Atypical Mycobacterial Lymphadenitis in the Head and Neck of Pediatric Patients

Background: There are limited data on the epidemiology, diagnosis and optimal management of nontuberculous mycobacterial lymphadenitis (NML) of the head and neck in children.

Materials and Methods: This is a retrospective cohort study of pediatric patients with head and neck NML presenting to Children’s Healthcare of Atlanta tertiary care hospitals from May 2014 to February 2016 following exposure to a single contaminated water source at a pediatric dental clinic in Atlanta, Georgia.

Results: A total of 21 patients (12 males, 9 females) with a mean age of 6.57 years were identified. All patients were healthy and underwent dental procedures between April 2014 and November 2015. The mean time before symptom onset following dental procedure was 45.1 days. Patients presented with cervical lymphadenitis (90.4%), gingival erythema (57.1%), mandibular expansion (14.3%), skin erythema (14.3%) and pulmonary nodules (19.0%). Significant laboratory findings on presentation were a normal white blood count (88.9%), elevated erythrocyte sedimentation rate (58.3%) and elevated C-reactive protein (47.4%). Patients underwent one to five admissions (mean 2.05) with a mean number of 9.0 total inpatient days. All patients underwent surgery (72.7% lymph node excision, 27.3% subtotal lymph node excision). All pathologic specimens showed necrotizing granulomatous inflammation. Acid-fast bacteria were found in 72.7% of specimens. 59.1% of cultures were positive, 100% of which grew Mycobacterium abscessus. 12 patients (54.5%) required long-term intravenous dual or triple antibiotic therapy. Complications were noted in 14 patients (66.7%) including marginal mandibular nerve weakness (33.3%), catheter-associated complications (33.3%), hearing loss (23.8%), exanthematous drug reaction (19%) rather than (189.0%) and neutropenia (9.5%). 15 patients (71.4%) had complete resolution of lymphadenitis and 3 patients (14.3%) had partial resolution.

Conclusion: Surgical treatment of NML of the head and neck with anti-mycobacterial chemotherapy is an effective choice of treatment; however risk of complication of each modality is high.

References:

1.Rahal A, Abela A, Arcand PH, Quintal MC, Lebel MH, Tapiero BF: Nontuberculous mycobacterial adenitis of the head and neck in children: Experience from a tertiary care pediatric center. Laryngoscope 111(10):1791-6, 2001

2. Zimmermann P, Tebruegge M, Curtis N, Ritz N. The management of non-tuberculouscervicofacial lymphadenitis in children: A systematic review and meta-analysis. J Infect 71(1):9-18, 2015