Nontuberculous Mycobacterial Cervicofacial Lymphadenitis Research Articles

Regional differences in admissions and surgical management of pediatric nontuberculous mycobacterial cervicofacial lymphadenitis

ObjectivesThis study aims to determine the overall incidence of medical and surgical admissions related to non-tuberculous mycobacterial cervicofacial lymphadenitis (NTMCL) and determine if rates vary by geographic region in the US. It also aims to assess if the relative frequency of varying treatment modalities for NTMCL differ among geographic regions. Study designPopulation-based inpatient registry analysis. SettingAcademic medical center. MethodsThe Kids’ Inpatient Database (2016 and 2019) was used to determine NTMCL-related admissions and common head and neck procedures performed during these admissions were identified. Analysis was performed on regional differences in demographic factors and procedures performed during NTMCL-related admissions. ResultsThere were 159 weighted admissions (1.31 per 100,000) for NTMCL in 2016 and 2019 in the US, with the Midwest having the highest proportion of NTML-related admissions (1.59:100,000). NTMCL-related admissions were 2.21 times as likely to be elective rather than non-elective in the Midwest when compared to all other geographic regions (p = 0.038). The Midwest was 2.83 times as likely to treat with surgery (p = 0.011), while the Northeast was negatively associated with performing procedures (OR 0.38; p = 0.026). In the Midwest, significantly more excisional surgeries were preformed when compared to other regions, with an OR of 2.98 (p = 0.003). ConclusionThe Midwest had the highest incidence of pediatric NTMCL-related admissions and was more likely to perform excisional surgery as primary NTMCL treatment. Regions that rarely see pediatric NTMCL have a more inconsistent approach to management.

Evaluation of Anti-Glycopeptidolipid-Core Immunoglobulin A Antibody Detection for the Diagnosis of Nontuberculous Mycobacterial Cervicofacial Lymphadenitis.

A multicenter cross-sectional diagnostic study was carried out including 45 children with nontuberculous mycobacterial cervicofacial lymphadenitis and controls. The tested immunoassay, detecting M. avium-specific anti-glycopeptidolipid-core immunoglobulin A antibodies, had inadequate diagnostic performance in the studied population and seems to be of no additional value in detecting cases of nontuberculous mycobacterial cervicofacial lymphadenitis.

Comparison of treatment modalities for non-tuberculous mycobacterial cervicofacial lymphadenitis in children.

We aim to compare the different treatment modalities of non-tuberculous cervicofacial lymphadenitis in children, by means of a retrospective study conducted in the University Hospitals of Leuven of patients treated between 2012 and 2022. For this retrospective cohort study, data were collected and pseudonimised from 52 patients with non-tuberculous cervicofacial lymphadenitis, who were treated in our hospital between January 2012 and December 2022, either conservatively, antibiotically, surgically, or with a combination of these options. We only included patients who were considered immunocompetent. All of the included patients were below 10 years at time of treatment. We collected data regarding time to resolution and adverse effects, i.e., skin discoloration, excessive scar formation, fistula formation, persistence of adenopathies after treatment, need for additional treatment, facial nerve paresis/paralysis, or systemic side-effects due to antibiotic treatment. The mean time to resolution (in days) when looking at primary treatments, was shortest in partial excisions (16), followed by complete excisions (19), antibiotic therapy (129), incision and drainage (153), curettage (240), and finally conservative management (280). Taking into account isolated treatments (i.e., both primary and adjuvant), we also observed consistently faster time to resolution in surgical and antibiotic treatments when compared to conservative treatment. Antibiotic therapy (p = 0.003), incision and drainage (p = 0,004) were associated with a significantly higher need for adjuvant treatment. Curettage was associated with a higher incidence of fistula formation (p = 0,006) and higher number of adjuvant treatments (p = 0,002). This study shows a faster resolution of nontuberculous mycobacterial cervicofacial lymphadenitis in children when treated surgically, more specifically when treated with partial or complete lymph node excision. Antibiotic treatment also leads to faster resolution than conservative management. There was a low rate of complications, and no permanent facial nerve damage was reported.

Non-Tuberculous Mycobacterial Cervicofacial Lymphadenitis in Children-10-Year Experience in a Tertiary Pediatric Center.

Lymphadenitis is the most common manifestation of non-tuberculous mycobacteria (NTM) infection in children. We describe the epidemiology and clinical characteristics of NTM lymphadenitis, determine diagnostic yield from tissue sampling, and review management and outcomes. This was a 10-year retrospective review of children aged 0-16 years diagnosed with NTM cervicofacial lymphadenitis who were seen in a pediatric infectious disease clinic in a tertiary public hospital. Data relating to patient demographics, clinical features, surgical and antimicrobial treatment, complications, and outcomes were retrieved from patients' electronic medical records and analyzed. There were 48 episodes of NTM cervicofacial lymphadenitis in 45 children (17 males and 28 females). Of these episodes, 43.7% manifested as a unilateral single node, mostly parotid (39.6%) and submandibular (29.2%). All patients underwent diagnostic fine-needle aspiration or surgery. Surgical excision more frequently yielded positive histological findings (P = .016). NTM was identified in 22/48 episodes (45.8%) via culture or molecular sequencing. Mycobacterium abscessus was most commonly found (47.8%). Thirty-eight children (79.2%) received antibiotics. Outcomes in 43 episodes revealed full resolution in 69.8%, while 25.6% had de novo disease and 4.6% experienced recurrence at the same site. Overlying skin changes and multiple or bilateral nodal diseases were significantly associated with de novo disease or recurrence (P = .034 and .084, respectively). Complications occurred in 11/70 (15.7%) procedures. Antibiotic-associated adverse effects occurred in 14/38 (36.8%) episodes. NTM lymphadenitis remains a challenging condition. More aggressive management with surgical excision and antibiotics is recommended for those with overlying skin changes and extensive nodal disease.

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

BackgroundNontuberculous 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. MethodsThis 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. ResultsThe 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. ConclusionsThe 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 EvidenceLevel III

Long-Term Outcome of Surgical Treatments for Nontuberculous Mycobacterial Cervicofacial Lymphadenitis in Children

Information on long-term treatment outcome for nontuberculous mycobacterial (NTM) cervicofacial lymphadenitis in children is scarce. The purpose of this study is to evaluate long-term outcome for surgical treatment, which is the mainstay treatment modality. This case series describes recurrence rates of surgically treated NTM cervicofacial lymphadenitis patients with a follow-up of at least 10 years. The current study data were partially collected from a randomized, prospective, multicenter, multidisciplinary trial (CHIMED study), which was conducted between 2000 and 2006 to determine the optimal treatment for NTM cervicofacial lymphadenitis in children. After the CHIMED trial inclusion ended, our institute continued to serve as a referral center. This enabled us to enlarge the surgical CHIMED cohort by adding patients who were treated during 2007 to 2010 in our center and collect the rest of the current study data. About 427 children with chronic cervicofacial lymphadenopathy were analyzed. Among these, 290 had microbiologically confirmed cervicofacial mycobacterial infections (n=3 Mycobacterium tuberculosis, n=1 Mycobacterium bovis, n=286 NTM). Of these 286 children with NTM cervicofacial lymphadenitis, 189 were treated surgically (median age: 41 months, range: 9-144, 46.0% males). The affected lymph nodes were excised in 151 children (79.9%), and curettage was performed in 38 children (20.1%). One patient (0.07%) experienced a reactivation/recurrence 2 years after surgical excision and required another surgical excision. Three children (7.9%) experienced infection reactivation/recurrences after curettage, confirmed by redness or a draining fistula, within the first year after healing. Two of these 3 patients were treated with additional surgical excisions. The long-term outcome of surgical excision for NTM cervicofacial lymphadenitis is favorable with a low recurrence rate. Curettage or a conservative wait-and-see approach can be considered an alternative in advanced and surgically challenging cases. However, healing will take longer, and late recurrences are possible.

Long-term outcome of nonsurgical treatment of nontuberculous mycobacterial cervicofacial lymphadenitis in children

Chronic cervicofacial lymphadenitis in children is often caused by nontuberculous mycobacteria (NTM). Children with NTM infection who were not surgically treated were evaluated for long-term outcome with a follow-up of at least 10 years. Among the 117 nonsurgically treated children, the median age was 46 months (range, 9-155 months), 56 were male (47.9%), and 61 were female (52.1%). Of the overall group, 75 received antibiotic therapy consisting of clarithromycin and rifabutin (64.1%), and for 54, observation (a wait-and-see approach) was chosen (46.2%). In 100 patients, treatment was considered successful (85%), with a median resolution of 24 (range, 11-134) weeks in the antibiotic group compared to 44.5 (range, 18-130) weeks in the wait-and-see group (P < .05). After 6 months, 58 patients in the antibiotic group were successfully treated (77%), whereas 42 patients of the wait-and-see group demonstrated complete resolution after a median observation time of 44.5 weeks (100%). In 10 patients who experienced complete resolution of the lymphadenitis, infection recurrence developed years later (10%). Nonsurgical treatment of NTM infection can be considered an alternative in advanced and surgically challenging cases. However, healing will take months to years, and late recurrences are possible.

Cervicofacial non-tuberculous mycobacterial lymphadenitis: clinical determinants of incomplete surgical removal

In patients with non-tuberculous mycobacterial cervicofacial lymphadenitis, incomplete surgical removal of infected lymph nodes leads to delayed healing and a higher recurrence rate, with eventual spontaneous drainage through the skin. However, complete surgical removal is not always achievable due to the extent of the infected tissue and proximity to vulnerable structures, such as the facial or accessory nerve. The aim of this study was to identify the clinical determinants of the (in)ability to perform complete surgical removal. The electronic health records of patients aged 0–15 years with bacteriologically proven non-tuberculous mycobacterial cervicofacial lymphadenitis, who underwent surgical treatment and preoperative sonographic imaging, were analysed. This was a case–control study. A total of 103 patients met the inclusion criteria. Most of the infections were unilateral, submandibular, and caused by Mycobacterium avium. Multiple logistic regression analysis revealed that higher age (odds ratio 1.24, 95% confidence interval 1.04–1.47) and fistulization (odds ratio 3.15, 95% confidence interval 1.13–8.75) were significantly associated with a limited ability to surgically remove all infected tissue. However, a larger sonographic lymph node size was not significantly associated. These findings could aid clinicians when informing the parent(s)/guardian(s) of the patient preoperatively and in properly estimating the intraoperative and postoperative course.

What is the optimal management of pediatric nontuberculous mycobacterial cervicofacial lymphadenitis?

What is the optimal management of pediatric nontuberculous mycobacterial cervicofacial lymphadenitis?

Nontuberculous mycobacterial cervicofacial lymphadenitis—A review and proposed classification system

Objective To describe a clinical staging system for nontuberculous mycobacterial (NTM) cervicofacial lymphadenitis that has both diagnostic and therapeutic implications. Methods A Medline database search was performed using key words “nontuberculous mycobacteria”. All articles pertaining to nontuberculous mycobacterial cervicofacial lymphadenitis were reviewed for data evaluation regarding diagnosis and treatment methodologies. Results Nontuberculous cervicofacial lymphadenitis infections pass through distinctly segmented clinical phases. In Stage I, a painless mass presents with notable increase in vascularity. Stage II is characterized by liquefaction of the affected lymph node, causing the mass to appear fluctuant. Significant skin changes characterize Stage III, whereby overlying skin may develop violaceous discoloration and become notably thinner, or parchment-like, with a “shiny” appearance. During Stage IV, the lesion fistulizes to the skin surface causing a draining wound. Conclusions While nontuberculous mycobacterial cervicofacial lymphadenitis has typically been thought of as a surgical disease, further characterization is warranted. We present a new classification system for appraising the clinical stages of nontuberculous mycobacterial cervicofacial lymphadenitis that may be used as part of a greater approach to disease management: (1) after other causes have been ruled out, the possibility of a tuberculous scrofula must be eliminated, and the degree of diagnostic suspicion must be categorized; (2) the clinical stage of the infection can be determined using the classification system described; and (3) a stage-specific treatment may be chosen based on the individual patient.

Surgical Treatment for Nontuberculous Mycobacterial (NTM) Cervicofacial Lymphadenitis in Children

To compare surgical excision with surgical curettage in the treatment of nontuberculous mycobacterial (NMT) cervicofacial lymphadenitis in children. Fifty children, 22 boys and 28 girls, with a PCR- or cultured-confirmed diagnosis of cervicofacial NTM infection were included in the study. Twenty-five children were randomized to surgical excision of the involved lymph nodes, and 25 children to surgical curettage. The median age of the children was 36 months (range, 14-120 months). All children had a red, fluctuating lymphadenitis, and there were no marked differences between the treatment groups with respect to mean duration of lymph node swelling before presentation, location, and the size of the lymph node swelling. Most (84%) of the involved nodes were located in the submandibular region and 6% were located in the preauricular region. Multiple locations (both preauricular and submandibular) were observed in the remaining 10%. Mycobacterium avium (74%) and Mycobacterium haemophilum (22%) were the predominant NTM species. Mean wound healing time for the excision group was 3.6 ± 1.2 weeks versus 11.4 ± 5.1 weeks for the curettage group (P ≤ .05). Postoperative transient marginal mandibular nerve weakness of the facial nerve was seen in 4 patients (16%) of the excision group. In all these patients the function of the nerve returned to normal within 12 weeks. No facial nerve problems were observed in the curettage group. Postoperative infections were not observed. Surgical excision leads to a quick resolution of NTM cervicofacial lymphadenitis. Curettage leads to delayed healing but might be considered as an alternative if excision of the necrotized lymph nodes is technically difficult in cases of adherence of the facial nerve branche.

Conservative Wait-and-See Therapy Versus Antibiotic Treatment for Nontuberculous Mycobacterial Cervicofacial Lymphadenitis in Children

In this explorative study, 50 children with microbiologically confirmed nontuberculous mycobacterial cervicofacial lymphadenitis were randomized to either receive antibiotic therapy or follow a conservative wait-and-see approach. Our primary objective was to assess the time for all infected lymph nodes to heal in patients after the nonantibiotic, wait-and-see treatment, compared with patients after a 12-week course of clarithromycin and rifabutin. Fifty children (19 boys and 31 girls) with a polymerase chain reaction (PCR)- or culture-confirmed diagnosis of cervicofacial nontuberculous mycobacterial infection were included in our study. Twenty-five children were randomized to receive antibiotic therapy and 25 to be given a wait-and-see approach. The median age of the children was 35 months (range, 14-114 months). The median time to resolution of the disease for the antibiotic group was 36 weeks, compared with 40 weeks for the wait-and-see group. Adverse effects of antibiotic therapy included gastrointestinal complaints, fever, and reversible extrinsic tooth discoloration. In children with an advanced stage of nontuberculous mycobacterial cervicofacial lymphadenitis, we observed no significant differences in median healing time between the wait-and-see group and the group receiving clarithromycin and rifabutin antibiotic therapy.

Nontuberculous mycobacterial cervicofacial lymphadenitis in children from the multicenter, randomized, controlled trial in The Netherlands: Relevance of polymorphisms in candidate host immunity genes

Objective The annual incidence of nontuberculous mycobacterial (NTM) cervicofacial lymphadenitis in otherwise healthy children is unexpectedly high (8 per million). It mostly arises as localized cervicofacial lymphadenitis. Previous research has suggested environmental risk factors for oral exposure to NTM and a temporal association with eruption of teeth. We studied 22 polymorphisms in relevant candidate genes, some related to periodontitis, in children with NTM lymphadenitis. We also tested for the most common mutation in IFNGR1. Methods We analyzed DNA from 81 Dutch children with NTM from a nationwide surveillance study and 215 community controls for 22 polymorphisms in CD209, IL1B, IL8, IL10, IL12B, IL12RB1, IL18, PTX3, TLR4, TNF, VDR and SLC11A1 by MassArray platform (Sequenom) and CONTING. We screened for 818del4 in IFNGR1 by PCR and VspI restriction enzyme cleavage. Results We found a positive association between NTM lymphadenitis and +3953TT in IL1B (OR 2.9; 95%-CI: 1.2–7.2). Furthermore, our results showed that −592C/A heterozygosity in IL10 is linked to protection from disease (OR 0.54; 95%-CI: 0.3–0.95), but that other polymorphisms were unrelated to localized NTM disease. However, these associations were not robust to Bonferroni's correction for multiple testing. None of the children carried the IFNGR1 818del4 mutation. Conclusions Dominance of environmental factors over genetic ones and insufficient sample size might explain the fragility of this study's results. Nevertheless, the association between NTM lymphadenitis and 3953C>T, a polymorphism previously linked to periodontitis, supports our hypothesis that oral exposure to mycobacteria during eruption of teeth plays a role in the etiology of cervical NTM lymphadenitis.

ESTHETIC OUTCOME OF SURGICAL EXCISION VERSUS ANTIBIOTIC THERAPY FOR NONTUBERCULOUS MYCOBACTERIAL CERVICOFACIAL LYMPHADENITIS IN CHILDREN

One hundred children with microbiologically proven nontuberculous mycobacterial cervicofacial lymphadenitis were randomly assigned to excision of the involved lymph nodes, or antibiotic therapy consisting of clarithromycin and rifabutin. The esthetic outcome was rated using a revised and weighted Observer Scar Assessment Scale. The median weighted esthetic outcome in surgical patients was significantly better (30.6) than that for patients treated with antibiotics (42.2).

Treatment of non‐tuberculous mycobacterial cervicofacial lymphadenitis in children: critical appraisal of the literature

Surgical excision has historically been the treatment of choice for non-tuberculous mycobacterial cervicofacial lymphadenitis. Emerging data suggests antibiotic treatment alone could be an attractive alternative to surgery. We questioned (1) what treatment offers best cure rates in children with this condition and (2) the evidence for antibiotic treatment alone. Structured literature search according to the Evidence Based Medicine guidelines. SEARCH STRATEGY/METHODS: A structured search was conducted in PubMed, Embase and the Cochrane Library from 1966 up to November 2007. Relevant papers were critically appraised. Six papers were included, one of which was a randomised controlled clinical trial (RCT). In general, treatment sequencing was not consistent. Surgery and medical treatment were often used in combination, resulting in high overall cure rates. In the RCT surgery and antibiotic treatment were compared as single modalities. The outcome of surgery was far superior (96%versus 66% cure rate, respectively). Other studies indicated that substantial cure rates (up to 67%) were achieved with medical management alone, but failed to identify factors predicting response. Surgical excision still is the backbone in the management of cervicofacial non-tuberculous mycobacterial lymphadenitis, although a considerable number of children can be cured with antibiotics alone or combined modality treatment. To date it is unclear which subset of patients can benefit from antibiotic treatment only.

Treatment outcomes for nontuberculous mycobacterial cervicofacial lymphadenitis in children based on the type of surgical intervention

To report treatment outcomes of nontuberculous mycobacteria (NTM) cervicofacial lymphadenitis. A retrospective study from 1995 to 2006. Fifty-one patients (mean age, 30.3 months). All but one patient presented with lymphadenopathy. The mean time from symptoms to diagnosis was 42.3 days. Tuberculin skin testing (TST) was performed on 21 of 51 patients and was positive on 14 of 21 patients. Imaging was ordered in 23; 19 had CT scans. Pathology confirmed caseating granuloma in 45 (88%); cultures grew Mycobacterium avium-intracellulare complex in 46 of 51. Interventions included fine-needle aspiration (5, 10%), incision and drainage +/- curettage (24, 46%), and complete excisional biopsy (20, 38%). Of those who underwent complete excisional biopsy initially, 95 percent were cured compared with 32 of 51 (63%) with nonexcisional surgery. Macrolides and rifampin were more likely to be recommended in referred cases and when nonexcisional surgical treatment was not feasible or had failed. The average total duration of antibiotic therapy was 89.1 days. NTM infections require high levels of suspicion for timely diagnosis, and complete excisional biopsy results in least likelihood of persistent/recurrent disease.

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

The optimal treatment of nontuberculosis mycobacterial cervical lymphadenitis in children has not been established. Until recently, surgical excision was the standard treatment, but the number of reports of successful antibiotic treatment is increasing, which questions whether surgery is the preferred treatment. In this randomized, multicenter trial, we compared surgical excision with antibiotic treatment. One hundred children with microbiologically proven nontuberculous mycobacterial cervicofacial lymphadenitis were randomly assigned to undergo surgical excision of the involved lymph nodes or to receive antibiotic therapy with clarithromycin and rifabutin for at least 12 weeks. The primary end point was cure, defined as regression of the lymph node enlargement by at least 75%, with cure of the fistula and total skin closure without local recurrence or de novo lesions after 6 months, as assessed by clinical and ultrasound evaluation. Secondary end points included complications of surgery and adverse effects of antibiotic therapy. Intention-to-treat analysis revealed that surgical excision was more effective than antibiotic therapy (cure rates, 96% and 66%, respectively; 95% confidence interval for the difference, 16%-44%). Treatment failures were explained neither by noncompliance nor by baseline or acquired in vitro resistance to clarithromycin or rifabutin. Surgical complications were seen in 14 (28%) of 50 patients; staphylococcal wound infection occurred in 6 patients, and a permanent grade 2 facial marginal branch dysfunction occurred in 1 patient. The vast majority of patients who were allocated to antibiotic therapy reported adverse effects (39 [78%] of 50 patients), including 4 patients who had to discontinue treatment. Surgical excision is more effective than antibiotic treatment for children with nontuberculous mycobacterial cervicofacial lymphadenitis.

Tuberculin Skin Testing Is Useful in the Screening for Nontuberculous Mycobacterial Cervicofacial Lymphadenitis in Children

We evaluated the diagnostic usefulness of tuberculin skin testing in the screening for nontuberculous mycobacterial (NTM) infection in children. We enrolled 180 children who had chronic cervicofacial lymphadenitis in our study. Skin testing was done using antigens of Mycobacterium tuberculosis, Mycobacterium avium, Mycobacterium kansasii, and Mycobacterium scrophulaceum. The reference standard for NTM infection was a positive culture result, identification by PCR, or both. Receiver operating characteristic analysis was used to identify the optimal cutoff point in skin induration for the detection of NTM infection. Accuracy of the mycobacterial skin tests was quantified using sensitivity and specificity rates and positive and negative predictive values at the optimal skin induration cutoff. A total of 112 NTM infections were identified, of which 83 were caused by M. avium, 21 by Mycobacterium haemophilum, and 8 by other NTM species. At the optimal cutoff for a positive test (5 mm), tuberculin skin testing had a sensitivity and specificity of 70% and 98%, respectively, and a positive predictive value and a negative predictive value of 98% and 64%, respectively, compared with a sensitivity and a specificity of 93% and 97%, respectively; M. avium sensitin, the best-performing skin test, had positive and negative predictive values of 98% and 90%, respectively. Tuberculin skin testing could be valuable as a first step in the diagnostic analysis of cervicofacial lymphadenitis in children without a history of TB exposure or bacille Calmette-Guérin vaccination.

Cervicofacial Lymphadenitis in Children Caused by Mycobacterium haemophilum

Nontuberculous mycobacterial (NTM) lymphadenitis in children is most often caused by Mycobacterium avium. In a prospective, multicenter trial of the optimal treatment, 23.7% of the NTM cervicofacial lymphadenitis cases in children were caused by Mycobacterium haemophilum. In this article, we describe the epidemiological and clinical features of M. haemophilum cervicofacial lymphadenitis. The diagnosis of Mycobacterium avium or M. haemophilum infection was established by culture or polymerase chain reaction. Demographic characteristics and data regarding clinical presentation and possible environmental exposure were compared for patients infected with M. avium and those infected with M. haemophilum. Ninety-four (69.9%) of 135 infections were caused by M. avium, 32 (23.7%) by M. haemophilum, and 9 (6.4%) by other NTM species. The median age of the M. haemophilum-infected children was 72 months, compared with 41 months for the M. avium-infected children (P < .001), with an equal distribution for both sexes. Involvement of multiple lymph nodes was frequently observed among the M. haemophilum-infected patients (56% of patients). Extranodal localizations were only observed in M. haemophilum-infected patients. Children with M. haemophilum infection were more likely to have a non-Dutch background (P = .001), and in most cases, they had a history of contact with swimming water (P = .03), whereas M. avium-infected patients were more likely to have a history of playing in sandpits (P = .01). In a multivariate analysis, only older age and a non-Dutch background were predisposing risk factors for M. haemophilum infection, compared with M. avium infection. Higher age, non-Dutch background, and involvement of multiple cervicofacial lymph nodes with extranodal localizations distinguished M. haemophilum infection from M. avium infection.

Antibiotic Therapy for Nontuberculous Mycobacterial Cervicofacial Lymphadenitis

To evaluate the efficacy of antibiotic treatment of nontuberculous mycobacterial (NTM) cervicofacial lymphadenitis, both as an alternative and as adjuvant to surgical excision. Retrospective chart review of pediatric patients with NTM cervicofacial lymphadenitis treated from January 1993 to November 2003 at an academic tertiary care children's hospital. Fifty-five patients (age range, 15 mo-16 y) with the diagnosis of NTM cervicofacial lymphadenitis by fine-needle aspiration biopsy that had 1) lymph node culture positive for an atypical mycobacteria, 2) histological findings consistent with mycobacterial infection (granulomas) with negative bartonella serological titers, 3) histological stain positive for the presence of acid-fast bacillus in the absence of tuberculous infection, or 4) positive Mantoux tuberculin skin test result with a negative finding on polymerase chain reaction for tuberculous mycobacteria. Clinical response was defined as complete or partial resolution of skin changes and palpable lymphadenopathy in response to antibiotic therapy consisting of macrolide therapy alone or in combination with other anti-mycobacterial pharmaceuticals. Of the 55 children studied, 45 of 55 (82%) with both single and multiple lesions underwent a trial of medical therapy, and 30 of 45 lesions (67%) ranging in size from 1 x 1 to 6 x 5 cm achieved resolution without surgical excision. Of the other 15 patients treated initially with medical therapy, 6 of 15 (40%) responded well to a course of antibiotic therapy before undergoing surgical excision, and 7 of 15 (47%) patients were nonresponsive to antibiotic therapy and required surgical excision to resolve the neck mass. The remaining 2 of 15 patients (13%) proceeded to surgery only after a course of antibiotics of 3 weeks or less. Ten of the 55 patients (18%) underwent surgical excision initially, with 5 of 10 patients (50%) receiving postoperative antibiotics for treatment of residual disease or prevention of recurrence. Some NTM cervicofacial lymphadenitis infections appear to respond to medical therapy alone. A trial of antibiotic therapy might be considered in patients with NTM cervicofacial lymphadenitis before surgical excision or as an adjuvant to surgical excision.