小朋友頸部淋巴腺炎，mycobacterial dz, NTM or TB?

義大利研究…
小朋友頸部淋巴腺炎，aspiration? biopsy? excision?
serum antibody for EBV? CMV? toxoplasmosis?

NTM要excision, TB要吃藥

先aspiration/biopsy for culture/PCR
then wait for result

TB的小朋友比較老 10 vs 3 y/o，比較有可能CXR(+)

Cervical Lymphadenitis: What Differentiates Tuberculosis from Atypical Mycobacteria?

In Italy, children with TB are older than those with atypical mycobacteria and are more likely to be foreign born in a developing country and to have abnormal chest x-rays.

Subacute cervical lymphadenitis can be secondary to infection with multiple pathogens, including tuberculosis (TB), atypical/nontuberculosis mycobacteria (NTM), Epstein-Barr virus, bartonella, and toxoplasmosis; serologic tests are available for all except the mycobacterial etiologies. Distinguishing between TB and NTM is important because treatment is medical for TB and surgical for NTM. Traditionally, fine-needle aspiration or biopsy is needed to determine the correct treatment approach.

Investigators in Italy retrospectively examined clinical and laboratory data for all 299 children (age, <16 years) with diagnosis of mycobacterial disease at two referral clinics from 1999 to 2009. Of 121 children (40%) with a clinical diagnosis of cervical mycobacterial lymphadenitis, 16 (21%) had culture-confirmed or polymerase chain reaction–confirmed TB, and 59 (79%) had NTM. Children with TB were significantly older than children with NTM (10.1 vs. 3.7 years) and more likely to be foreign born in a developing country (75.0% vs. 8.5%) and to have abnormal chest x-rays (56.3% vs. 8.5%). Only one child with TB (14.3%) had known exposure. All children with TB had tuberculin skin test indurations ≥5 or 10 mm, as did 71% and 47% of NTM patients, respectively.

Comment: This evaluation of patients with culture-proven diagnoses identified clinical and laboratory variables that can help distinguish between TB and NTM and possibly obviate the need for aspiration. The authors provide mathematical formulas for predicting the likelihood of TB in individual children. For example, the probability of TB for a 5-year-old with lymphadenitis who was born in Italy and has a negative chest x-ray is about 0.04; this child could undergo excision directly without requiring biopsy first. The probability of TB would be higher (0.90) for a 5-year-old child who was born in a developing country and has an abnormal x-ray; this child could have gastric aspirates collected and cultured and start antituberculosis medications without requiring biopsy. For those with less-certain risk, biopsy still might be necessary.

— Peggy Sue Weintrub, MD

Published in Journal Watch Pediatrics and Adolescent Medicine August 11, 2010
Citation(s):

Carvalho AC et al. Differential diagnosis of cervical mycobacterial lymphadenitis in children. Pediatr Infect Dis J 2010 Jul; 29:629.

* Medline abstract (Free)

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