-VI. The patient also had bead-like enlarged lymph nodes from the perihilar to the para-aortic regions. Although percutaneous lymph node biopsy showed no evidence of malignancy, 18 F-fluorodeoxyglucose positron emission tomography revealed accumulation in the lesion and lymph nodes. Lymph nodes were harvested laparoscopically for intraoperative pathological examination. With no evidence of malignancy, laparoscopic liver resection was continuously performed as a diagnostic treatment. The patient was given a pathological diagnosis of IPT and was discharged on the 16th day and is well 2 years after surgery. The minimally invasive laparoscopic approach to diagnostic treatment could be useful with secure advantages.

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

BACKGROUND

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

CASE SUMMARY

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

CONCLUSIONS

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

Tonsillectomy for periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis syndrome (PFAPA)

BACKGROUND

Periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome is a rare clinical syndrome of unknown cause usually identified in children. Tonsillectomy is considered a potential treatment option for this syndrome. This is an update of a Cochrane Review first published in 2010 and previously updated in 2014.

OBJECTIVES

To assess the effectiveness and safety of tonsillectomy (with or without adenoidectomy) compared with non-surgical treatment in the management of children with PFAPA.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2019, Issue 4); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 15 October 2019.

SELECTION CRITERIA

Randomised controlled trials comparing tonsillectomy (with or without adenoidectomy) with non-surgical treatment in children with PFAPA.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. The primary outcomes were the proportion of children whose symptoms have completely resolved and complications of surgery (haemorrhage and number of days of postoperative pain). Secondary outcomes were: number of episodes of fever and the associated symptoms; severity of episodes; use of corticosteroids; absence or time off school; quality of life. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

Two trials were included with a total of 67 children randomised (65 analysed); we judged both to be at low risk of bias. One trial of 39 participants recruited children with PFAPA syndrome diagnosed according to rigid, standard criteria. The trial compared adenotonsillectomy to watchful waiting and followed up patients for 18 months. A smaller trial of 28 children applied less stringent criteria for diagnosing PFAPA and probably also included participants with alternative types of recurrent pharyngitis. This trial compared tonsillectomy alone to no treatment and followed up patients for six months. Combining the trial results suggests that patients with PFAPA likely experience less fever and less severe episodes after surgery compared to those receiving no surgery. The risk ratio (RR) for immediate resolution of symptoms after surgery that persisted until the end of follow-up was 4.38 (95% confidence interval (CI) 0.64 to 30.11); number needed to treat to benefit (NNTB) = 2, calculated based on an estimate that 156 in 1000 untreated children have a resolution) (moderate-certainty evidence). Both trials reported that there were no complications of surgery. However, the numbers of patients randomly allocated to surgery (19 and 14 patients respectively) were too small to detect potentially important complications such as haemorrhage. Surgery probably results in a large overall reduction in the average number of episodes over the total length of follow-up (rate ratio 0.08, 95% CI 0.05 to 0.13), reducing the average frequency of PFAPA episodes from one every two months to slightly less than one every two years (moderate-certainty evidence). Surgery also likely reduces severity, as indicated by the length of PFAPA symptoms during these episodes. One study reported that the average number of days per PFAPA episode was 1.7 days after receiving surgery, compared to 3.5 days in the control group (moderate-certainty evidence). The evidence suggests that the proportion of patients requiring corticosteroids was also lower in the surgery group compared to those receiving no surgery (RR 0.58, 95% CI 0.37 to 0.92) (low-certainty evidence). Other outcomes such as absence from school and quality of life were not measured or reported.

AUTHORS' CONCLUSIONS

The evidence for the effectiveness of tonsillectomy in children with PFAPA syndrome is derived from two small randomised controlled trials. These trials reported significant beneficial effects of surgery compared to no surgery on immediate and complete symptom resolution (NNTB = 2) and a substantial reduction in the frequency and severity (length of episode) of any further symptoms experienced. However, the evidence is of moderate certainty (further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate) due to the relatively small sample sizes of the studies and some concerns about the applicability of the results. Therefore, the parents and carers of children with PFAPA syndrome must weigh the risks and consequences of surgery against the alternative of using medications. It is well established that children with PFAPA syndrome recover spontaneously and medication can be administered to try and reduce the severity of individual episodes. It is uncertain whether adenoidectomy combined with tonsillectomy adds any additional benefit to tonsillectomy alone.

Surgical outcomes and unique histological features of tonsils after tonsillectomy in adults with periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome

OBJECTIVES

Data on the adult-onset periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome are scarce. European studies reported that unlike pediatric-onset PFAPA, tonsillectomy is ineffective for adult-onset PFAPA. The aims of this study were (1) to assess the response to tonsillectomy in a cohort of Japanese adult-onset PFAPA patients and (2) to evaluate the histologic appearance of tonsils in adult-onset PFAPA patients and to compare them with those of tonsils from age- and sex-matched controls with chronic tonsillitis.

METHODS

In this retrospective cohort study, 5 adults with PFAPA and 15 controls who had undergone tonsillectomy were recruited. The size of the tonsil germinal centers was measured by hematoxylin and eosin staining, and the number and density of B and T lymphocytes in germinal centers were measured by immunohistochemistry, using CD3, CD4 and CD8 as T cell markers and CD20 as B cell marker.

RESULTS

All patients had complete remission of the symptoms after surgery. PFAPA patients had significantly smaller germinal center areas than controls. The number and density of CD8+ cells in germinal centers were significantly lower in tonsils from PFAPA compared with controls. No differences were found between the two groups in CD3+, CD4+, and CD20+ cells. These results are compatible with the tonsillar features of pediatric-onset PFAPA.

CONCLUSION

Our report demonstrates that tonsillectomy might be effective for adult-onset PFAPA and that tonsils of adult- and pediatric-onset PFAPA share the same histological features. These results suggest that the pathogenic mechanisms of adult- and pediatric-onset PFAPA are identical.

Paediatric oropharyngeal tularaemia requiring surgical intervention

Tularaemia is a rare infectious disease endemic in most European countries caused by the bacterium Francisella tularensis 1 Patients often show acute non-specific symptoms, which causes a delay in diagnosis and proper treatment, potentially resulting in significant morbidities such as deep neck abscess, meningitis, endocarditis and septic shock. The authors present a case of a 5-year old boy with a 4-day history of fever, sore throat and painful cervical lymphadenopathy, whose clinical progression worsened despite being treated with recommended antibiotics as per WHO guidelines once the diagnosis of Tularaemia was confirmed by serologic tests. He developed a parapharyngeal abscess and a persistent left necrotic cervical lymph node, which both were surgically drained and excised, respectively, and an extended course of antibiotic was given. Subsequently, the patient fully recovered from the illness and the follow-up was negative for relapse.

Incidence of indications for tonsillectomy and frequency of evidence-based surgery: a 12-year retrospective cohort study of primary care electronic records

BACKGROUND

Neither the incidence of indications for childhood tonsillectomy nor the proportion of tonsillectomies that are evidence-based is known.

AIM

To determine the incidence of indications for tonsillectomy in UK children, and the proportion of tonsillectomies meeting evidence-based criteria.

DESIGN AND SETTING

A retrospective cohort study of electronic medical records of children aged 0-15 years registered with 739 UK general practices contributing to a research database.

METHOD

Children with recorded indications for tonsillectomy were identified from electronic medical records. Evidence-based indications included documented sore throats of sufficient frequency and severity (Paradise criteria); periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome (PFAPA); or tonsillar tumour. Other indications were considered non-evidence-based. The numbers of children subsequently undergoing tonsillectomy was then identified. The numbers with evidence-based and non-evidence-based indications for surgery among children who had undergone tonsillectomy were determined.

RESULTS

The authors included 1 630 807 children followed up for 7 200 159 person-years between 2005 and 2016. Incidence of evidence-based indications for tonsillectomy was 4.2 per 1000 person years; 13.6% (2144/15 760) underwent tonsillectomy. Incidence of childhood tonsillectomy was 2.5 per 1000 person years; 11.7% (2144/18 281) had evidence-based indications, almost all with Paradise criteria. The proportion of evidence-based tonsillectomies was unchanged over 12 years. Most childhood tonsillectomies followed non-evidence-based indications: five to six sore throats (12.4%) in 1 year, two to four sore throats (44.6%) in 1 year, sleep disordered breathing (12.3%), or obstructive sleep apnoea (3.9%).

CONCLUSION

In the UK, few children with evidence-based indications undergo tonsillectomy and seven in eight of those who do (32 500 of 37 000 annually) are unlikely to benefit.

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

AIM OF STUDY

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Role of needle aspiration and surgical excision in management of suppurative Bacillus Calmette Guerin lymphadenitis

The aim was to determine the role of needle aspiration and surgical excision in the management of suppurative Bacillus Calmette Guerin (BCG) lymphadenitis. This prospective study was done in Rafha Central Hospital, over 1.5 years. Thirty two patients were enrolled after informed consent. Needle aspiration was done if size of lymphadenitis was up to 3cm. Surgical excision was done primarily for size more than 3cm or in cases of failed aspiration. Eighteen were males and 14 were females. Median age was 3.75 months (IQR 2-7). All were full term with normal birth weight and vaccinated in first 2 days of life. Predominantly single region of lymphadenitis was involved in 75% cases; with left axilla being mainly affected (56.3% cases). Needle aspiration was done in 18 cases and surgical excision was carried out in 14 cases. Resolution of lymphadenopathy was 7 days in cases of surgical excision, while within 60 days in cases of aspiration. Failure of aspiration was noted in cases of multiple, matted suppurative lymph nodes.

Management of nontuberculous mycobacterial lymphadenitis in a tertiary care children's hospital: A 20year experience

PURPOSE

Nontuberculous mycobacteria are uncommon cause of chronic cervicofacial lymphadenitis in healthy children. We describe clinical features and management strategies of cervicofacial nontuberculous mycobacterium lymphadenitis in a tertiary pediatric hospital.

METHODS

Retrospective analysis of medical records of children discharged from 1992 to 2014 with a diagnosis of cervicofacial nontuberculous mycobacterium was made. Diagnosis certainty was based on microhistological investigations. Clinical stage was evaluated according to lymph node size and presence of fistulas. Successful therapy was defined by the regression of the lymph node enlargement (>75%) or complete surgical excision without relapse.

RESULTS

Cervicofacial nontuberculous mycobacterium was diagnosed in 33 patients. Complete excision was performed in 73% of cases primarily observed in our hospital, while 83% of those referred from other hospitals required further surgical treatment. No case of relapse was observed after one year of follow-up.

CONCLUSIONS

We recommend surgical approach as the first therapeutic option in the management of cervicofacial nontuberculous mycobacterium lymphadenitis.

LEVELS OF EVIDENCE

Prognosis and Retrospective Study - Level II.

[Tonsillectomy in Cases with Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Cervical Adenitis Syndrome]

The periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is an autoinflammatory disease, characterized, as its name suggests, by periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis. This syndrome is the most common cause of recurrent fever in children, however the rate of recognition of this syndrome is still low. Tonsillectomy has been suggested as an effective treatment, even though the precise, pathophysiology underlying this syndrome remains unknown. In this study, we investigated the outcomes in patients who underwent tonsillectomy. In particular, we examined the surgical outcomes and clinical features of the patients who underwent tonsillectomy. A total of 19 patients with PFAPA syndrome underwent tonsillectomy at our hospital from July 2013 to May 2016. Before the surgery, while all the patients had received medications, none showed complete resolution of the syndromes. However, of the 19 patients, 15 showed complete resolution of the syndrome immediately after the surgery. Four patients had fever even after the surgery. Three patients showed partial remission, with the frequency and duration of the episodes decreasing after the surgery. However, in one patient, the fever persisted as before the surgery. There were no significant differences in the clinical characteristics, such as the age at onset, fever episodes, associated symptoms, or age at surgery among the three groups. However, we observed a trend towards a higher frequency of a family history in patients with persistent symptoms after surgery. Tonsillectomy was highly effective against PFAPA syndrome, however, some patients failed to respond to the procedure. Therefore, it is important to carefully evaluate the risks and benefits in each case. The indications for tonsillectomy have not yet been clearly established. It is essential to continue further investigations to establish effective therapeutic strategies for this syndrome.

[CAUSES AND WAYS OF THE NECK PHLEGMON SPREADING ON MEDIASTINUM WITH A DESCENDING PURULENT MEDIASTINITIS OCCURRENCE]

Results of treatment in 2000-2016 yrs of 183 patients for the neck phlegmon were analyzed. In 60 (32.8%) of them a descending purulent mediastinitis (DPM) was diagnosed. The main causes of the DPM occurrence were tonsilogenic and odontogenous factors. Postoperative lethality in DPM have constituted 25%.

Human Immunodeficiency Virus Lymphadenitis Patterns on Fine-Needle Aspiration Cytology

OBJECTIVE

The aim of this work was to study the microscopic patterns of human immunodeficiency virus (HIV) lymphadenitis on fine-needle aspiration cytology (FNAC) and correlate them with cluster of differentiation 4 (CD4) counts.

STUDY DESIGN

A retrospective study of known HIV-positive patients who underwent lymph node FNAC over a period of 5 years (2009-2013) was undertaken. The cytology slides were retrieved and reviewed. Out of 317 cases, 38 (11.7%) were diagnosed as HIV lymphadenitis. We analysed the cytomorphological patterns of HIV lymphadenitis and correlated them with the CD4 cell counts.

RESULTS

Smears of HIV lymphadenitis were classified akin to histology patterns (A, B, and C) depending on cellularity, number of tingible body macrophages, mitosis, apoptotic bodies, plasma cells, Warthin-Finkeldey giant cells, and proliferating blood vessels. Thirty-one cases showed pattern A, 3 showed pattern B, and 4 were of pattern C. Pattern A had the highest CD4 cell count.

CONCLUSION

Histologic patterns of HIV lymphadenitis are recognisable on FNAC smears. These can offer a clue to the diagnosis and guide further workup, even in the absence of history. The changes can mimic those of the infective lymphadenitis, Castleman disease, and lymphoma. Hence, the clinical history, serological correlation, and awareness of cytomorphology can aid the correct diagnosis.

Cytomorphological Analysis of Lymph Node Lesions in HIV-Positive Patients with CD4 Count Correlation: A Cross-Sectional Study

OBJECTIVES

To study the cytomorphological spectrum of lymph node lesions in HIV-positive patients and correlate the cytological findings with the CD4 count.

STUDY DESIGN

This was a cross-sectional study of 23 months' duration which included 110 HIV-positive cases proved according to the guidelines of the National AIDS Control Organisation. Fine-needle aspiration cytology (FNAC) was done on clinically palpable lymph nodes. Special stains and culture were done wherever necessary. CD4 count was done by flow cytometry and subsequently correlated with the cytological findings.

RESULTS

Our study included 110 cases, ranging in age from 6 to 70 years, peaking in the 3rd to 4th decade (n = 46). The male-to-female ratio was 1.75:1 and the predominant site was the cervical group of lymph nodes (n = 71). Each lesion was correlated with CD4 count, laboratory and clinical findings, and was further segregated based on WHO and CDC staging. Cytological lesions were tubercular (53.6%), reactive (27.1%), suppurative (6.4%) lymphadenitis, lymphoma (4.5%), cystic lymphoid hyperplasia (2.8%), metastases (1.9%), cryptococcal lymphadenitis (0.9%). The mean CD4 count was 217.4, 434.4, 181.4, 149, 580, 225, and 207 cells/µL, respectively. There was a highly significant correlation of cytological findings with CD4 count (χ2 value = 44.57 and p < 0.001).

CONCLUSION

FNAC is a primary, safe, and valuable tool for the identification of opportunistic infections, neoplastic and nonneoplastic lesions, as well as therapeutic modality in certain conditions. Correlation of lesions with CD4 count provides information about immune status, HIV stage and segregating cases, and also aids further evaluation and management.

Pediatric retropharyngeal lymphadenitis: Differentiation from retropharyngeal abscess and treatment implications

Objectives

Our objectives were to review the retropharyngeal anatomy, define retropharyngeal adenitis and abscess, and determine if CT may guide the clinician in treatment planning for pediatric retropharyngeal infections.

Study Design and Setting

A retrospective chart review and CT scan review of 30 children with retropharyngeal infections.

Results

All patients had retropharyngeal adenitis. Average volume of the low-attenuation focus in the medical treatment group was 1.2 cm3. Average volume in the surgical group was 4 cm3. Surgery patients with no purulent findings were then grouped with the medical treatment group; the average volume of the low-attenuation focus in this group was 2.2 cm3. Average volume in the group in which purulence was identified was 4.4 cm3.

Conclusion

CT can identify patients with retropharyngeal infections who have a high likelihood of being successfully treated with antibiotics alone.

Significance

CT imaging may assist in avoiding unnecessary surgical exploration.

[A Case of Perirenal Non-Specific Lymphadenitis Resected by Laparoscopic Operation for the Possibility of Malignancy]

Various types of tumors, including benign tumors, arise from the renal parenchyma or renal capsule, but it is difficult to predict the histological type preoperatively. Here, we report a case of perirenal non-specific lymphadenitis resected laparoscopically. A 79-year-old man with a history of diabetic mellitus and noninvasive bladder cancer had an incidentally-detected enhanced mass in contact with the surface of the left kidney. Given the possibility that the tumor was malignant, we resected the mass laparoscopically. Intraoperative findings revealed that the tumor did not invade the renal parenchyma, and it could be easily resected. Microscopic findings showed that the tumor consisted of inflammation of a lymph node, lymphoid follicles with hyperplasia of germ center and granulomatous inflammation with giant cells, and there was no malignant finding. Despite various additional examinations, the specific cause of the lymphadenitis was not clarified, leading to a final diagnosis of non-specific lymphadenitis. To our knowledge this is the first report about perirenal non-specific lymphadenitis difficult to distinguish from perirenal malignant tumor in preoperative computed tomography imaging.

Nontuberculous Mycobacterial Disease in Children - Epidemiology, Diagnosis & Management at a Tertiary Center

Background

There are limited data on the epidemiology, diagnosis and optimal management of nontuberculous mycobacterial (NTM) disease in children.

Methods

Retrospective cohort study of NTM cases over a 10-year-period at a tertiary referral hospital in Australia.

Results

A total of 140 children with NTM disease, including 107 with lymphadenitis and 25 with skin and soft tissue infections (SSTIs), were identified. The estimated incidence of NTM disease was 0.6–1.6 cases / 100,000 children / year; no increasing trend was observed over the study period. Temporal analyses revealed a seasonal incidence cycle around 12 months, with peaks in late winter/spring and troughs in autumn. Mycobacterium-avium-complex accounted for most cases (77.8%), followed by Mycobacterium ulcerans (14.4%) and Mycobacterium marinum (3.3%). Polymerase chain reaction testing had higher sensitivity than culture and microscopy for acid-fast bacilli (92.0%, 67.2% and 35.7%, respectively). The majority of lymphadenitis cases underwent surgical excision (97.2%); multiple recurrences in this group were less common in cases treated with clarithromycin and rifampicin compared with clarithromycin alone or no anti-mycobacterial drugs (0% versus 7.1%; OR:0.73). SSTI recurrences were also less common in cases treated with two anti-mycobacterial drugs compared with one or none (10.5% versus 33.3%; OR:0.23).

Conclusions

There was seasonal variation in the incidence of NTM disease, analogous to recently published observations in tuberculosis, which have been linked to seasonal variation in vitamin D. Our finding that anti-mycobacterial combination therapy was associated with a reduced risk of recurrences in patients with NTM lymphadenitis or SSTI requires further confirmation in prospective trials.

Polyclonal, newly derived T cells with low expression of inhibitory molecule PD-1 in tonsils define the phenotype of lymphocytes in children with Periodic Fever, Aphtous Stomatitis, Pharyngitis and Adenitis (PFAPA) syndrome

PURPOSE

PFAPA syndrome is a benign, recurrent inflammatory disease of childhood. Tonsillectomy is one of the therapeutic options with a yet unexplained biological mechanism. We tested whether specific lymphocyte subsets recruited from blood to human tonsils participate in PFAPA pathogenesis.

METHODS

Paired tonsils/peripheral blood (PB) samples were investigated (a) from children with PFAPA that successfully resolved after tonsillectomy (n=10) (b) from children with obstructive sleep apnoea syndrome as controls (n=10). The lymphocyte profiles were analysed using 8-colour flow cytometry, immunoglobulin (IGH) and T-cell receptor (TCR) gene rearrangements via PCR and next generation sequencing; a TREC/KREC analysis was performed using qPCR.

RESULTS

The PFAPA tonsils in the asymptomatic phase had a lower percentage of B-lymphocytes than controls; T-lymphocyte counts were significantly higher in PB. The percentages of cytotoxic CD8pos T-lymphocytes were approximately 2-fold higher in PFAPA tonsils; the transitional B cells and naïve stages of both the CD4pos and CD8pos T-lymphocytes with a low expression of PD-1 molecule and high numbers of TREC were also increased. With the exception of elevated plasmablasts, no other differences were significant in PB. The expression levels of CXCL10, CXCL9 and CCL19 genes were significantly higher in PFAPA tonsils. The IGH/TCR pattern showed no clonal/oligoclonal expansion. DNA from the Epstein-Barr virus, Human Herpervirus-6 or adenovirus was detected in 7 of 10 PFAPA tonsils but also in 7 of 9 controls.

CONCLUSIONS

Our findings suggest that the uninhibited, polyclonal response of newly derived lymphocytes participate in the pathogenesis of PFAPA. Because most of the observed changes were restricted to tonsils and were not present in PB, they partly explain the therapeutic success of tonsillectomy in PFAPA syndrome.

Managing cervical lymphadenitis--a total pain in the neck!

Patients presenting with cervical lymphadenitis are a complex and common occurrence in a general pediatric practice. Although Staphylococcus aureus (often methicillin-resistant S. aureus [MRSA]) and Streptococcus pyogenes predominate as causative pathogens, the next most common pathogens, Bartonella, atypical mycobacterium, and mononucleosis, also must be considered early on. The best way to diagnose and manage these cases initially is to proceed methodically, with detailed history and physical examination, initial streptococcal mono rapid tests, serial office visits, and complete blood counts. In nonviral cases, an empiric oral antibiotic trial is usually prescribed as early as possible to cover for MRSA or Bartonella. Very tender or reddened lymph nodes larger than 5 cm that are unresponsive and worsening may likely require inpatient parenteral antibiotics and sometimes surgical removal. The practitioner must also realize that submandibular and supraclavicular node locations are highly suggestive of atypical mycombacterium and cancer, respectively.

Tonsillectomy for periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis syndrome (PFAPA)

BACKGROUND

Periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome is a rare clinical syndrome of unknown cause usually identified in children. Tonsillectomy is considered a potential treatment option for this syndrome. This is an update of a Cochrane review first published in 2010.

OBJECTIVES

To assess the effectiveness and safety of tonsillectomy (with or without adenoidectomy) in children with PFAPA.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 30 October 2013.

SELECTION CRITERIA

Randomised controlled trials comparing tonsillectomy (with or without adenoidectomy) with non-surgical treatment in children with PFAPA.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

Two trials were included with a total of 67 children randomised (65 analysed); we judged both to be at low risk of bias.One trial of 39 participants recruited children with PFAPA syndrome diagnosed according to rigid, standard criteria. The trial compared adenotonsillectomy to watchful waiting and followed up patients for 18 months. A smaller trial of 28 children applied less stringent criteria for diagnosing PFAPA and probably also included participants with alternative types of recurrent pharyngitis. This trial compared tonsillectomy alone to no treatment and followed up patients for six months.Combining the trial results suggests that patients with PFAPA experience less fever and less severe episodes after surgery compared to those receiving no surgery. The risk ratio (RR) for immediate resolution of symptoms after surgery that persisted until the end of follow-up was 4.38 (95% confidence interval (CI) 0.64 to 30.11); number needed to treat to benefit (NNTB) = 2, calculated based on an estimate that 156 in 1000 untreated children have a resolution).There was a large overall reduction in the average number of episodes over the total length of follow-up in these studies (rate ratio 0.08, 95% CI 0.05 to 0.13), reducing the average frequency of PFAPA episodes from one every two months to slightly less than one every two years. The severity, as indicated by the length of PFAPA symptoms during these episodes, was also reduced. One study reported that the average number of days per PFAPA episode was 1.7 days after receiving surgery, compared to 3.5 days in the control group. The proportion of patients requiring corticosteroids was also lower in the surgery group compared to those receiving no surgery (RR 0.58, 95% CI 0.37 to 0.92).Both trials reported that there were no complications of surgery. However, the numbers of patients randomly allocated to surgery (19 and 14 patients respectively) were too small to detect potentially important complications such as haemorrhage. Other outcomes such as quality of life, number of days with pain after surgery and absence from school were not measured or reported.

AUTHORS' CONCLUSIONS

The evidence for the effectiveness of tonsillectomy in children with PFAPA syndrome is derived from two small randomised controlled trials. These trials reported significant beneficial effects of surgery compared to no surgery on immediate and complete symptom resolution (NNTB = 2) and a substantial reduction in the frequency and severity (length of episode) of any further symptoms experienced. However, the evidence is of moderate quality (further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate) due to the relatively small sample sizes of the studies and some concerns about the applicability of the results. Therefore, the parents and carers of children with PFAPA syndrome must weigh the risks and consequences of surgery against the alternative of using medications. It is well established that children with PFAPA syndrome recover spontaneously and medication can be administered to try and reduce the severity of individual episodes. It is uncertain whether adenoidectomy combined with tonsillectomy adds any additional benefit to tonsillectomy alone.

Tonsillectomy efficacy in children with PFAPA syndrome is comparable to the standard medical treatment: a long-term observational study

OBJECTIVES

Tonsillectomy has recently been suggested as an effective treatment for PFAPA syndrome but little is known about its long-term efficacy. We compared the clinical features and the long-term outcome of a large cohort of patients with PFAPA syndrome treated with tonsillectomy or with standard medical treatment.

METHODS

We conducted a retrospective study on patients with PFAPA syndrome followed at a tertiary care centre from January 1993 to August 2010. Clinical characteristics and laboratory parameters were evaluated at onset and during the follow-up. Disease outcomes of patients who underwent tonsillectomy and of those treated with medical therapy (NSAIDs, prednisone) were compared. Clinical remission on medication (CRM) was considered the persistence of fever attacks which were well controlled by medical therapy, clinical remission (CR) was defined as the absence of fever attacks, without any treatment, for more than 12 months.

RESULTS

275 patients with PFAPA syndrome, 59.6% males, aged 27.9 months at onset and followed for mean 54.5 months, entered the study. CR was reported in 59.6% of the patients and was significantly less frequent in those with positive family history for PFAPA (46.4% vs. 66.1%, p=0.003). 27/41 patients (65.9%), responded to tonsillectomy and this result was comparable with that observed in those treated with medical therapy (59.1%, p=0.51). Disease duration, age at remission or presence of associated symptoms were not significantly different in both groups. No predictors of tonsillectomy failure were found.

CONCLUSIONS

In a large cohort of patients with PFAPA syndrome, tonsillectomy efficacy was comparable to the standard medical treatment.

An atypical deep neck infection in a two-year-old child

Non-tuberculous mycobacteria are one of the major causes of lymphadenitis in children and seldom of deep neck infections. We reported the case of an immunocompetent two-year-old girl with adenitis and retropharyngeal abscess caused by an atypical mycobacterium. She had a positive tuberculin skin test, whereas the Quantiferon TB Gold test was negative. The child underwent a complete nodal excision. The search for acid fast bacilli was positive and Mycobacterium scrofulaceum was isolated from the surgically removed material. The retropharyngeal abscess was treated only with antimicrobial therapy, which resulted in an appreciable size reduction of the abscess. After two months antimicrobial treatment was interrupted, and complete resolution was achieved after twelve months. No relapse of disease or possible long-term complications were observed. The surgical wound healed completely, with normal overlying skin and a good aesthetic result. The clinical management of atypical mycobacteria lymphadenitis and retropharyngeal abscess in children is discussed.

Histology of solid lateral cervical masses biopsied in children

INTRODUCTION

Solid cervical lateral neck masses in children may require surgical biopsy to confirm appropriate diagnostic and begin a directed therapeutic treatment. We aimed to describe the contribution of pathological results and compare them with the clinical diagnosis and the paraclinical tools.

METHODS

A retrospective review of surgical biopsies for solid lateral neck masses in children over a ten year period in a pediatric tertiary center was conducted. Demographic, imaging, laboratory analysis, surgical and pathological data were collected and analyzed using descriptive statistics with SPSS 17.0.

RESULTS

44 biopsies were done between 2002 and 2012. Inflammatory masses were found in 26/44 biopsies with half of them (13/26) being nontuberculous mycobacterial (NTM) lymphadenitis. Non-inflammatory/benign masses represented 9/44 biopsies and 5/44 masses were of malignant etiology. Malignant masses imaging had a sensitivity and specificity of 33% and 75%, respectively, for ultrasound, whereas Neck CT scan had 33% and 77%, respectively. The contribution of pathological results to the clinical management was questionable in 39% (17/44) of biopsies.

CONCLUSION

Inflammatory masses with NTM lymphadenitis were the most common diagnosis. Imaging was not helpful in establishing the diagnosis. Heterogeneity in the management of solid lateral neck masses between clinicians was important and indicates the need for guideline approach.

PFAPA with facial swelling- a new association?

PFAPA (periodic fever, apthous stomatitis, pharyngitis, cervical adenitis) is a rare condition of unknown cause affecting children. Although the exact etiology is unknown, inflammatory, immunological or genetic causes have been suggested. The diagnosis is made by exclusion of other causes of periodic fever. Although management is essentially symptomatic, single corticosteroid dose, tonsillectomy and Cimetidine has been shown to be associated with resolution of symptoms. Although abdominal pain and genital ulcers have been reported in association with PFAPA, unilateral transient facial swelling has not been previously reported. The authors present a hitherto unreported association of PFAPA with recurrent episodes of unilateral facial swelling.

Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome and IgA nephropathy

BACKGROUND

A syndrome of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA), as well as immunoglobulin A nephropathy (IgAN), may be caused by autoimmune reactivity nephropathy.

CASE-DIAGNOSIS/TREATMENT

A 10-year-old boy presented with periodic fever, exudative tonsillitis, oral aphthous ulcer, and cervical lymph node inflammation. These conditions had occurred at intervals of about 2-6 weeks since the age of 3 years. Microscopic hematuria, first detected at age 8 years, worsened during episodes of PFAPA-related fever; since 10 years of age, the hematuria was accompanied by sustained proteinuria. Examination of a kidney biopsy specimen led to a diagnosis of IgAN. In the kidney specimen, fractalkine immunoreactivity and heavy macrophage infiltration were prominent. Multi-drug cocktail therapy improved the urinalysis findings, and subsequent tonsillectomy succeeded in controlling recurrences of PFAPA and IgAN. In a post-treatment renal biopsy specimen, mesangial proliferation was decreased, and fractalkine immunoreactivity was absent.

CONCLUSION

Immunologic reactions against certain antigens in local mucosa, including tonsils, may be impaired in PFAPA and IgAN, as evidenced by the suppression of both diseases in our patient by tonsillectomy. Accordingly, the concurrence of PFAPA and IgAN in our patient appeared to be a consequence of shared autoimmune mechanisms and systemic and local increases in cytokine concentrations, rather than coincidence.

[Bilateral peritonsillar abscess with lymph node abscess in a infant. A rare case]

Peritonsillar abscess (PTA) comprises approximately 30% of soft tissue head and neck abscesses. Bilateral occurrence in infants is rare. The present case demonstrates a bilateral peritonsillar abscess with a lymph node abscess in a 10.5-month-old infant without the typical clinical findings of PTA. This report highlights the importance of including peritonsillar abscesses in the differential diagnosis of abscess-forming cases of lymphadenitis colli refractory to therapy, even if the classical symptoms are absent. In individual cases, the indication for image-guided procedures to establish the diagnosis of PTA should be made generously.

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.

[Lymphadenitis caused by nontuberculous mycobacteriae]

Lymphadenitis caused by nontuberculous mycobacteriae has been increasingly seen in Finland since the cessation of universal BCG vaccination in 2006. An otherwise healthy child develops a slowly growing unilateral mass in the cervicofacial region. Without treatment, the lymphadenitis suppurates and forms a draining sinus, which dries after some weeks or months, leaving a scar. Surgical excision is curative treatment but cannot always be performed because of risk to the facial nerve or need of extensive surgery. In these cases, observation without antimicrobial treatment is usually recommended. The parents need professional information and support.

Tonsillectomy for periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis syndrome (PFAPA)

BACKGROUND

PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis syndrome) is a rare clinical syndrome of unknown cause usually identified in children.

OBJECTIVES

To assess the efficacy of tonsillectomy (with or without adenoidectomy) in children with PFAPA.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2010 Issue 1); MEDLINE (PubMed); EMBASE; CINAHL; mRCT (metaRegister of clinical trials, including ClinicalTrials.gov); NRR (National Research Register); LILACS; KoreaMed; IndMed; PakMediNet; China Knowledge Network; CAB Abstracts; Web of Science; BIOSIS Previews; ICTRP (International Clinical Trials Registry Platform) and Google. The date of the last search was 21 January 2010.

SELECTION CRITERIA

Randomised studies comparing adeno-/tonsillectomy with non-surgical treatment.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data.

MAIN RESULTS

Two trials involving 67 children were included. One high quality study demonstrated a dramatic benefit of adenotonsillectomy in children with PFAPA diagnosed according to rigid, standard criteria with a relative 'risk' (RR) of symptom resolution after 18 months of 12.63 (95% CI 1.81 to 87.98) and a lower rate of episodes per patient-month (rate ratio 0.07; 95% CI 0.04 to 0.13). A less methodologically rigorous study enrolled some children with PFAPA, but probably included others with alternative types of recurrent pharyngitis, and performed tonsillectomy alone. This also demonstrated a significant benefit for surgery at six months: RR 1.93 (95% CI 1.11 to 3.36); rate ratio episodes per patient-month 0.10 (95% CI 0.04 to 0.28). The pooled relative risk of symptom resolution was 3.25 (95% CI 1.78 to 5.92) and the resulting number needed to treat (NNT) 2 (95% CI 1 to 3).

AUTHORS' CONCLUSIONS

The trials included in this review reported follow up at 18 and six months respectively but it is well-established that children with PFAPA recover spontaneously and treatment can be administered to try and reduce the severity of individual episodes. Therefore, the parents and carers of children with PFAPA must weigh the risks and consequences of surgery (hospitalisation, a predictable period of time postoperatively away from school/nursery, the risks of surgery) against the alternative of a finite period of recurrent episodes of disease at predictable intervals, potentially requiring time off school and the regular use of medication. It is uncertain whether adenoidectomy combined with tonsillectomy adds any additional benefit to tonsillectomy alone.

Dermatopathic lymphadenitis imitating a deep neck space infection

INTRODUCTION

Dermatopathic lymphadenitis (DL) represents a benign form of reactive lymph node hyperplasia. Symptoms attributed to DL alone are expected to be mild. The purpose of this study was to present a rare case of DL in a young girl that manifested as a deep neck space infection. Differential diagnostic process and the difficulties we faced in managing this case will be discussed.

CASE PRESENTATION

A 10-year-old girl with clinical signs indicative of deep neck space infection was admitted in our department. Her clinical course and imaging findings strongly suggested the presence of a deep cervical abscess, although this was not proven in the operating room, in 2 operating sessions. The complete clinical picture developed during her in-hospital care set the suspicion of Kawasaki disease; however, the results of the histology of the cervical nodes were consistent with dermatopathic lympadenitis, which was the final diagnosis in our patient.

CONCLUSION

Dermatopathic lymphadenitis is a rare diagnosis in the head and neck area. However, it must be included in the differential diagnostic process because its management differs from that of other head and neck lymphadenopathies, keeping in mind that the spectrum of its clinical symptomatology may vary from a mild lymph node enlargement to acute symptoms and signs of a deep neck infection.

Splitting the dose of neonatal BCG vaccination: a naïve practice

Bilateral axillary lymphadenitis complicating BCG vaccination in both arms (0.025 ml) in an immunocompetent 13-month-old boy is described. Prompt administration of isoniazid and erythromycin did not prevent suppuration of the affected lymph nodes. It was managed by bilateral surgical excision of the nodes.

Effectiveness of adenotonsillectomy in PFAPA syndrome: a randomized study

OBJECTIVE

To evaluate whether adenotonsillectomy leads to complete resolution in children with PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) syndrome.

STUDY DESIGN

Thirty-nine children with PFAPA syndrome were randomized to either adenotonsillectomy (surgery group; n = 19) or expectant management (control group; n = 20). All patients were then invited prospectively to record all PFAPA episodes, and were evaluated clinically every 3 months for 18 months after randomization.

RESULTS

The proportion of patients experiencing complete resolution was 63% in the surgery group and 5% in the control group (P < .001). The mean (+/- standard deviation) number of episodes recorded during the study period was 0.7 +/- 1.2 in the surgery group and 8.1 +/- 3.9 in the control group (P < .001). The episodes were less severe in the surgery group.

CONCLUSIONS

Adenotonsillectomy is an effective treatment strategy for children with PFAPA syndrome.

Surgical management of BCG vaccine-induced regional axillary lymphadenitis in HIV-infected children

There are as yet no clear surgical guidelines for the management of BCG vaccine-induced regional axillary lymphadenopathy.

OBJECTIVES

The aim of this study was to evaluate the management of the condition and to suggest possible management strategies.

METHODS

A retrospective study was undertaken of 23 cases of suspected ipsilateral BCG adenitis following neonatal BCG inoculation (2001 - 2004). Diagnosis of a BCG infection was confirmed by culture and/or gastric washout. The age of the patient and mode of presentation, imaging findings, and results of tuberculin skin testing (Mantoux test) were documented. Because of a change in management policy the first group of patients treated by primary surgery were compared with those treated by fine-needle aspiration (FNA). The influence of HIV status on outcome was assessed. Surgical complications and outcome were analysed.

RESULTS

Twenty-three children under 13 years of age (mean age 8.8 months, male/female ratio 1.9:1) were evaluated. Eighteen patients tested positive for HIV and 5 were HIV-negative. A positive culture for BCG bacillus was identified in 19 cases (83%) - by FNA (N=13, 68%), on pus swab (N=3, 16%), at surgery (N=1, 5%), and by gastric washing (N=2, 11%). Three HIV-negative children had granulomas on histological examination without a positive culture. Forty-five per cent of the 11 patients treated early in the study period by primary surgery (drainage/biopsy) had complications, which included a difficult anaesthetic induction and technical surgical difficulties. The postoperative incidence of wound dehiscence/infection was extremely high in this group and 18.2% developed postoperative cutaneous sinuses. Following a change in management policy, the following 12 patients, with a comparable HIV incidence, treated by initial conservative management, had a much lower incidence of post-procedural complications.

CONCLUSION

This study confirms a high perioperative complication rate associated with the primary surgical treatment of BCG lymphadenitis in both HIV-positive and negative patients. Primary surgical treatment (incisional drainage or biopsy) is therefore not considered an ideal form of management in BCG lymphadenitis because of the high fistulisation and poor wound healing, especially in the HIV-positive patient. It should be avoided as the initial approach, with needle aspiration being preferred. Surgery should therefore be confined to the unusual event of real doubt about the underlying diagnosis and the treatment of suppurative complications.

Diagnosis of myiasis by fine needle aspiration cytology: a case report

BACKGROUND

Myiasis is the infestation of tissues and organs by dipteran larvae and is endemic in tropical areas. Diagnosis usually is made by demonstration of a larva or larvae in infected tissue, generally recognizable to the naked eye. In our case, diagnosis was based on fine needle aspiration cytology (FNAC).

CASE

A 59-year-old female patient with a painful neck mass was examined at an otorhinolaryngologic department after symptoms for several weeks. The lesion was found to be an absceding lymphadenitis, based on clinical symptoms, palpation and imaging (ultrasound and computed tomography). The lesion did not improve with repeated courses of antibiotics, so surgery was performed. Pus cultures collected after incision were negative, leaving origin of the inflammation undetermined. Smears from FNA of the residual mass demonstrated a worm-like pathogen alien to most European pathologists' experience. The pathogen was identified as a dipteran larva, leading to accurate etiologic diagnosis of myiasis. More scrupulous examination of the patient's history revealed she had spent her vacation in Australia, where she probably acquired the infection.

CONCLUSION

Our case demonstrates the growing importance of the pathology of infectious diseases. One reason for this may be the ever-increasing possibility, frequency and distance of travel.

[Periodic fever--two children with periodic fever, aphthous stomatitis pharyngitis, adenitis syndrome]

PFAPA (periodic fever, aphthous stomatitis, pharyngitis, adenitis) syndrome is characterised by episodes of fever (>40 degrees C), lasting 4-5 days and recurring every 3-6 weeks, accompanied by aphthous stomatitis, pharyngitis or cervical adenitis. Between the episodes of fever there are no symptoms. Glucocorticoids are highly effective in controlling the symptoms, while tonsillectomy results in remission. We describe two children with PFAPA syndrome. Early diagnosis can significantly improve the patients' quality of life.

A randomized, controlled trial of tonsillectomy in periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome

OBJECTIVE

We carried out a prospective, randomized, controlled trial to clarify the effect of tonsillectomy on the clinical course of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome.

STUDY DESIGN

Twenty-six consecutive children (mean age 4.1 years) with at least 5 PFAPA attacks were recruited from 3 tertiary care pediatric hospitals during 1999-2003 and randomly allocated to tonsillectomy or follow-up alone. They were all followed up with symptom diaries for 12 months. Tonsillectomy was allowed after 6 months in the control group if the attacks recurred.

RESULTS

Six months after randomization all 14 children in the tonsillectomy group and 6/12 children in the control group (50%) were free of symptoms (difference 50%, 95% confidence interval 23% to 75%, P < .001). Tonsillectomy was performed on 5/6 of the patients in the control group who still had symptoms after 6 months. The remaining unoperated child in the control group had recurrences of the fever episodes throughout the follow-up, but the symptoms became less severe, and the parents did not choose tonsillectomy.

CONCLUSION

Tonsillectomy appeared to be effective for treating PFAPA syndrome. The fever episodes ceased without any intervention in half of the control subjects. We conclude that although the mechanisms behind this syndrome are unknown, tonsillectomy can be offered as an effective intervention for children with PFAPA.