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An 18-month-old male with cervical lump, intermittent fever
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A previously healthy 18-month-old male was seen by his primary provider for evaluation of progressive, right-sided cervical swelling for about 2 weeks. There was no fever, pain or erythema at that time, just diffuse swelling. Two weeks subsequent to that visit, he returned with intermittent fever to 102°F. By this time, the swelling was more discrete, forming a lump measuring 3 cm × 2 cm.
James H. Brien
Even though there was no known cat exposure, cat scratch disease was suspected, so the child was treated empirically with a 10-day course of azithromycin without improvement. At this time, he was referred to an otolaryngologist who ordered a CT scan of his neck (Figure 1), then performed a fine-needle aspiration for pathology, stains and culture for bacteria, fungi and acid-fast bacilli. The stains were all negative and a CBC was normal. The pathologist report was positive for necrotic granulomatous lymphadenitis.
Figure 1. The patient was referred to an otolaryngologist who ordered a CT scan of his neck
Figure 2. Examination reveals normal vital signs and a large, suppurative mass.
Source: Brien JH
His medical history is unremarkable and immunizations are documented up-to-date. There is no history of injury, allergies, travel, animal exposure, insect bites or medication use other than azithromycin. There has been no weight loss and he has not been sick in any other way.
Three weeks later (about 2 months after the onset), the culture was reported positive, and the patient was referred to the pediatric infectious diseases clinic.
Examination reveals normal vital signs and a large, suppurative mass (Figure 2). The rest of his exam was normal.
What’s Your Diagnosis?
A. Bartonella henselae
B. Mycobacteria avium-intracelllarae complex
C. Staphylococcus aureus
D. Mycobacteria tuberculosis
Case Discussion
The culture was positive for M. avium-intracellularae complex (B). Clarithromycin plus rifampin, per AAP Red Book recommendations, was empirically begun pending sensitivities, which soon revealed that it was pansensitive. Because the lesion was obviously fluctuant, with the possibility of spontaneous drainage, a few days later the child was taken to surgery for drainage and curettage (Figure 3), revealing a mixture of thick purulent material and necrotic debris (Figure 4). The pathology report confirmed the acid-fast organisms in the lesion.
Standard therapy for non-tuberculous mycobacteria lymphadenitis has been surgical removal, with or without medical treatment. However, there’s growing interest in the pediatric otolaryngology and general surgery community for thorough curettage rather than node removal. Simple incision and drainage is strongly discouraged, as this may lead to a chronic draining fistula. After 3 months of the described medical therapy, it was discontinued because he showed good healing and a year later remained well.
The child was taken to surgery for drainage and curettage (Figure 3), revealing a mixture of thick purulent material and necrotic debris (Figure 4).
There are several features that distinguish TB from non-tuberculous mycobacteria lymphadenitis. These include: 1) Age — TB adenitis usually occurs in children aged older than 12 years; 2) TB produces a stronger PPD skin test; 3) TB will more likely have pulmonary findings on imaging; 4) TB will more likely be associated with a history of exposure to another person with TB; and 5) TB will more likely be associated with fever and systemic symptoms.
Obviously, some overlap can occur, but now we have available immunologic-based testing (interferon-gamma release assay) to help distinguish TB form non-tuberculous mycobacteria infections (see Red Book), but culture remains the most reliable.
B. henselae, the causative agent of cat scratch disease (CSD), can result in a very similar clinical scenario, and patients often have been treated as such along the way before a definitive diagnosis is made. Not all cases of CSD will have a known exposure to cats, but by the time a CSD node gets to this point, the serum IgM would likely be positive. Also, the hint that the culture eventually turned up positive should be a clue that it was not B. henselae because it is not routinely recovered on culture.
Figure 5. S. aureus usually produces an acute infection with fairly rapid suppuration with significant swelling.
The management of suppurative CSD nodes remains a bit controversial, but most experts I know still favor needle aspiration over I & D for the same reasons noted above. However, this area still lacks good, scientific evidence.
The patient presented had a chronic lymphadenitis. S. aureus, whether methicillin-resistant or not, usually produces an acute infection with fairly rapid suppuration with significant swelling (Figure 5). This can usually be quickly ruled out with a good history and physical. Also, the Gram’s stain and or culture would have likely been positive.
Columnist Comments
We recently hosted Itzhak Brook, MD, for a Visiting Professorship at McLane Children’s Hospital (Figure 6), where he lectured on anaerobic infections, including those of the head and neck. He also gave Grand Rounds to the departments of pediatrics and surgery on his latest endeavor; teaching health care providers on the fears and dangers of being a patient.
Figure 6. Itzhak Brook, MD, left, was hosted for a Visiting Professorship at McLane Children’s Hospital, where he lectured on anaerobic infections, including those of the head and neck.
His presentations are drawn from his personal experience as a cancer survivor, as detailed in his most recent book, My Voice: A Physician’s Personal Experience with Throat Cancer. This Grand Rounds presentation is an inspiring message that all physicians should hear, as it can only make one a better practitioner, with a greater understanding of what their patients think and feel. The lecture can be seen at http://dribrook.blogspot.com/ by scrolling down to the section titled “Recent educational activities.” Despite his limited speaking ability due to the loss of his larynx, he very effectively speaks with the help of a voice prosthetic device and a microphone, for those of you who may be interested in hosting Dr. Brook to speak at your facility.
Lastly, congratulations go to Peter Zarb, a hospital-based pharmacist and researcher at the University of Antwerp, Belgium, who correctly answered the challenge issued in last month’s column regarding the molecular structure on the cover of the new Nelson’s Pediatric Antimicrobial Therapy handbook, by identifying the structure as daptomycin.
Disclosure: Dr. Brien reports no relevant financial disclosures.