Girl presents with pain, lymph node on neck
What’s your diagnosis?
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The following case was submitted by my friend Michael Cater, MD, a pediatrician at Children’s Hospital of Orange County, California. It is the second of four cases of his that I will share over the next few months.
To catch up on Dr. Cater’s previous cases, click here.
Girl presents with neck pain, underlying lymph node
An 8-year-old girl was seen for right-sided neck pain and an underlying lymph node measuring 2.5 cm with surrounding inflammatory swelling.
An intradermal purified protein derivative test was positive at 21 mm of induration with an indeterminant blood QuantiFERON-TB Gold Plus test. She was subsequently referred for further management. Upon arrival, she was found to be otherwise healthy, with no other complaints or evidence of any other health concerns. However, she was noted to have an old surgical scar near the same area of the current problem. Additional history revealed that 5 years earlier, she had surgery at the same location and took oral medicine for several months (records not available). Apparently, compliance and follow-up were not assured. Further history revealed that she was born in Mexico and frequently travels between southern California and her grandparents’ dairy farm in that country, where they are in the milk and cheese production business. There are no sick contacts at home.
Soon after presentation, she was taken to the operating room (OR) for excisional biopsy of the involved nodes. The specimen was submitted for Gram stain and culture and acid-fast bacillus (AFB) stain and culture. After 1 week, she developed an abscess adjacent to the surgical site (Figure 1), and she was taken back to the OR for drainage of copious purulent material and required additional extensive debridement of more necrotic tissue.
Figure 1. Post-op infection of recurrent scrofula at site of previous episode. Image: Michael Cater, MD.The Gram stain and culture were negative, but the AFB stain was positive (Figure 2), with the other culture pending.
Figure 2. Positive acid-fast bacillus (AFB) stain in another patient. Image: James W. Bass, MD, MPH.What’s your diagnosis?
A. Mycobacterium avium complex
B. Mycobacterium bovis
C. Mycobacterium chelonae
D. Mycobacterium fortuitum
Answer and discussion:
Mycobacterium bovis in this case was isolated by culture (answer B). If M. bovis is suspected but culture is negative, it can also be detected by deletion typing using a special PCR technique beyond the scope of this column (which is another way of saying, “beyond the scope of my brain”).
Figure 3. Scrofula due to Mycobacterium avium complex (MAC) initially diagnosed and treated as cat scratch disease without improvement. Image: James H. Brien, DO.This organism is usually clinically indistinguishable from Mycobacterium tuberculosis, in that it can cause the same diseases. The major clue in this case was the recurring exposure to the organism at her relatives’ dairy farm in Mexico, where they were producing and presumably consuming unpasteurized cheese and milk. This is the most common source. The organism is very uncommon in the United States due to the requirement of universal pasteurization of commercially prepared milk and milk products. In the mid-20th century, universal pasteurization was gaining support, and by 1973, pasteurization became federal law for any commercially produced milk products, which essentially eliminated Mycobacterium bovis disease in the U.S.
Figure 4. Imaging of patient seen in Figure 3. Image: James H. Brien, DO.By 2013, the U.S. Department of Agriculture saw to the eradication of M. bovis from almost all cattle herds in the U.S. The white-tailed deer, which is popular among deer hunters, remains an ongoing reservoir, requiring ongoing vigilance. As in this case, the few cases of M. bovis infections in the U.S. occur along the Mexican border, such as southern California, and most infections in children are lymphadenitis. See the Red Book reference below for more details about diagnosis and treatment of this rare but potentially lethal disease.
Figure 5. Closeup of lesion see on patient in Figure 3. Image: James H. Brien, DO.Regarding therapy, one should remember that M. bovis strains are almost universally resistant to pyrazinamide. As such, most experts recommend a 9- to 12-month course of therapy that includes isoniazid and rifampin and, depending on the severity of the disease, possibly ethambutol and streptomycin, pending sensitivity results. Lastly, consulting an infectious disease expert would be advisable.
Figure 6. Debridement of lesion seen in Figure 5. Image: James H. Brien, DO.Tuberculous and nontuberculous mycobacterial (NTM) infections have periodically appeared in this column, dating back to February 2000 (pulmonary TB). Mycobacterium avium complex (MAC), seen in the August 2012 column (Figures 3 to 7), is the most common cause of NTM cervical lymphadenitis, but TB cervical lymphadenitis does occur, mostly in adolescents, which was shown in the November 2006 column. NTM cervical adenitis tends to occur mostly in children aged younger than 12 years, peaking in those aged younger than 5 years.
Figure 7. Granulomatous tissue that was AFB stain positive; the culture grew MAC. Image: James H. Brien, DO.Treatment of MAC by thorough debridement of involved tissue is usually curative; however, if infected tissue is left behind, recurrence is not unusual (Figure 8). Therefore, many experts recommend following surgical excision with a 6- to 12-week course of clarithromycin or azithromycin to treat potential organisms that may have been beyond the edges of the tissue excised.
Figure 8. Picture of recurrent scrofula. Image: James W. Bass, MD, MPH.Mycobacterium chelonae is an unlikely cause of NTM cervical adenitis but can be treated the same as MAC. It is more likely to be found in soft tissue infections or contaminating vascular catheters. As with any unusual organism, reviewing current recommendations is always advised.
Figure 9. Mycobacterium fortuitum of lower leg inoculated from soil. Image: James H. Brien, DO.Lastly, Mycobacterium fortuitum is another NTM species that can cause a soft tissue infection by inoculation from a contaminated source, such as soil (Figures 9 and 10). There are numerous other NTM species, and it is always advisable to consult an ID specialist for current recommendations early on to know how best to proceed.
Figure 10. A close-up of Figure 9. Image: James H. Brien, DO.Columnist comments:
Once again, I want to thank Mike Cater for contributing this case, with more to come. Below are a couple of handy references on M. bovis. Also note that the 32nd edition of the Red Book (handy reference below) will be soon replaced with the new, 33rd edition. Regarding the new Red Book, it is to be dedicated to Sarah Long, MD, “in recognition of her lifetime of commitment to children and those who take care of them,” according to the AAP.
I began hearing about this doctor named Sarah Long when I was a resident (in the 1970s). As time went by, she continued to get my attention throughout my career as a general pediatrician, ID fellow and subsequent pediatric ID staff member in the Army Medical Corps, and later at Baylor Scott & White Health in Temple, Texas. For a long time, I only knew her by name, and seeing her at meetings from the back of the room (my usual spot). My admiration stemmed from her incredible depth and range of knowledge and her ability to communicate in plain, easy-to-understand English (for those of us a bit more simpleminded), which was also peppered at times with great humor. But more than that, while learning from her excellent teaching style, I was always entertained when she went against popular thought or opinion about topics such as outpatient blood cultures. It seemed that whatever minority opinion she had about a controversial topic, it ultimately became the “guideline.”
As time went by during my 30-year association with the Infectious Diseases in Children Symposium in New York (and briefly on the West Coast), we both shared positions on the planning committee and always as faculty members. We often sat together (with our spouses, Ellen and Bob) at the faculty dinners, giving all the lucky ones at her table a therapeutic dose of her witty sense of humor, which was always refreshingly informative and entertaining.
The past tense nature of this commentary might sound somewhat like an obituary, but it is only because I do not see Sarah anymore, as I do not speak at meetings or participate in the planning of the annual IDC meeting, and that is my regrettable albeit necessary loss. However, I can assure you, she is still working, and because of her humble nature, the parents and children she sees will never realize the gift they receive by her care.
I can think of no one who deserves this dedication more than Sarah Long, and I congratulate her. By the way, in addition to the handy references below, the most excellent reference is Dr. Long’s new, 6th edition of her book, Principles and Practice of Pediatric Infectious Diseases — specifically, chapter 135, regarding NTM.
References:
American Academy of Pediatrics. Committee on Infectious Diseases. Red Book. 2021–2024 Report of the Committee on Infectious Diseases. Academy of Pediatrics; 2024. https://redbook.solutions.aap.org/redbook.aspx. Accessed May 6, 2024.
CDC. Bovine TB in humans fact sheet. https://www.cdc.gov/tb/publications/factsheets/general/mbovis.htm. Last reviewed: Sept. 1, 2012. Accessed May 6, 2024.
Long SS, et al. Principles and Practice of Pediatric Infectious Diseases. 6th ed. Elsevier; 2023.
Schering S. 2024 Red Book dedicated to Dr. Long. AAP News. https://publications.aap.org/aapnews/news/27830/2024-Red-Book-dedicated-to-Dr-Long. Published Feb. 1, 2024. Accessed May 9, 2024.
For more information:
Brien is a member of the Healio Pediatrics Peer Perspective Board and an adjunct professor of pediatric infectious diseases at McLane Children's Hospital, Baylor Scott & White Health, in Temple, Texas. He can be reached at jhbrien@aol.com.