MULTI-DRUG RESISTANT MYCOBACTERIAL CERVICAL LYMPHOADENITIS IN CHILDREN OF NORTH SARDINIA

Introduction. Mycobacteria are causative agents of cervical lymphadenitis (MCL) in young children, with an increasing frequency up to 3 cases per 100.000. The affected lymph nodes progressively and slowly enlarge and may suppurate, with the formation of a sinus tract. One-hundred-thirty species of Mycobacteria have been isolated, including Mycobacterium tuberculosis (MT) and nontuberculous mycobacteria (NTM). The diagnostic approach includes the Mantoux skin test, interferon-gamma release assay (IGRA) and surgical excision. Medical therapy with at least 3 of the traditional anti-mycobacteria drugs is recommended, especially when surgical excision cannot be performed. Case series. This case series study was performed at the Pediatric Clinic, University of Sassari (Sassari, Italy) by reviewing the medical records of patients with MCL, over the period 2010-2015. Five cases of MCL, all girls with a single lesion, were identified: one was affected by MT, 3 by NTM, while, in one case, an etiology could not be determined. Detailed clinical data were available for 3 cases. The MT case was a 3-year-old child with right side MCL (4x3 cm), not painful and with intact skin. Among the patients affected by NTM, one was a 8-year-old child with right side MCL (2x2 cm), not painful and with intact skin, while another presented with right side MCL (>2cm), covered by violaceous skin and a visible suppurated sinus tract. All were Mantoux positives but IGRA negatives. The microbiological culture and/or molecular genetic analysis of the gastric aspirate confirmed the diagnosis of MT in one case, and of NMT in two cases (M. scrofulaceum and M. avium, respectively). Surgical excision was not possible both in the MT case, as the lesion was at high risk of facial nerve damage, and in the NTM case presenting with an advanced lesion. The MT case responded well to a standard, 9-month antituberculosis therapy. Both cases with NTM were found to be multi-drug resistants, including isoniazid, pyrazinamide and ethambutol; they responded to 3 months of therapy with clarithromycin combined with rifampicin, but recovery was faster after surgical excision of the lesion. Conclusion Early diagnosis is essential for the best treatment and outcome of MCL in young children. Mantoux skin test was found to be a good screening test. Surgical excision of the lesion still represents the best approach to treatment, especially in consideration of the increasing appearance of multi-drug resistant Mycobacteria.