Jerome A. Lindeboom

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

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.

Real-Time PCR Assay Using Fine-Needle Aspirates and Tissue Biopsy Specimens for Rapid Diagnosis of Mycobacterial Lymphadenitis in Children

ABSTRACT A real-time PCR assay was developed to diagnose and identify the causative agents of suspected mycobacterial lymphadenitis. Primers and probes for the real-time PCR were designed on the basis of the internal transcribed spacer sequence, enabling the recognition of the genus Mycobacterium and the species Mycobacterium avium and M. tuberculosis. The detection limit for the assay was established at 1,100 CFU/ml of pus, and the specificity tests showed no false-positive reaction with other mycobacterial species and other pathogens causing lymphadenitis. From 67 children with suspected mycobacterial lymphadenitis based on a positive mycobacterial skin test, 102 samples (58 fine-needle aspirates [FNA] and 44 tissue specimens) were obtained. The real-time PCR assay detected a mycobacterial infection in 48 patients (71.6%), whereas auramine staining and culturing were positive for 31 (46.3%) and 28 (41.8%) of the patients. The addition of the real-time PCR assay to conventional diagnostic tests resulted in the recognition of 13 more patients with mycobacterial disease. These results indicate that the real-time PCR is more sensitive than conventional staining and culturing techniques (P = 0.006). The M. avium-specific real-time PCR was positive for 38 patients, and the M. tuberculosis-specific real-time PCR was positive for 1 patient. Analysis of 27 patients from whom FNA and tissue biopsy specimens were collected revealed significantly more positive real-time PCR results for FNA than for tissue biopsy specimens (P = 0.003). Samples from an age-matched control group of 50 patients with PCR-proven cat scratch disease were all found to be negative by the real-time PCR. We conclude that this real-time PCR assay with a sensitivity of 72% for patients with lymphadenitis and a specificity of 100% for the detection of atypical mycobacteria can provide excellent support for clinical decision making in children with lymphadenitis.

Nontuberculous mycobacterial infection in children: a 2-year prospective surveillance study in the Netherlands

We performed a prospective, 2-year nationwide study to assess incidence and disease characteristics of suspected infections with nontuberculous mycobacteria (NTM) in children, via the Netherlands Pediatric Surveillance Unit. Data for 61 children were reported (median age, 31 months; interquartile range, 22-50 months; female sex, 37 subjects); 2 subjects had an underlying disease. Most children (53 [87%] of 61) had cervical lymph node enlargement, with abscess in 25 (47%) and fistula in 11 (21%). The estimated annual incidence of NTM infection was 77 cases per 100,000 children. In 16 children, the diagnosis was based solely on the results of skin tests with mycobacterial antigens. Cultures were performed in 36 cases and yielded mycobacteria in 27 (75%); Mycobacterium avium was isolated from 18 cultures. Children with a culture positive for mycobacteria did not differ in presentation, complications, or treatment from those whose cultures showed no growth. Thirty children underwent surgery, and chemotherapy was the single treatment in 24 (39%) of the cases. The treatment of localized NTM infection in immunocompetent children by antimycobacterial drugs should be evaluated further.

Prevalence of apical periodontitis relative to endodontic treatment in an adult Dutch population: a repeated cross-sectional study

OBJECTIVE We aimed to compare an Amsterdam subpopulations current prevalence of root canal fillings and associated periapical radiolucencies with a similar patient sample from 1988. STUDY DESIGN An Amsterdam subpopulation was evaluated for missing teeth, restorations, quality of endodontic treatment, and periapical radiolucency. RESULTS A total of 178 radiographs were evaluated and 4594 teeth were examined. Of these, 324 (7%) exhibited widening of the apical periodontal ligament or periapical radiolucency and 224 (4.8%) had been endodontically treated. A total of 118 teeth (2.5%) had radiographic signs of apical periodontitis. Of these lesions, 54 (45.7%) were linked to endodontically treated teeth (24.1% of endodontically treated teeth). Inadequate root canal fillings were frequent (55.8%). Apical radiolucency was significantly higher in these teeth than in adequately root-filled teeth. CONCLUSION Findings indicate that the periapical status in an Amsterdam subpopulation has not improved over almost 2 decades.

Cervicofacial Lymphadenitis in Children Caused by Mycobacterium haemophilum

BACKGROUND Nontuberculous mycobacterial (NTM) lymphadenitis in children is most often caused by Mycobacterium avium. In a prospective, multicenter trial of the optimal treatment, 23.7% of the NTM cervicofacial lymphadenitis cases in children were caused by Mycobacterium haemophilum. In this article, we describe the epidemiological and clinical features of M. haemophilum cervicofacial lymphadenitis. METHODS The diagnosis of Mycobacterium avium or M. haemophilum infection was established by culture or polymerase chain reaction. Demographic characteristics and data regarding clinical presentation and possible environmental exposure were compared for patients infected with M. avium and those infected with M. haemophilum. RESULTS Ninety-four (69.9%) of 135 infections were caused by M. avium, 32 (23.7%) by M. haemophilum, and 9 (6.4%) by other NTM species. The median age of the M. haemophilum-infected children was 72 months, compared with 41 months for the M. avium-infected children (P < .001), with an equal distribution for both sexes. Involvement of multiple lymph nodes was frequently observed among the M. haemophilum-infected patients (56% of patients). Extranodal localizations were only observed in M. haemophilum-infected patients. Children with M. haemophilum infection were more likely to have a non-Dutch background (P = .001), and in most cases, they had a history of contact with swimming water (P = .03), whereas M. avium-infected patients were more likely to have a history of playing in sandpits (P = .01). In a multivariate analysis, only older age and a non-Dutch background were predisposing risk factors for M. haemophilum infection, compared with M. avium infection. CONCLUSION Higher age, non-Dutch background, and involvement of multiple cervicofacial lymph nodes with extranodal localizations distinguished M. haemophilum infection from M. avium infection.

Mycobacterium haemophilum and Lymphadenitis in children

Mycobacterium haemophilum is the second most common pathogen in children with mycobacterial lymphadenitis.

Conservative Wait-and-See Therapy Versus Antibiotic Treatment for Nontuberculous Mycobacterial Cervicofacial Lymphadenitis in Children

BACKGROUND In this explorative study, 50 children with microbiologically confirmed nontuberculous mycobacterial cervicofacial lymphadenitis were randomized to either receive antibiotic therapy or follow a conservative wait-and-see approach. Our primary objective was to assess the time for all infected lymph nodes to heal in patients after the nonantibiotic, wait-and-see treatment, compared with patients after a 12-week course of clarithromycin and rifabutin. METHODS Fifty children (19 boys and 31 girls) with a polymerase chain reaction (PCR)- or culture-confirmed diagnosis of cervicofacial nontuberculous mycobacterial infection were included in our study. Twenty-five children were randomized to receive antibiotic therapy and 25 to be given a wait-and-see approach. RESULTS The median age of the children was 35 months (range, 14-114 months). The median time to resolution of the disease for the antibiotic group was 36 weeks, compared with 40 weeks for the wait-and-see group. Adverse effects of antibiotic therapy included gastrointestinal complaints, fever, and reversible extrinsic tooth discoloration. CONCLUSION In children with an advanced stage of nontuberculous mycobacterial cervicofacial lymphadenitis, we observed no significant differences in median healing time between the wait-and-see group and the group receiving clarithromycin and rifabutin antibiotic therapy.

Tuberculin Skin Testing Is Useful in the Screening for Nontuberculous Mycobacterial Cervicofacial Lymphadenitis in Children

BACKGROUND We evaluated the diagnostic usefulness of tuberculin skin testing in the screening for nontuberculous mycobacterial (NTM) infection in children. METHODS We enrolled 180 children who had chronic cervicofacial lymphadenitis in our study. Skin testing was done using antigens of Mycobacterium tuberculosis, Mycobacterium avium, Mycobacterium kansasii, and Mycobacterium scrophulaceum. The reference standard for NTM infection was a positive culture result, identification by PCR, or both. Receiver operating characteristic analysis was used to identify the optimal cutoff point in skin induration for the detection of NTM infection. Accuracy of the mycobacterial skin tests was quantified using sensitivity and specificity rates and positive and negative predictive values at the optimal skin induration cutoff. RESULTS A total of 112 NTM infections were identified, of which 83 were caused by M. avium, 21 by Mycobacterium haemophilum, and 8 by other NTM species. At the optimal cutoff for a positive test (5 mm), tuberculin skin testing had a sensitivity and specificity of 70% and 98%, respectively, and a positive predictive value and a negative predictive value of 98% and 64%, respectively, compared with a sensitivity and a specificity of 93% and 97%, respectively; M. avium sensitin, the best-performing skin test, had positive and negative predictive values of 98% and 90%, respectively. CONCLUSION Tuberculin skin testing could be valuable as a first step in the diagnostic analysis of cervicofacial lymphadenitis in children without a history of TB exposure or bacille Calmette-Guérin vaccination.

Esthetic outcome of surgical excision versus antibiotic therapy for nontuberculous mycobacterial cervicofacial lymphadenitis in children.

One hundred children with microbiologically proven nontuberculous mycobacterial cervicofacial lymphadenitis were randomly assigned to excision of the involved lymph nodes, or antibiotic therapy consisting of clarithromycin and rifabutin. The esthetic outcome was rated using a revised and weighted Observer Scar Assessment Scale. The median weighted esthetic outcome in surgical patients was significantly better (30.6) than that for patients treated with antibiotics (42.2).

A comparison of two implant techniques on patient-based outcome measures: a report of flapless vs. conventional flapped implant placement

BACKGROUND Flapless implant surgery is considered to offer advantages over the traditional flap access approach. There may be minimized bleeding, decreased surgical times and minimal patient discomfort. Controlled studies comparing patient outcome variables to support these assumptions, however, are lacking. AIM The objective of this clinical study was to compare patient outcome variables using flapless and flapped implant surgical techniques. PATIENTS AND METHODS From January 2008 to October 2008, 16 consecutive patients with edentulous maxillas were included in the study. Patients were randomly allocated to either implant placement with a flapless procedure (eight patients, mean age 54.6 + or - 2.9 years) or surgery with a conventional flap procedure (eight patients, mean age 58.7 + or - 7.2 years). All implants were placed using a Nobel guide CT-guided surgical template. Outcome measures were the Dutch version of the Impact of Event Scale-Revised (IES-R), dental anxiety using the s-DAI and oral health-related quality of life (OHIP-14). RESULTS Ninety-six implants were successfully placed. All implants were placed as two-phase implants and the after-implant placement dentures were adapted. No differences could be shown between conditions on dental anxiety (s-DAI), emotional impact (IES-R), anxiety, procedure duration or technical difficulty, although the flapless group did score consistently higher. The flap procedure group reported less impact on quality of life and included more patients who reported feeling no pain at all during placement. CONCLUSIONS Differences found in the patient outcome variables do suggest that patients in the flapless implant group had to endure more than patients in the flap group.