VIENNA — Management of nontuberculous mycobacterial lymphadenitis in immunocompetent children by observation alone—that is, natural healing—is an effective alternative to surgery and/or antibiotic therapy, a large Israeli case series suggests.
All the standard pediatric and ENT textbooks describe complete surgical excision of the infected lymph node as the treatment of choice.
However, management with observation alone avoids a raft of shortcomings that come with surgery, including the expense of hospitalization and general anesthesia, along with the nontrivial risks of postoperative facial nerve palsy and infection, Dr. Jacob Amir said at the meeting.
The outcomes achieved with the observational approach are quite acceptable, although total resolution takes months, added Dr. Amir, professor of pediatrics at Schneider Children's Medical Center of Israel, Petah Tikva.
He reported on 92 consecutive immunocompetent children with culture-proven nontuberculous mycobacterial facial or cervical lymphadenitis whose parents opted for conservative management with observation only.
In 89 patients, the affected lymph nodes followed a closely similar course: First, the overlying skin turned violaceous in color; then, discharge of purulent material occurred for 3-5 weeks. In the other three patients, the swollen lymph nodes resolved without a change in skin color or a drainage phase.
Complete healing occurred in 65 children (71%) in 3-6 months; in another 25 (27%), by 9 months; and in the final 2, by 12 months. There were no complications.
Dr. Amir characterized the final aesthetic outcomes as “fair” in the 89 children with purulent discharge. At 2 years of follow-up, they had a flesh-colored, flat scar at the drainage site.
These favorable study results raise a philosophical question, in Dr. Amir's view: “What is successful treatment in a self-limited condition like nontuberculous mycobacterial lymphadenitis?”
The best answer would come from a randomized trial of natural healing versus surgery, he added.
Surgery has already been established as superior to antibiotic therapy in the only randomized trial ever conducted in children with nontuberculous mycobacterial lymphadenitis. In this Dutch multicenter trial, 100 affected children were randomized to surgical excision or at least 12 weeks of antibiotic therapy with clarithromycin plus rifabutin (Clin. Infect. Dis. 2007;44:1057-64).
Surgery was significantly more effective, with a 96% cure rate compared with 66% with antibiotic therapy. However, it is noteworthy that surgical complications occurred in 28% of patients, including staphylococcal wound infections in six children and facial nerve weakness in seven. And 78% of children in the antibiotic arm reported adverse events, Dr. Amir said.
In the Israeli conservative-management series, 90% of the infections were determined to be due to Mycobacterium avium complex or M. haemophilum. In the 1970s, M. scrofulaceum was the most common cause, but in the series reported by Dr. Amir, this species accounted for less than 10% of cases.
In young children, nontuberculous mycobacterial infections most often take the form of painless unilateral lymph-adenitis, occurring chiefly in the submandibular, pre- and postauricular, and cervical areas or on the cheek. Affected children generally have no fever; they have leukocytosis, an elevated C-reactive protein or erythrocyte sedimentation rate, or other systemic symptoms.
Dr. Amir and his coinvestigators decided to conduct a systematic study of observational management after making two key observations: Children whose parents eschewed more aggressive interventions in favor of natural healing eventually seemed to experience total resolution, and kids who underwent total surgical excision of their infected node often returned several months later with another infected lymph node, necessitating another round of treatment.
Dr. Amir noted that the observation-only approach represents outside-the-box thinking for otolaryngologists. A recent survey of 200 American pediatric otolaryngologists showed that 59% managed children with nontuberculous mycobacterial lymphadenitis using surgical excision plus adjunctive antibiotics, 24% resorted to surgical excision alone, and 17% used antibiotics without surgery. Most remarkably, in his view, 59% of the time the pediatric otolaryngologists treated children based only on the clinical picture, without identifying an etiologic organism (Int. J. Pediatr. Otorhinolaryngol. 2010;74:343-6).
Disclosures: Dr. Amir reported having no financial conflicts of interest.
Healing was complete in 71% of children in 3-6 months, 27% by 9 months, and 2% by 12 months.
Source DR. AMIR