Clinical Case Presentation - Duke Pediatrics Intranet

Your thoughts on the differential?How would you proceed withsubsequent clinical evaluation?

1 yo with left cheek swelling• An Otorhinolaryngologist wasconsulted• Admitted for treatment with IVClindamycin• CT scan of the neck was obtained

1 yo with left cheek swelling

1 yo with left cheek swelling• Received 3 days of IV Clindamycinwith resolution of fever• D/C’d home on 7 day course of POAmox/Clav, WBC 15K• At completion of antibiotic course,had persistent left LAD and swelling,WBC 22K

How has your differential changed?What further testing would you obtain?

1 yo with left cheek swelling• Normal Chemistries and LFTs• WBC 22.7, Plts 475• Manual Diff: 52% seg, 1% bands, 41% lymp• LDH 1014, Uric acid normal• ESR 57• Chest radiograph: normal

1 yo with left cheek swelling• EBV titers negative• Bartonella serologies negative• Toxoplasma IgG/IgM negative• HHV6 IgG positive, IgM negative• Pediatric Surgery consulted, excisionalbiopsy attempted• AFB culture of bx grew Mycobacteiumavium complex

1 yo with left cheek swelling• Subsequent clinical course– Started on Clarithromycin and Rifabutin– Continued to have swelling and drainage requiringmultiple I/D and debridements– IV amikacin added 2/2 lack of clinical response 2months after initiation of therapy (6 month course)– Continued Clarithromycin and Rifabutin– Swelling eventually resolved after >1 year oftherapy

Non-Tuberculous Lymphadenitis

Clinical Manifestations• Subacute or chroniclymphadenitis• Painless (cervical)lymph node swelling• Pink or violaceousdiscoloration• May develop a drainingsinus tract

Clinical ManifestationsAtypical MCAM. tuberculosisAge 1-6 years >4 yearsRace White Black, AsianExposure to TB Absent PresentAbnormal CXR Rare OftenResidence Suburban, Rural UrbanPPD > 15mm Uncommon OftenBilateralinvolvement Rare Not uncommonAdapted from Baker and Kealy. Cervical lymphadenopathy in Feign etal. Textbook of Pediatric Infectious Diseases 2004. p. 187

Diagnostic Workup - PPDLineboom et al. 2006. Clinical Infectious Diseases 43:1547-51

Diagnostic Workup - PPDLineboom et al. 2006. Clinical Infectious Diseases 43:1547-51

Diagnostic Workup - BiopsyEvans et al. 1998. J. Clin. Pathol. 51:925-927

TreatmentBerger et al. 1996. J. Pediatr. 128(3):383-386

TreatmentBrian et al. 2006. Acta Paediatrica 95:182-188

TreatmentSurgical Excision 48/50 [96%]Antibiotic therapy 33/50 [66%]95% CI for the differenceLindeboom et al. 2007. Clinical Infectious Diseases 44:1057-1064

TreatmentLindeboom et al. 2007. Clinical Infectious Diseases 44:1057-1064

Conclusions•PPD useful in areas with low incidence of Tuberculosisand BCG vaccination•If incomplete or no excision, use medical therapy withclarithromycin and rifabutin•Surgical excision is superior to antibiotic therapy