Head and neck lymphadenitis originating from nontuberculous mycobacterial infections in children is well documented. In most cases, Mycobacterium avium is the causative microorganism,1 but infections caused by Mycobacterium haemophilum in immunocompetent children have been described in the cervicofacial region.2–7 Inguinal lymphadenitis caused by M. haemophilum has not been previously described.
A 5-year-old girl with a previous state of good health presented with fever of 1 week's duration and an enlarged, painful lymph node in the left groin. She had a small indolent wound on the dorsum of her left foot for 2 weeks. There was no history of trauma. Treatment with amoxicillin–clavulanate acid for bacterial lymphadenitis was ineffective. Because the wound on her foot would not heal, surgical exploration looking for a foreign body was performed. At the same time, fine needle biopsy of the inguinal lymph node was done for bacterial cultures and pathologic examination. Histopathologic analysis revealed lymphadenitis with granulomatous inflammation, whereas the Ziehl-Neelsen stain demonstrated acid-fast bacilli. Standard mycobacterial culturing was performed at 35°C in liquid MGIT medium and on solid Löwenstein-Jensen medium. M. haemophilum-specific culturing was performed at 30°C with added iron citrate and in MGIT with X-factor strip added. After 2 weeks, M. haemophilum was cultured. Considering the various treatment options, the parents decided to choose conservative treatment with antimycobacterial therapy consisting of clarithromycin and rifabutin for 12 weeks. The drugs were well tolerated by the child and only a slight yellowish skin discoloration was noted as a side effect of rifabutin. Laboratory examination revealed no abnormalities. During antimycobacterial therapy, the inguinal lymph node started suppurating, and after 12 weeks of treatment, complete necrosis of the lymph node was visible (Fig. 1). The parents and the pediatric surgeon agreed on surgical excision of the affected inguinal lymph nodes. At operation, superficial and deep lymph nodes were affected and excised. No short-term postoperative complications were noted, but 6 months after surgery, lymphedema of the dorsum of the left foot developed. Compression treatment with a class 2 elastic stocking for 3 months was successful.
Mycobacterium haemophilum is an uncommon pathogen in humans and mainly causes infections in immunocompromised patients. Cutaneous lesions, osteomyelitis, disseminated infection with lymphadenopathy and are principal manifestations of M. haemophilum infections.8 Since the first case report of a cervicofacial lymphadenitis in an immunocompetent child in 1981,2 only 7 additional children with head and neck lymphadenitis have been added to the literature.3–6 Recently, we described a larger series of immunocompetent children with cervicofacial lymphadenitis caused by M. haemophilum.7 Inguinal lymphadenitis caused by M. avium and Mycobacterium scrofulaceum have been reported,9 but no previous reports on inguinal lymphadenitis caused by M. haemophilum have been described. In our patient, diagnosis was established by culture. M. haemophilum infection can often be undetected because routine microbiologic techniques (ie, mycobacterial culture on standard culture media such as Loewenstein-Jensen media incubated at 37°C) are insufficient. M. haemophilum grows only selectively on ferric ion supplemented culture media and requires incubation at a temperature of 30°C.10 Recently, we reported the application of a Mycobacterium genus-specific real-time polymerase chain reaction in combination with amplicon sequencing and M. haemophilum-specific polymerase chain reaction to diagnose M. haemophilum cervicofacial lymphadenitis.10 Antimycobacterial therapy consisting of clarithromycin and rifabutin for a period of 12 weeks was used to treat the M. haemophilum inguinal lymphadenitis in our patient. Like many other nontuberculous mycobacteria, M. haemophilum does not respond to treatment with isoniazid or pyrazinamide, but it may respond to quinolones, the macrolides and the rifamycins.8 In our patient, complete resolution of M. haemophilum infection was achieved after surgical removal of the affected lymph nodes. Surgery is considered to be the treatment of choice in selected cases for nontuberculous cervicofacial lymphadenitis.1 Conservative treatment with or without antibiotics is sometimes used as an alternative in the head and neck region to prevent the risk of facial nerve dysfunctions and to avoid facial scarring. Surgical excision of the affected inguinal lymph nodes could have been the preferred primary management in the presented case.
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