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15 April 2007

Volume 44, Number 8
Clinical Infectious Diseases 2007;44:1057–1064
© 2007 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2007/4408-0007$15.00
DOI: 10.1086/512675
MAJOR ARTICLE

Surgical Excision versus Antibiotic Treatment for Nontuberculous Mycobacterial Cervicofacial Lymphadenitis in Children: A Multicenter, Randomized, Controlled Trial

Jerome A. Lindeboom,1,4

Ed J. Kuijper,5

Elisabeth S. Bruijnesteijn van Coppenraet,5

Robert Lindeboom,3 and

Jan M. Prins2

Departments of 1Oral and Maxillofacial Surgery and 2Internal Medicine, Division of Infectious Diseases, Tropical Medicine and AIDS, Center for Infection and Immunity, 3Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, and 4Academic Center for Dentistry, University of Amsterdam, Amsterdam, and 5Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands

Background.The optimal treatment of nontuberculosis mycobacterial cervical lymphadenitis in children has not been established. Until recently, surgical excision was the standard treatment, but the number of reports of successful antibiotic treatment is increasing, which questions whether surgery is the preferred treatment. In this randomized, multicenter trial, we compared surgical excision with antibiotic treatment.

Methods.One hundred children with microbiologically proven nontuberculous mycobacterial cervicofacial lymphadenitis were randomly assigned to undergo surgical excision of the involved lymph nodes or to receive antibiotic therapy with clarithromycin and rifabutin for at least 12 weeks. The primary end point was cure, defined as regression of the lymph node enlargement by at least 75%, with cure of the fistula and total skin closure without local recurrence or de novo lesions after 6 months, as assessed by clinical and ultrasound evaluation. Secondary end points included complications of surgery and adverse effects of antibiotic therapy.

Results.Intention‐to‐treat analysis revealed that surgical excision was more effective than antibiotic therapy (cure rates, 96% and 66%, respectively; 95% confidence interval for the difference, 16%–44%). Treatment failures were explained neither by noncompliance nor by baseline or acquired in vitro resistance to clarithromycin or rifabutin. Surgical complications were seen in 14 (28%) of 50 patients; staphylococcal wound infection occurred in 6 patients, and a permanent grade 2 facial marginal branch dysfunction occurred in 1 patient. The vast majority of patients who were allocated to antibiotic therapy reported adverse effects (39 [78%] of 50 patients), including 4 patients who had to discontinue treatment.

Conclusions.Surgical excision is more effective than antibiotic treatment for children with nontuberculous mycobacterial cervicofacial lymphadenitis.

Received 16 September 2006; accepted 5 December 2006; electronically published 2 March 2007.

Reprints or correspondence: Dr. Jerome A. Lindeboom, Dept. of Oral and Maxillofacial Surgery, Academic Medical Center and Academic Center for Dentistry, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands ().

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Alexander K. C. Leung, H. Dele Davies. (2009) Cervical lymphadenitis: Etiology, diagnosis, and management. Current Infectious Disease Reports 11:3, 183-189
Online publication date: 1-Jun-2009.
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Stan Deresinski, Section Editor. (2009) In the Literature. Clinical Infectious Diseases 48:2, iv-v
Online publication date: 15-Jan-2009.
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M.K. Timmerman, A.D. Morley, J. Buwalda. (2009) Treatment of non-tuberculous mycobacterial cervicofacial lymphadenitis in children: critical appraisal of the literature. Clinical Otolaryngology 33:6, 546-552
Online publication date: 1-Jan-2009.
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Jeffrey R. Starke. (2008) COMMENTARY: The Natural History of Nontuberculous Mycobacterial Cervical Adenitis. The Pediatric Infectious Disease Journal 27:10, 923-924
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Avraham Zeharia, Tal Eidlitz-Markus, Yishai Haimi-Cohen, Zmira Samra, Lea Kaufman, Jacob Amir. (2008) Management of Nontuberculous Mycobacteria-Induced Cervical Lymphadenitis With Observation Alone. The Pediatric Infectious Disease Journal 27:10, 920-922
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Daniel S. Roberts, Jayme R. Dowdall, Leslie Winter, Carol A. Sulis, Gregory A. Grillone, Kenneth M. Grundfast. (2008) Cervical Tuberculosis: A Decision Tree for Protecting Healthcare Workers. The Laryngoscope 118:8, 1345-1349
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F. S. Gittinger, A. Raible, V. A. J. Kempf. (2008) Non-tuberculous mycobacterial infection of the parotid gland in an immunosuppressed adult. Journal of Medical Microbiology 57:4, 536-539
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L. E. S. Bruijnesteijn van Coppenraet, P. E. W. Haas, J. A. Lindeboom, E. J. Kuijper, D. Soolingen. (2008) Lymphadenitis in children is caused by Mycobacterium avium hominissuis and not related to ‘bird tuberculosis’. European Journal of Clinical Microbiology & Infectious Diseases 27:4, 293-299
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Jerome A. Lindeboom, Ed J. Kuijper, and Jan M. Prins. (2007) Reply to Haimi‐Cohen et al.. Clinical Infectious Diseases 45:4, 520-521
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Yishai Haimi‐Cohen, Jacob Amir, and Avraham Zeharia. (2007) Nontuberculous Mycobacterial Lymphadenitis in Children. Clinical Infectious Diseases 45:4, 520-520
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Mark P. Nicol and Robert J. Wilkinson. (2007) Editorial Commentary: Evidence Guiding the Treatment of Children with Mycobacterial Diseases. Clinical Infectious Diseases 44:8, 1065-1066
Online publication date: 15-Apr-2007.
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