Non-tuberculous mycobacterial cervical lymphadenitis in the immunocompetent child: diagnostic and treatment approach

Abstract

Non-tuberculous mycobacterial disease in the otherwise well child commonly presents as a localized, slow-progressing, cervicofacial lymphadenopathy. Despite recent advances, several aspects of the susceptibility to and the course of the disease remain to be better understood, and diagnosis and management of non-tuberculous mycobacterial lymphadenitis in children are often controversial. Differential diagnosis should include other infections, in particular tuberculosis, local cysts and malignancies. In the majority of cases, untreated disease progresses to spontaneous drainage, fistula formation and scarring and a high index of clinical suspicion is necessary for timely diagnosis and treatment. Excisional surgery seems to remain the gold standard. Medical treatment might be considered as an appropriate alternative in case there is a high risk of surgical complications or in case surgery has already been unsuccessful. Family reassurance and the watch-and-wait approach may be an option in milder disease.

Keywords::

• child
• diagnostic approach
• immunocompetent
• lymphadenitis
• non-tuberculous mycobacteria
• treatment

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Non-tuberculous mycobacteria (NTM) are ubiquitous in the environment, but very rarely cause disease in the immunocompetent child. The majority of cases are caused by Mycobacterium avium complex; other encountered species, largely depending on geographical area, include Mycobacterium malmoense, Mycobacterium haemophilum, Mycobacterium simiae and Mycobacterium fortuitum.

• Localized cervicofacial lymphadenitis is the most common manifestation of NTM disease in the otherwise well child.

• The disease typically begins as a unilateral, non-tender node that enlarges over several weeks, with progress to fluctuation, discoloration, thinning of the overlying skin, sinus fistula formation and scarring.

• Definitive diagnosis requires isolation of NTM from culture or PCR of fistula drainage, or tissue specimens. A presumptive diagnosis is based on clinical and/or histopathological findings (positive acid-fast bacilli strains, granulomas). Exclusion of other diseases, including tuberculosis, is essential.

• Although the watch-and-wait approach might be an option in mild forms of NTM lymphadenitis, most children will require treatment.

• Surgical excision has always been the treatment of choice, if it can be performed safely. Emerging data suggest a benefit from the addition of antimicrobial treatment. For patients who are not candidates for surgery, antimicrobial therapy with or without curettage might be considered.

• Pending culture results, a combination of a macrolide with another agent (rifampin, ethambutol), are recommended. The optimal duration of treatment is undetermined; patients typically are treated until their symptoms resolve, that is, usually 3–6 months.

• NTM lymphadenitis may progress to scarring and cosmetic sequelae; however, in the immunocompetent host it does not progress to generalized disease and the ultimate outcome is good.