Cervical Tuberculous Lymphadenitis Associated With New-Onset Acanthosis Nigricans Following Antitubercular Therapy: A Case Report.

Cervical tuberculous lymphadenitis (CTL), also known as scrofula, is an extrapulmonary manifestation of tuberculosis, a disease that is endemic to many developing countries, particularly Sub-Saharan Africa and Asia, but may also be found worldwide in developed countries like the United States. CTL can be difficult to detect and may mimic other similar-appearing conditions, so a high index of suspicion is required to accurately diagnose the condition when a patient presents with one or more neck masses. Incision and drainage and excisional surgery are aggressive options available to treat CTL but are not preferred due to a high risk of serious adverse events like fistulization and hematological dissemination. Clinicians typically opt for traditional tubercular RIPE (rifampin, isoniazid, pyrazinamide, and ethambutol) therapy for its high efficacy in treating extrapulmonary tuberculosis. Despite this preference, RIPE therapy has been known to elicit a myriad of side effects that demand close monitoring by clinicians. One side effect of the RIPE regimen that has yet to be reported is acanthosis nigricans (AN), a dermatological sign that presents as thickening and darkening of the skin, often in intertriginous areas. AN frequently occurs in conjunction with insulin resistance, and interestingly, the RIPE drug isoniazid has been implicated in insulin derangements in patients, most notably diabetics. However, the incidence of AN secondary to isoniazid use has not been explicitly recorded in the literature to date. Herein we present a novel case of a young man from Nepal with CTL treated via RIPE therapy who developed AN likely secondary to isoniazid use.

Recurrent Cervical Lymphadenitis Responding to Antibiotics Turned Out to Be Lymphoma on Biopsy: A Case Report.

Recurrent cervical lymphadenitis is a common clinical presentation often managed with empiric antibiotic therapy. However, despite antibiotic treatment, persistent lymphadenopathy warrants consideration of alternative etiologies, including malignancy. We present the case of a 71-year-old female with recurrent cervical lymphadenitis that initially responded to antibiotics but was ultimately diagnosed as lymphoma upon biopsy. Despite conservative management, the patient's symptoms persisted, prompting surgical excision of the lymph node. Histopathological examination confirmed the lymphoma diagnosis, highlighting the importance of considering malignancy in cases of persistent lymphadenitis. This case underscores the significance of prompt evaluation, including biopsy, to ensure timely diagnosis and appropriate management in patients with recurrent cervical lymphadenitis.

Extrapulmonary Tuberculosis Presenting As Stage V Bilateral Cervical Lymphadenitis With Cortical Cerebral Watershed Infarct Along With Maxillary and Sphenoid Sinusitis.

Extrapulmonary tuberculosis is an infrequently reported condition. However, in endemic settings, it contributes to a significant number of cases. The most common site of extrapulmonary tuberculosis is the lymph nodes. Herein, an exceedingly rare case of extrapulmonary tuberculosis presenting as bilateral cervical lymphadenitis with external cerebral watershed infarct along with sphenoid and maxillary sinusitis in an Indian male is presented. A detailed literature search revealed that a case with all these clinical conditions together has never been reported to date. A diagnostic workup supported by radiometric investigations helped in the diagnosis, and timely management was initiated.

Risk Factors for Invasive Interventions in Hospitalized Children With Suppurative Cervical Lymphadenitis.

Suppurative cervical lymphadenitis sometimes resolves with oral antibiotic treatment; however, many children are hospitalized for intravenous treatment due to lack of improvement. When there is no substantial improvement, the possibility of a liquefaction process is considered, and as a result, source control such as needle aspiration or open surgical drainage is recommended. We examined, among pediatric patients hospitalized with suppurative cervical lymphadenitis, clinical and laboratory predictors for invasive intervention that may lead to early imaging and intervention, hasten recovery, and shorten length of hospitalization. We compared laboratory and clinical characteristics of pediatric patients hospitalized with suppurative cervical lymphadenitis during 2010-2017, according to 3 treatments: needle aspiration (N = 54), open surgical drainage (N = 37), and conservative adequate antibiotic treatment only (N = 292). Physical indicators such as local erythema and fluctuation were found as predictors for invasive interventions in hospitalized pediatric patients diagnosed with suppurative cervical lymphadenitis. No significant associations were found between invasive interventions and laboratory parameters assessed in this study. Children who underwent interventions displayed a prolonged average length of hospitalization and received extended antibiotic treatment prior to hospital admission. In hospitalized pediatric patients diagnosed with suppurative cervical lymphadenitis, physical examination findings are the main predictive factors for invasive interventions. Consequently, when such straightforward clinical findings are observed in the context of insufficient improvement during antibiotic treatment, they should prompt consideration of invasive intervention.

HBHA-IGRA and cytotoxic mediators release assays for the diagnosis of cervical tuberculous lymphadenitis.

IMPORTANCE: Cervical tuberculous lymphadenitis (CTL), the most frequent extrapulmonary form of tuberculosis, is currently a major health problem in Tunisia and in several regions around the world. CTL diagnosis is challenging mainly due to the paucibacillary nature of the disease and the potential misdiagnosis as cervical non-tuberculous lymphadenitis. This study demonstrates the added value of the heparin-binding hemagglutinin-interferon-gamma release assay as an immunoassay in the context of CTL.

Evaluation of a Neck Mass in a Six-Month-Old Infant: A Case Report.

Pediatric neck masses are one of the commonly encountered problems in clinical practice. They comprise a wide spectrum of congenital to acquired lesions manifesting in early or late childhood. They often pose a diagnostic challenge to the physician. We hereby present a case report of a six-month-old boy with a left-sided neck mass. Findings of a detailed workup were consistent with acute bacterial cervical lymphadenitis, ruling out neoplasia. The child showed significant improvement after including extended coverage of antibiotic therapy for methicillin-resistant Staphylococcus aureus (MRSA) and was put under follow-up.

Cervical lymphadenitis caused by Mycobacterium avium in a patient treated with Janus kinase inhibitors.

A woman diagnosed with rheumatoid arthritis and treated with Janus kinase (JAK) inhibitors presented with a gradually enlarging bilateral submandibular lymph nodes swelling that had lasted several weeks. A lymph node biopsy showed epithelioid granulomatous lymphadenitis with caseous necrosis. Mycobacteria grew in acid-fast bacteria culture and were identified as Mycobacterium avium by polymerase chain reaction. The patient was diagnosed with cervical lymphadenitis caused by M. avium. A computed tomography scan showed no evidence of a mass or infection at other sites, including the lungs; therefore, the mass was excised without any antimicrobial treatments. Her neck mass had not recurred at 9 months after the excision. JAK inhibitors have emerged as an important new class of oral therapy for rheumatoid arthritis and other diseases. Physicians should be aware of the relatively rare complications, such as cervical lymphadenitis caused by nontuberculous mycobacteria, when using JAK inhibitors.

International Pediatric Otolaryngology Group: Consensus guidelines on the diagnosis and management of non-tuberculous mycobacterial cervicofacial lymphadenitis.

INTRODUCTION: Non-tuberculous mycobacterial (NTM) infection commonly manifests as subacute or chronic cervicofacial lymphadenitis in immunocompetent children. The optimal management of this pathology remains controversial. OBJECTIVES: This international consensus guideline aims to understand the practice patterns for NTM cervicofacial lymphadenitis and to address the primary diagnostic and management challenges. METHODS: A modified three-iterative Delphi method was used to establish expert recommendations on the diagnostic considerations, expectant or medical management, and operative considerations. The recommendations herein are derived from current expert consensus and critical review of the literature. SETTING: Multinational, multi-institutional, tertiary pediatric hospitals. RESULTS: Consensus recommendations include diagnostic work-up, goals of treatment and management options including surgery, prolonged antibiotic therapy and observation. CONCLUSION: The recommendations formulated in this International Pediatric Otolaryngology Group (IPOG) consensus statement on the diagnosis and management of patients with NTM lymphadenitis are aimed at improving patient care and promoting future hypothesis generation.

Tender cervical lymphadenitis as a herald of multi-system inflammatory syndrome in COVID-19 infection of children and adolescents: a report of two cases.

BACKGROUND: Post-COVID-19 multisystem inflammatory syndrome (MIS) has been increasingly recognized but fever with isolated tender cervical lymphadenitis as the initial presentation has been rarely reported. We present 2 female patients one a child and the other an adolescent. CASE PRESENTATION: Case 1 was a 13-year-old girl who presented with tender cervical lymphadenopathy and fever 3-weeks post-COVID-19, and then developed features of MIS 5 days later. Case 2, also female, was 18 years old. She had no history of COVID-19 infection or immunization but had a serologic diagnosis of COVID-19. She similarly presented with fever and tender cervical lymphadenopathy, and then progressed rapidly to develop features of MIS. Both patients responded well to treatment with immunosuppressants and intravenous immunoglobulin. CONCLUSION: Tender cervical lymphadenopathy could be the herald of multi-system inflammatory syndrome following COVID-19 infection among children and adolescents, which the clinicians must have a good suspicion about.

Linfadenitis por Mycobacterium lentiflavum / Lymphadenitis caused by Mycobacterium lentiflavum

La linfadenitis cervical es la infección por micobacterias no tuberculosas (MNT) más frecuente en niños inmunocompetentes menores de 5 años. La mayoría de los casos a nivel mundial se debe a Mycobacterium avium complex (MAC). Mycobacterium lentiflavum (M. lentiflavum) se ha considerado una causa rara de MNT causante de linfadenitis. Presentamos dos casos de linfadenitis cervical y preauricular atendidos en un centro de salud de Madrid durante los años 2019-2020, que persisten a pesar de tratamiento antibiótico. Se realizaron test sanguíneos, serología, así como radiografía de tórax y prueba de tuberculina. Con la sospecha diagnóstica de MNT, los pacientes fueron derivados a un hospital terciario, donde se aisló M. lentiflavum. Aunque la actual evidencia acerca del tratamiento para la resolución de la linfadenitis es la escisión quirúrgica completa, en este caso fue descartada por la localización de los nódulos y el riesgo de dañar el nervio facial y la glándula parótida. Debido a que M. lentiflavum es resistente a la mayoría de los fármacos antituberculosos, se decidió, de acuerdo con los padres, un tratamiento conservador. Concluimos que M. lentiflavum debe ser considerado un importante patógeno emergente causante de linfadenitis y debe sospecharse en un paciente con una única linfadenitis cervical o preauricular que persiste a pesar de tratamiento antibiótico (AU)

Cervical lymphadenitis is the most common infection caused by non-tuberculous mycobacteria (NTM) in immuno-competent children under 5 years. Most cases of NTM associated cervical lymphadenitis worldwide are caused by Mycobacterium avium complex (MAC). Mycobacterium lentiflavum (M. lentiflavum) has been considered a rare cause of NTM associated lymphadenitis. We present two case reports of cervical and pre-auricular lymphadenitis managed in primary care in the Region of Madrid (Spain), between 2019-2020, that persisted despite antibiotic treatment. Routine blood tests, chest x-ray and tuberculin skin test were performed. As NTM was suspected, patients were referred to a tertiary hospital, where they underwent ultrasound guided aspiration, which cultured M. lentiflavum. Although, the first line treatment for NTM lymphadenitis is complete surgical excision, in these cases the proximity of the lymph nodes to the facial nerve and parotid gland meant this was not an option. Instead, a conservative approach of watch-and-wait was chosen in collaboration with the parents, as M. lentiflavum is resistant to most antituberculosis drugs. We conclude that M. lentiflavum should be considered as an important emergent pathogen causing cervical lymphadenitis, especially in cases with a single cervical or pre-auricular lymphadenitis resistant to antibiotic treatment. (AU)

Profile and histopathology features of top three cases of Extra Pulmonary Tuberculosis (EPTB) in West Nusa Tenggara: A retrospective cross-sectional study.

BACKGROUND: Tuberculosis (TB) is an infectious disease that might threaten life with a high incidence rate globally, especially in developing countries such as Indonesia. Although some TB cases are found in the lungs, the incidence of patients with extra-pulmonary TB infection also shows a significant number. However, these cases are still underreported, especially in Indonesia. Histopathological examination is one of the gold standards for diagnosing EPTB. MATERIALS AND METHODS: This is a cross-sectional retrospective descriptive study. This study uses data from medical records and histopathological examination results of extra-pulmonary TB patients at two hospitals in West Nusa Tenggara between May 2010 and February 2020. The inclusion criteria for this study were patients diagnosed with EPTB histopathologically and had complete paraffin block. In addition, the exclusion criteria were patients with incomplete data in the medical record. The data recorded include gender, age, organ location, area of residence, and histopathological features. RESULTS: There were 1.817 cases of extra-pulmonary TB in West Nusa Tenggara from May 2010 to February 2020. The top three organs were from the neck (84.7%), breast (14.1%), and colon (1.2%), with a total of 1362 cases. Women dominate the top three cases of EPTB with 894 patients (65.7%) and in the age group 21-30 (28%). Central Lombok has the most EPTB patients (450; 33.07%). Microscopic examination revealed well-organized granulomas in 988 patients (72.6%) and poorly organized granulomas in 374 patients (27.4%). CONCLUSION: The three most frequent cases of EPTB found in West Nusa Tenggara are cervical lymphadenitis TB, mastitis TB, and colitis TB, with the majority of cases being well-organized granulomas. Further studies dealing with better designs and larger sample sizes need to be considered. The results of this study are significantly needed to determine the intervention strategies to reduce morbidity and mortality due to EPTB.

Cervical abscess caused by Mycobacterium tilburgii in a patient carrying anti-interferon gamma autoantibody: A case report and literature review.

Mycobacterium tilburgii, a nonculturable mycobacterium, is an important nontuberculous mycobacterium that occasionally causes serious infections in patients with cellular immune deficiencies. Due to its nonculturable nature, information about its drug susceptibility is not available, and data about its clinical response to antimycobacterial treatment remains insufficient. Here, we report a case of a patient who presented with neck swelling and was finally diagnosed with cervical abscess caused by M. tilburgii carrying anti-interferon gamma autoantibodies using a molecular method. The relevant literature was reviewed in the context of epidemiological and clinical data on M. tilburgii infections. In this report, 15 patients were reported to be infected with M. tilburgii. Almost all patients had a cellular immune deficiency and presented with disseminated infections. Multiple refractory or relapse cases that often required prolonged antimycobacterial treatment have been reported, although a few fatal cases have also been reported. In conclusion, M. tilburgii is an important pathogen in patients with cellular immune deficiency. Physicians should thoroughly investigate cellular immune deficiency, including adult-onset immune deficiency with anti-interferon gamma autoantibodies, in patients with M. tilburgii infection.

Not Just a Sore Throat: A Case of a Retropharyngeal Abscess Causing Midline Shift of the Nasopharynx.

A retropharyngeal abscess (RPA) is a deep neck space infection that can present with subtle symptoms. Although it is an uncommon diagnosis, an RPA can be life-threatening as it can result in airway compromise if not treated promptly. In this article, we report a case of a 21-month-old infant with a retropharyngeal abscess that required prompt recognition and treatment.

Kawasaki Shock Syndrome with Initial Presentation as Neck lymphadenitis: A Case Report.

Kawasaki disease (KD) is an acute systemic vasculitis of unknown cause that mainly affects infants and children and can result in coronary artery complications if left untreated. A small subset of KD patients with fever and cervical lymphadenitis has been reported as node-first-presenting KD (NFKD). This type of KD commonly affects the older pediatric population with a more intense inflammatory process. Considering its unusual initial presentation, a delay in diagnosis and treatment increases the risk of coronary artery complications. Herein, we report the case of a 9-year-old female with fever and neck mass that rapidly deteriorated to shock status. A diagnosis of KD was made after the signs and symptoms fulfilled the principal diagnostic criteria. The patient's heart failure and blood pressure improved dramatically after a single dose of intravenous immunoglobulin. This case reminds us that NFKD could be the initial manifestation of KDSS, which is a potentially fatal condition. We review the literature to identify the overlapping characteristics of NFKD and KDSS, and to highlight the importance of early recognition of atypical KD regardless of age. We conclude that unusually high C-reactive protein, neutrophilia, and thrombocytopenia serve as supplemental laboratory indicators for early identification of KDSS in patients with NFKD.

Usefulness of brain natriuretic peptide to distinguish Kawasaki disease from cervical lymphadenitis.

BACKGROUND: Cervical lymphadenitis (CL) cannot be easily distinguished from Kawasaki disease (KD). We therefore explored whether brain natriuretic peptide (BNP) levels are useful in this context. METHODS: We retrospectively analyzed 14 children with CL and 177 children with KD. Patients with KD were divided into three groups according to their clinical symptoms at hospitalization - 97 patients had typical KD, 35 had node-first KD (NFKD), and 45 had KD without lymphadenopathy. We reviewed data on clinical and laboratory parameters, including serum BNP levels, at hospitalization together with factors that might distinguish KD from CL. RESULTS: Patients with CL were older than those with KD. Serum BNP levels were higher in all the KD groups than in the CL group. Multivariate logistic regression analyses indicated that higher BNP levels were associated with NFKD (odds ratio: 1.12, 95% confidence interval: 1.01-1.25). The receiver operating characteristic curve yielded a BNP cutoff of 18.3 pg/mL, with a sensitivity of 0.680, a specificity of 0.857, and an area under the curve of 0.806 (95% confidence interval: 0.665-0.947). CONCLUSIONS: Serum BNP levels can be used to distinguish KD from CL, especially in patients with NFKD.

Screening of susceptibility genes and an immunological study in a patient with recurrent cervical lymphadenitis caused by Candida albicans / 中华皮肤科杂志

Objective:To explore genetic etiology and evaluate antifungal immunity in a patient with recurrent cervical lymphadenitis caused by Candida albicans. Methods:Next-generation sequencing was performed to screen susceptibility genes for mycosis in a patient with recurrent cervical lymphadenitis caused by Candida albicans and his parents. Peripheral blood mononuclear cells (PBMCs) and neutrophils were extracted from the patient and 6 healthy controls, and subjected to in vitro co-culture with Candida albicans. Western blot analysis was performed to determine the expression of caspase recruitment domain-containing protein 9 (CARD9) in PBMCs of the patient, enzyme-linked immunosorbent assay to detect levels of tumor necrosis factor-α (TNF-α), interleukin (IL) -6, IL-17A, IL-1β and granulocyte-macrophage colony-stimulating factor (GM-CSF) in the co-culture medium, and a colony-counting method was used to detect the survival rate of Candida albicans after treatment with neutrophils. Statistical analysis was carried out by using t test for comparisons between two groups. Results:Two compound heterozygous mutations were identified in the CARD9 gene of the patient, including c.68C>A (p.S23X) in exon 2 inherited from his father and c.820dupG (p.D274Gfs*61) in exon 6 inherited from his mother. Western blot analysis showed that the relative expression level of CARD9 protein in the PBMCs was 0.41 ± 0.07 in the healthy control group, but CARD9 expression was absent in the patient. After stimulation with heat-inactivated Candida albicans spores, the levels of TNF-α, IL-6, IL-17A, IL-1β and GM-CSF secreted by PBMCs of the patient were significantly lower than those by PBMCs of the healthy controls (all P < 0.001). After 30- and 120-minute in vitro co-culture with neutrophils, the survival rates of Candida albicans were significantly higher in the patient (78.00%, 74.00%, respectively) than in the healthy controls (70.91% ± 1.75%, 34.55% ± 5.35%, t = 3.74, 6.99, respectively, both P < 0.05) . Conclusion:Compound heterozygous mutations were identified in the CARD9 gene of the patient with recurrent cervical lymphadenitis caused by Candida albicans, which led to the absence of CARD9 protein expression, and the patient had a defect in the immunity against Candida albicans.

Role of ultrasound in the diagnosis of cervical tuberculous lymphadenitis in children.

BACKGROUND: To describe sonographic characteristics of cervical tuberculous lymphadenitis (CTBL) in children, clinical information, and sonograms of 348 lymph nodes (LNs) from 57 children with CTBL were retrospectively analyzed in this study. METHODS: We retrospectively reviewed the clinical data and sonograms of 348 LNs from 31 boys and 26 girls with CTBL, who were confirmed by pathology or laboratory examination, at the Hangzhou Red Cross Hospital between June 2014 and December 2020. The age of the children ranged from 1 to 14 years (average 7.1 ± 2.9 years). RESULTS: Night sweats, fatigue and loss of appetite were the most common clinical symptoms observed in children with CTBL. Unilateral LN involvements were common. Occasionally, CTBL was found in healthy children with no symptoms. On sonography, the hilus was absent or unclear in all LNs. The short-to-long axis (S/L) ratio was ≥ 0.5, and the edges were unclear in most LNs. Other accompanying findings included necrosis (47.4%), an echogenic thin layer (36.8%), surrounding soft-tissue edema (38.5%), multiple intra-nodal strong echo (28.2%), sinus (22.7%) and abscess formation (6.9%). The Doppler ultrasound showed that the majority of vascularity patterns of CTBL were capsular or peripheral (33.3%). CONCLUSIONS: Ultrasound is a recommended examination method for children from different age groups with cervical lymphadenitis. The ultrasonic signs of hilus absence, S/L ratio ≥ 0.5, unclear edge, necrosis, echogenic thin layer, strong echoes and capsular or peripheral vascularity may aid in the diagnosis of cervical tuberculous lymphadenitis.

Needle aspiration of lateral neck abscess in children: A simple and effective treatment.

BACKGROUND: Cervical abscesses frequently occurred in pediatric patients. Surgical drainage is currently recommended in the cases not responding to medical therapy. Needle aspiration may represent a simple, effective and minimally invasive treatment for acute neck suppuration in selected cases. OBJECTIVE: To evaluate the effectiveness of needle aspiration in the treatment of cervical abscesses in pediatric age as an alternative to surgical drainage. METHODS: From November 2013 to November 2019, at the ENT Department of the "Bambino Gesù" Pediatric Hospital, Rome, we treated 47 children with cervical abscess by performing aspiration with a 19 G needle in wakefulness after applying local anesthetic. Parenteral antibiotic treatment was associated with all patients both before and after treatment. RESULTS: Complete regression of the abscess occurred in 46 children with no evidence of recurrence in the follow-up period. Surgical drainage was required in only one patient due to the lack of resolution of the abscess episode. No complications such as hematomas or hypertrophic scars were found in any patient. CONCLUSIONS: Our results confirm the effectiveness of needle aspiration in the treatment of cervical abscesses in children as an alternative to surgical drainage.

Salivary duct carcinoma of the submandibular gland presenting a diagnostic challenge: A case report.

BACKGROUND: Salivary duct carcinoma (SDC) is a rare, extremely aggressive malignancy that arises in the submandibular gland. It can metastasize locally early and therefore is an important differential diagnosis of metastatic disease in cervical lymph nodes or specific lymphadenitis such as tuberculous cervical lymphadenitis. CASE SUMMARY: We report a case of SDC in the submandibular gland that presented diagnostic difficulty. The lesion was coincidentally discovered through examination of the radiolucent area of the maxilla. Imaging failed to confirm the possibility of specific inflammation, leading us to execute an open biopsy to verify the diagnosis. The surgical specimen showed that the submandibular gland was primarily replaced with a calcified body. Following histological analysis and confirmation, we performed surgical resection, radiotherapy, and various chemotherapies. CONCLUSION: Radiographic imaging characteristics of lymph node metastases of salivary gland cancer, especially of SDC, may resemble other cervical lymphadenitis; calcification at the submandibular gland is the landmark of SDC occurring at the subman-dibular gland.