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Infectious Diseases Society of America

Emerging Infections Network

Report for Query:

‘Nontuberculous Mycobacterial Lymphadenitis in Children’

Overall response rate: 129/214 (60.3%) physicians with pediatric practices responded from 6/14/07 to 7/18/07.

Note: Not all respondents answered all questions, so totals for individual questions vary.

Responders as percent of overall members in each category:

Practice type: Academic institution 83 (60% of 138 members)

Private practice 16 (57% of 28 members)

Other 8 (67% of 12 members)

Question 1. Cases of NTM lymphadenitis seen in last 6 months:

• 80 members answered zero, while 49 answered with a range of cases seen from 1-15

Mean (std deviation), range #cases/#members

Total cases 1.07, (1.9), 0-15 111 from 49

No. cases confirmed by culture 1.5 (1.46), 0-10 72 from 48

Proportion cases confirmed by culture 72% (33.9), 0-100

No. cases confirmed by PCR 0.09 (0.30), 0-1 5 from 5

Proportion cases confirmed by PCR 5.9% (19.0), 0-100

Details of 87 cases of NTM lymphadenitis:

Age: Mean 3.93 years, range 2 months to 16 years

Gender:

Male 47 (57%)

Female 35 (43%)

Region of lymphadenitis:

Cervical 77 (88%)

Axillary 0

Inguinal 4 (5%)

Other 6 (7%) (1= mediastinal and paratracheal disease)

Identified organism:

M. avium complex 45 (52%)

M. abscessus/chelonae 5 (6%)

M. chelonae 2 (2%)

M. fortuitum 4 (5%)

Other 3 (3%) (M. lentiflavum; ‘suspected NTM but was S. aureus’)

NOS 2 (2%)

Treatment:

Surgery 27 (32%)

Antibiotics 14 (16%)

Both 44 (52%)

PPD status:

Negative 57 (67%)

Positive 15 (18%)

Not done 13 (15%)

Race/ethnicity:

Non-hispanic white 59 (69%)

Hispanic white 15 (18%)

Black 10 (12%)

Asian 1 (1%)

Question 2: The incidence of NTM lymphadenitis is:

Not changing 73 (71%)

Increasing 16 (15%)

Decreasing 14 (14%)

Question 3: What percent of suspected NTM cases are confirmed by (answered by 91 members):

Mean, median (std deviation), range

Tissue culture 66.2%, 70% (27.2), 0-100

Tissue PCR 5.6%, 0% (14.5), 0-100

Not confirmed 29.5%, 25% (26.6), 0-100

Question 4. Treatment – What percent of your NTM cases are:

Undergo surgical excision 79.0%, 90% (24.7), 0-100

Require adjunctive antibiotics 40.2%, 30% (36.1), 0-100

Treated with antibiotics alone 18.7%, 5% (25.9), 0-90

Require repeat surgery 8.9%, 5% (12.2), 0-66.7

Comments about mycobacterial lymphadenitis or this survey:

Treatment, specific case information

• Combination antibiotic therapy is more effective than single agent. Surgery is more effective than antibiotic therapy

• Surgery only a last-resort

• We usually get patients referred by ENT as their node is in the facial nerve distribution

• Most of my ENT colleagues will not remove the involved nodes due to location (close to facial nerve).

• Many of my patients who require repeat surgery are initially operated on by surgeons less familiar with the treatment so the initial surgery is incomplete. I have had patients with culture confirmed NTM fail antibiotic therapy and some with extensive disease respond completely to antibiotic therapy.

• We do surgical excision but if the lymph node cannot be completely excised (often because of proximity to critical structures)

• My biggest problem is getting them referred to me BEFORE they have received multiple rounds of inappropriate antibiotics and inappropriate surgical procedures without the proper cultures.

• It is impossible to know whether antibiotics are "required" and extremely difficult to tell whether they help. The nature history of the infection is spontaneous rupture and prolonged drainage. Most of my cases end up with prolonged drainage from the spontaneous rupture or following surgical excision. None of my cases have been life threatening in any way but all are life annoying and very cosmetically unappealing.

•The surgeons see the patient usually before ID and refer pt after excision when histopathology shows caseating granuloma or culture is positive for MAC. At that point I've started azithromycin and continued until the scar is well healed and I don't feel any underlying lymph node. On occasion with a difficult to excise node we've treated with azithromycin until the node is smaller and then excised any remaining node.

• Some patients with positive PPD (age, size dependent) need both M.tb and NTM therapy until results available.

• 14 were ................
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