Clinical presentation

Presentation typically involves neck mass, fever, cervical lymphadenopathy, poor oral intake, and neck stiffness. Coticchia and colleagues found that children younger than 4 years with bacterial cervical lymphadenitis had a higher incidence of agitation, cough, drooling, lethargy, palatal or pharyngeal swelling, respiratory distress, retractions, rhinorrhea, and stridor than children older than 4 years.

Diagnosis

Diagnosis can be made clinically, although is usually supported by imaging that includes ultrasound (US) or CT. Imaging modalities may aid in revealing characteristics consistent with an infected congenital anomaly such as a branchial cleft cyst or a thyroglossal duct cyst. Common pathogens include streptococcus and staphylococcus species, which can account for up to 80% of cultures.

Management

Up to 90% to 100% of community-acquired MRSA is sensitive to clindamycin and trimethoprim-sulfamethoxazole. Nosocomial strains of MRSA may have a resistance to these 2 antibiotics at a rate of up to 10% to 20% and is universally resistant to erythromycin. Treatment involves broad-spectrum (with gram-positive and gram-negative coverage) oral or intravenous antibiotics with surgical intervention reserved for those with frank abscess formation seen on imaging or failure of medical management. Increasing antibiotic resistance plays a role in empiric antibiotic therapy because up to 18% of methicillin-sensitive S aureus is resistant to clindamycin. Cabrera and colleagues retrospectively reviewed 89 children with head and neck infections and the most common bacteria isolated was group B streptococcus. Age seems to be a determining factor in the bacterial type because children less than age 1 year are more likely to have S aureus as the infecting organism.

Infection progression

Often, when these infections progress to suppuration, surgical intervention is required because complications of this this process can include

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  Airway obstruction

  
  
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  Internal jugular vein thrombosis

  
  
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  Neurologic defects

  
  
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  Carotid blowout

  
  
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  Death

Adenitis may spread and seed adjacent deep cervical spaces such as the retropharyngeal space, parapharyngeal space, or submandibular space. The retropharyngeal space lies posterior to the buccopharyngeal fascia and may be synonymous with the prevertebral space. A transoral approach is used for incision and drainage of this area. The parapharyngeal space lies lateral to the buccopharyngeal fascia and medial to the pterygoid muscle and parotid gland and may be approached via a transoral or external transcervical approach. The submandibular space, which runs from the hyoid bone to the mandible, is also approached via an external transcervical approach.

Clinical presentation

Presentation of an Actinomycosis infection can occur at any age. In the pediatric population it occurs with dental caries and lymphadenopathy at the angle of the mandible or in the submandibular region. Acutely, this can present as cellulitic change in the overlying skin with edema and pain. The chronic form of the disease can present as chronic inflammation and induration, and progress to multiple abscesses with draining sinus tracts, of which 25% contain sulfur granules. Presentation can include low-grade fever and enlargement of locoregional cervical lymph nodes but can also become more extensive and include osteomyelitis.

Diagnosis

Diagnosis is based on culture results of incisional or excisional biopsy, or fine-needle aspiration (FNA) samples with multiple biopsies at different levels recommended to enhance possibly of diagnosis. CT or MRI can be used to evaluate this area with the common findings of an enhancing soft tissue mass with an low attenuating center with adjacent soft tissue inflammation. An actinomycosis infection in a child indicates the need for evaluation for an underlying immunologic deficiency such as chronic granulomatous disease (CGD).

Management

The treatment choice is penicillin G (50–75 mg/kg/d intravenously in 4 daily divided doses) for 4 to 6 weeks. This may be followed by oral penicillin V (30–60 mg/kg/d administered in 4 divided doses) for 2 to 12 months. Tetracycline can be used for patients who are allergic to penicillin; however, it can cause dental staining. Duration of therapy depends on disease burden, sites of infection, and radiologic and clinical response to therapy. Medical therapy alone may be adequate for treatment but adjuvant surgical debridement may also be indicated. Surgical therapy, although not curative alone, is indicated for curettage of bone, resection of necrotic tissue, excision of sinus tracts, and drainage of soft tissue abscesses.

Clinical presentation

Patients may present with general malaise, headache, and fever; however, the most common clinical manifestations range from painless lymphadenopathy not involving the overlying skin to large cervical abscesses. After upper-extremity adenopathy, head and neck presentation is the second most common site. Cervical and submandibular nodes make up most of the sites affected, followed by preauricular or parotid involvement.

Diagnosis

Diagnosis is based on biopsy or serologic testing. Previously, diagnosis was clinical and based on history of contact with a kitten, positive CSD skin test, regional lymphadenopathy in which other causes have been ruled out, and an excisional lymph node biopsy with histopathologic findings of CSD. Warthin-Starry silver staining is used to visualize pleomorphic bacilli in the walls of blood vessels and in microabscesses. Bacilli may stain positive by Warthin-Starry staining early in the disease process but is rarely detected later in the disease. On excisional biopsy in the early stage of the disease, reactive lymphoid hyperplasia develops, whereas later in the course of the disease granuloma formation and microabscesses may form. Serologic testing consists of IgG and IgM antibodies, with IgM antibodies the most sensitive. If negative, polymerase chain reaction (PCR) detection of Bartonella DNA is used on biopsy material. Both granulomas and abscesses may be found in the same specimen. The resultant lymphadenopathy enlarges and may not resolve for 2 or 3 months.

Management

Treatment is usually supportive but definitive diagnosis must be ascertained before observation. Signs of systemic disease, which may be seen in immune-compromised hosts, can include endocarditis, osteolytic lesions, and meningoencephalitis. Systemic symptoms warrant treatment consisting of ciprofloxacin, erythromycin, rifampin, or gentamycin.

Diagnosis

Diagnosis remains difficult unless there is a high level of suspicion for this process as the primary symptom is a painless neck mass. The organism is very slow growing and biopsy must be obtained to obtain tissue for diagnosis. Nocardia infections diagnosed in children require further work-up for an underlying immunodeficiency.

Management

The treatment choices for Nocardia infections are: trimethoprim-sulfamethoxazole, imipenem, amikacin, and linezolid. Boiron and colleagues reviewed nocardial infections from 1987 to 1990 and determined that recent treatment with corticosteroids represented a significant factor for increased mortality from these infections.

Clinical presentation

The typical presentation is a painless neck mass seen in an immunocompetent child that has been unresponsive to standard antibiotics. This can be associated with skin discoloration, including erythema or a violaceous discoloration, and, less often, fistula formation. This occurs most often in female patients and children younger than 5 years old. These lesions are slow growing but a late complication is fistulization and drainage. Infection commonly involves the submandibular and cervical area and upper cervical area and often presents with parotid involvement ( Figs. 2 and 3 ).

Atypical mycobacteria infection with associated skin involvement.

Atypical mycobacteria infection with skin involvement and fistulization.

Diagnosis

Diagnosis is based on purified protein derivative (PPD) intradermal testing or on cultured tissue and PCR testing for mycobacterial RNA from biopsy (excisional or FNA). Imaging usually involves US, CT, or MRI. Findings on these studies are nonspecific but can consist of solid hypoechoic masses that can appear hypodense on CT. Histopathologic results reveal chronic granulomatous inflammation with areas of caseous necrosis.

Management

Treatment usually involves an oral antibiotic regimen consisting of rifampin and clarithromycin. If this fails, surgical excision or curettage can be used as an alternative approach to reduce the burden of disease. If surgical excision is planned, the technique involves removing that total mass en bloc with any involved skin or adjacent tissue, closing the skin to prevent fistula formation. When adherence to facial nerve is encountered or tissue involvement is extensive, a wait-and-see approach can be considered with adjuvant oral antimycobacterial antibiotics. Recent studies have suggested that observation, with or without antibiotic therapy, often can lead to resolution of 6 months to 1 year. Some investigators have postulated that the depth of cervical disease helps determine outcome, whereas disease deeper to the sternocleidomastoid muscle was more likely to require no intervention and resolve without morbidity.

Clinical presentation

Individuals infected typically have pulmonary hilar and cervical lymphadenopathy that is commonly bilateral. This typically indicates hematogenous spread from pulmonary disease. Cervical lymphadenopathy can be part of the primary infection or secondary (organ) tuberculosis. Early-phase lymphadenitis is characterized by a nontender, firm lymph node, which develops caseous necrosis and softens into an abscess.

Diagnosis

Screening for this disease process is based on a positive PPD. Other diagnostic tests may include chest radiograph (CXR) and excisional biopsy or FNA of cervical lymph node with PCR testing. Ziehl-Neelsen staining of obtained tissue occasionally shows short rod-shaped bacteria in the coagulation necrosis. Histology is characterized by central caseous necrosis surrounded by an epithelioid cell layer and sporadic Langerhans giant cells.

Management

Healing occurs with calcification of the affected node. Treatment consists of isolation of a patient with active disease along with a multidrug antitubercular regimen. Incision and drainage of cervical lymphadenopathy should be avoided because there is concern for fistulization.