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Treatment for Nontuberculous Mycobacterial Cervicofacial Lymphadenitis in Children
Abstract & Commentary
By Dean L. Winslow, MD, FACP, Chief, Division of AIDS Medicine, Santa Clara Valley Medical Center; Clinical Professor of Medicine, Stanford University School of Medicine, Section Editor, HIV, is Associate Editor for Infectious Disease Alert.
Source: Lindeboom JA, et al. Surgical excision versus antibiotic treatment for nontuberculous mycobacterial cervicofacial lymphadenitis in children: a multicenter, randomized, controlled trial. Clinc Infect Dis 2007; 44:1057-1064.
Synopsis: 100 children with microbiologically documented nontuberculous mycobacterial cervicofacial lymphadenitis were randomly assigned to undergo surgical excision of the involved lymph nodes vs. antibiotic therapy with clarithromycin plus rifabutin for at least 12 weeks. Intention to treat analysis revealed that surgical excision resulted in cure in 96% vs. 66% of those receiving antibiotic therapy.
A typical mycobacteria are the most common cause of chronic cervicofacial lymphadenitis in children. The lymph nodes often suppurate and form a chronic sinus tract. Surgical excision has historically been considered the treatment of choice but enthusiasm for surgery is tempered by the need for hospitalization and concern about the potential complications of facial paralysis and scarring. Due to the demonstration of clinical activity of macrolides and rifabutin in some immunocompromised patients with nontuberculous mycobacterial infections and occasional case reports in the literature describing clinical response of cervical lymphadenitis to antimicrobial agents in children, medical therapy of this condition has been attempted more frequently in recent years.
In addition to performing a prospective randomized trial which answers an important clinical question, the paper is also a good up to date review of a common pediatric clinical problem. M.avium was the pathogen isolated in 71% of patients, M.haemophilum in 22%, with M.malmoense, M.kansasii, M.fortuitum, and M.chelonae in a handful of other cases. In vitro susceptibility of the isolates to both clarithromycin and rifabutin was demonstrated in 88-89% of isolates and was equal between the medically and surgically treated groups. Surgical complications were seen in few patients. Staphylococcal wound infections occurred in 6 patients, partial weakness of the marginal branch of the facial nerve was seen in 7 patients but resolved completely by 12 weeks in 6 of the 7 patients.
This paper is an important contribution to the literature and reaffirms that in some diseases "old" therapies are still the best ones we have.