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Abstract & Commentary
Management of Non-tuberculosis Mycobacterial Cervical Lymphadenitis in Children
By Hal B. Jenson, MD, FAAP, Professor of Pediatrics, Tufts University School of Medicine; Chief Academic Officer, Baystate Medical Center, Springfield, MA, is Associate Editor for Infectious Disease Alert.
Dr. Jenson reports no financial relationships relevant to this field of study.
Synopsis: A randomized, non-inferiority study of 12 weeks of antibiotic therapy (clarithromycin and rifabutin) versus observation only of non-tuberculous mycobacterial cervical lymphadenitis in children found no significant differences in median healing time (36 weeks versus 40 weeks, respectively).
Source: Lindeboom JA. Conservative wait-and-see therapy versus antibiotic treatment for nontuberculous mycobacterial cervicofacial lymphadenitis in children. Clin Infect Dis. 2011;52:180-184.
A randomized study was conducted from january 2005 to December 2007 in Amsterdam, among 50 immunocompetent children 14-114 months of age (median age, 35 months) with culture- or PCR-confirmed non-tuberculous mycobacterial cervicofacial lymphadenitis. All children had erythematous, fluctuating lymphadenitis. Cultures were positive for 70% of children, and PCR results were positive for the remaining 30%. Mycobacterium avium (70%) and Mycobacterium haemophilum (24%) were the predominant mycobacterial species. Children were randomized to receive either a 12-week course of clarithromycin (15 mg/kg in 2 divided doses daily) plus rifabutin (5 mg/kg once daily) or observation only.
The median time to resolution of disease in the antibiotic group was 36 weeks (range, 20-64 weeks; IQR, 20-52 weeks) compared to 40 weeks (range, 20-68 weeks; IQR 31-47 weeks) for the observation group (p = 0.38, Mann-Whitney U test). In-vitro testing of isolates showed 91% susceptibility to clarithromycin and 94% susceptibility to rifabutin. Adverse effects of antibiotic therapy included abdominal pain (28%, occurring within 2 weeks), fever (60%, occurring within 2 weeks), and reversible extrinsic tooth discoloration (64%) that required treatment by a dental hygienist.
There have not been controlled clinical trials of surgery (either incisional drainage or excision) vs. antibiotics to guide management of non-tuberculous mycobacterial cervical lymphadenitis in children. Based on anecdotal reports and case series, the consensus-recommended management has been complete surgical excision whenever possible. Incision and drainage procedures have often been complicated by fistula formation and prolonged drainage. Excision is curative, but is also associated with scarring, and may be not be feasible with extensive infection, especially with lymph-node adherence to branches of the facial nerve. Temporary facial nerve weakness is reported in 20% of cases following surgery, with permanent facial weakness in 2% of cases.
Non-tuberculous mycobacterial infection in immunocompetent patients is benign, and all cases ultimately resolve, though spontaneous regression may take several months to 2-3 years. The advantage of surgical excision is faster resolution, which is offset by the adverse effects and cost of a three-month course of antibiotics. This study showed no significant differences in median healing time with antibiotic treatment vs. observation only. This finding confirms the traditional approach of not administering antibiotics. The study also showed that healing and resolution can be expected in approximately 40 weeks with observation alone. This finding suggests that the traditional approach of excision may be unnecessary in many cases.