Cervical lymphadenitis due to mycobacterium interjectum

Abstract

In children, cervical lymphadenitis is the most common type of infection caused by non-tuberculous mycobacteria. The isolated species are frequently identified as M. avium, M. scrofulaceum, and M. malmoense; they often cause indolent cervical adenitis and the treatment of choice is radical excision. [1][2][3][4] In recent times, new mycobacteria species have been described: M. lentiflavum, M. interjectum, which cause lymphadenitis in children as in the case presented here. [1][2][3][4][5][6] A 2-year-old boy presented with a 3-month history of a 2 Â 2 cm submandibular adenopathy in the right cervical area, which did not remit with antibiotic treatment (amoxicillin-clavulanate). On examination, a tumor was found in the right submandibular region, which was indolent, fluctuant, inflamed and with a high temperature.The patient had not received a BCG vaccination and tested positive (14 mm) on the PPD RT-23 2 TU Mantoux tuberculin test. In blood screening most noteworthy was: Leucocytes 9500 (37% neutrophyles, 49% lymphocytes, and 10% monocytes) and a globular sedimentation rate of 62.In the neck ultrasound examination, in the right submandibular region, a small irregular lump was appreciated, which went from the adenopathy with necrosis to the surface of the skin.Due to suspicion of tuberculous adenopathy, treatment was initiated with rifampicin, isoniazid, and pyrazinamide for 9 months.The drainage liquid of the adenopathy was sent to the laboratory resulting in negative staining and cultures. The remitted sample was decontaminated using the N-acetyl-L-cysteine-NaOH method, it was cultured in a Löwenstein-Jensen medium and inoculated in a liquid medium BACTEC MGIT 960 System (Mycobacteria growth indicator tube: Becton Dickinson, Heidelberg, Germany). After 4 weeks of incubation in the liquid medium, a scotochromogenic mycobacteria grew which was sent to the National Microbiology Centre of Majadahonda for its molecular typing and antimicrobial sensibility.The isolate was identified by phenotipic and genotypic methods. We performed a subculture on Löwenstein-Jensen and observed smooth colonies of about 1-2 mm in diameter, with bright yellow pigmentation after 3 weeks of incubation at 378C. The growing was inhibited at 22 and 428C. The majority of the biochemical tests were negative (niacin production, Tween-80 hydrolysis, tolerance for NaCl 5%, nitrate reductase, arylsulfatase, and urease). Only two tests were positive, the tellurite reduction and weakly the heat-stable catalase test. The genetic studies were performed by PCR-RFLP of hsp65 gene. 7 The analyzed strain showed two fragments (sized 240 and 210 bp) and two fragments (sized 130 and 110 bp) by BstEll and Haell restriction enzyme digestion, respectively. The size of the fragments corresponds to M. Interjectum.The identification was confirmed by sequencing of 16S rRNA gen. The DNA sequence of the 1,514 bp 16S rRNA region was amplified using the primer described by Springer et al. 8 The PCR conditions were those described previously by Kirschner et al. 9 The se...

Submandibular lymphadenitis caused by Mycobacterium interjectum: contribution of new diagnostic tools

“…The true prevalence of M. interjectum infection is probably underestimated because conventional identification methods based on phenotypical and biochemical characteristics may produce ambiguous results and misidentification (e.g., M. scrofulaceum) [6]. So far, only nine patients with infection caused by M. interjectum in children have been published (Table 1) [3,6,[10][11][12][13][14]. All INH isoniazid, RIF rifampin, PZA pyrazinamide, EMB ethambutol, R resistant, S suceptible patients were younger than 4 years (range 18 months to 3 years) and presented with isolated and unilateral chronic cervical lymphadenitis like most other MOTT infection except two patients who had adenitis located in the cheek and over the thyroid isthmus.…”

“…All INH isoniazid, RIF rifampin, PZA pyrazinamide, EMB ethambutol, R resistant, S suceptible patients were younger than 4 years (range 18 months to 3 years) and presented with isolated and unilateral chronic cervical lymphadenitis like most other MOTT infection except two patients who had adenitis located in the cheek and over the thyroid isthmus. In several of these patients, a diagnosis of TB was initially suspected, which led to unnecessary prolonged antituberculous treatment [10,13]. In all patients, culture obtained from biopsy or from surgical material grew on solid or on liquid culture medium within an average of 2 to 4 weeks.…”

The First Case of <i>Mycobacterium interjectum</i> Pulmonary Disease in Japan: A Case Report

“…Since the first report of M. interjectum in 1993 (1), several reports have described it as a causative agent of lymphadenitis in healthy children. Table 1 shows the details from previous reports of extrapulmonary lesions (1,2,(5)(6)(7)(8)(9)(10)(11)(12)(13)(14). In many cases, the infection is refractory to antimicrobial agents and is treated surgically.…”

Cutaneous infection due toMycobacterium interjectumin an immunosuppressed patient with microscopic polyangiitis

“…As only a few cases have been reported, standard therapy has not been established. Antibiotic therapy failed in all patients 3,9 except one, 10 and they underwent total resection. Only one patient, a 2‐year‐old boy with cervical lymphadenitis who was treated with rifampicin, isoniazid and pyrazinamide, 10 was reported to recover, although in another patient the same regimen failed 3 .…”

“…Antibiotic therapy failed in all patients 3,9 except one, 10 and they underwent total resection. Only one patient, a 2‐year‐old boy with cervical lymphadenitis who was treated with rifampicin, isoniazid and pyrazinamide, 10 was reported to recover, although in another patient the same regimen failed 3 . All patients treated surgically 1,3,9 recovered completely, and no relapse was observed.…”