Dr.Venkatesh Kumar, Dr.Vinitha Prasad, Dr.Stefy , Dr.Shela,Dr.C.Jayakumar.
Four year old ,1st child of NCM developmentally normal and immunized for age male child presented with swelling over left side of neck ,gradually increasing in size, associated with pain and no active discharge of 20 days duration. Child was managed local health care facility with Oral antibiotics which was changed to parenteral later .
USG Neck -Significantly enlarged Left submandibular lymph nodes with few enlarged level-2 lymph nodes on left side with no matting or abscess formation;
FNAC – Acute Lymphadenitis.
As fever and productive cough recurred,he came to AIMS for further evaluation.
Examination showed 4 x 4 cm ,tender and enlarged submandibular lymph nodes
Other components :PICCE normal
.Auxology revealed normal growth parameters.
Systemic examination was within normal limits.
Differential diagnosis considered were:
1.Leukemia
2.Infectious mononucleosis.
3.GABHS pharyngitis
4.Toxoplasmosis,CMV
5.Lymphoma
6.Kikuchi-Fujimato’s disease
7.M.tuberculosis
8.Castleman’s disease,
9 Cat scratch disease
INVESTIGATIONS:
CBC: TC-22.9 ku/ml,N-61%,L-29.6%, Hb-13.3 gm/dl, Plt-479 ku/ml(Neutrophilic leucocytosis)
LFT and RFT- within normal limits.
CRP:5.28 mg/l,LDH: 307 U/L, Serum complements:C3-186 mg/dl, C4-43.2 mg/dl.
URE-Normal.
Chest Xray: Minimal Right paracardiac infiltrates.
USG Abdomen-Normal.
USG Neck: 3.2 X 2.4 cm sized 3.2 x 2.4 cm sized well organized collection with thick echogenic contents within and marked surrounding soft tissue inflammation in left submandibular region.
Gastric aspirate for GeneXpert: Negative
ANA-IFA: Negative
Child was started on Inj.Piptaz considering the possibility of cervical lymphadenitis.
Later Incision & Drainage with Excisional biopsy was done .
Pus and Slough sent for C/S: No growth.
Pus for Gram’s and AFB smear: Negative
Slough for GeneXpert: Negative.
Excisional biopsy (Left cervical abscess biopsy): shows granulomatous inflammation and necrosis.
Inj.Piptaz was given for a total of 10 days duration.
As there was improvement in symptoms ,child was discharged and was asked to review after 1 week.
At review,size of the swelling remained the same as that at the discharge and there was pain over the swelling with no active discharge or any other systemic involvement.
Repeat USG Neck showed Localised collection with echogenic contents measuring 11x 7 mm continuous with the lymph node essentially unchanged as in prior USG,surrounding soft tissue thickening persists. Minimal subcutaneous soft tissue inflammation persisting at the site of prior incision and drainage.
Immunoglobulin profile and NBT-DHR test done and was found to be normal.
Dental consultation done in view of persistance of swelling(H/O root canal treatment +) and advised CT Mandible.
CT-Mandible done showed Periosteal reaction in the adjacent mandibular bone suggestive of osteomyelitis
AFB Culture from the Pus/slough: Non Tuberculous Mycobacterium(Rapid grower) in the culture.
Diagnosis: NTM cervical lymphadenitis with Adjacent Mandibular osteomyelitis
Discussion:
Atypical mycobacteria( non tuberculous
mycobacteria) NTM is associated with pediatric lymphadenitis,otomastoiditis, serious lung infections and rarely disseminated disease. NTM are acquired from environmental sources (existing as saprophytes in soil and water) and not person-to-person spread.
Mycobacterium avium complex(MAC ;i.e.,M.avium,M.intracellulare and M.chimaera) and Mycobacterium kansasii are most frequently isolated species.
Mycobacterium marinum- fish tank granuloma.
Mycobacterium ulcerans- Buruli ulcer disease.
Patho- NTM infections are likely to result in granulomas that are non-caseating,poorly defined (non-palisading),irregular or serpiginous or even absent,with only chronic inflammatory changes observed.
In patients with AIDS and disseminated NTM infection,the inflammatory reaction is usually scant,and tissues are filled with large number of histiocytes packed with AFB. Lymphadenitis of the superior anterior cervical or submandibular lymph nodes is the most common manifestations of NTM in children.
Cutaneous disease- erythematous papule develop at the site of minor abrasion(Fish tank granuloma)-M.marinum .Otomastoiditis- rare extrapulmonary NTM that specifically affects children with tympanostomy tubes and h/o topical antibiotic or steroid use- M.abscessus > M.avium complex. Pulmonary infections(acute pneumonitis,chronic cough,wheezing associated with paratracheal or peribronchial lymphadenitis and airway compression) .Chronic pulmonary infections specifically affect children with Cystic fibrosis and are caused M.abscessus and M.avium complex. Isolation of causative NTM bacteria Mycobacterium culture,preferably with histologic confirmation of granulomatous inflammation suffices for the diagnosis. Definitive diagnosis: excision of involved lymph node for culture and histology. Fine needle aspiration for PCR and culture can enable earlier diagnosis,before excisional biopsy.
Treatment: Slow growers(M.kansasii,M.marinum,M.xenopi,M.ulcerans,M.malmoense) are usually susceptible to 1st line antitubercular drugs(Rifampicin and Ethambutol). Rapid growers(M.fortuitum,M.chelonae,M.abscessus) are highly resistant to antitubercular drugs.Susceptibility to macrolides,aminoglycosides,carbapenems,
tetracyclines and Glycylcyclines are most relevant for therapy guidance. In all NTM infections,multidrug therapy(MDT) is essential to avoid development of resistance.
Carry home message: Not all the cervical lymphadenitis can be due to common causes, sometimes the possibility of rarer causes like Non –tuberculous mycobacteria should also be considered