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242 Lymphadenopathy in African Children

Cervical lymphadenopathy has been reported to occur in 4–9% of antituberculous therapy, surgical excision has become the treatment of
children with pulmonary tuberculosis, with 57% occurring between choice for nontuberculous mycobacterial lymphadenopathy. Surgical
the ages of 1 and 3 years. Clinical suspicion of cervical TB is high in management encompasses total excision or curettage of the affected
children with a previous history of TB or close contact with a TB patient lymph node(s) and remains the treatment of choice due to the high cure
from an endemic region. The significance increases in the presence of a rate with a single procedure. For lesions in proximity to the facial nerve
markedly positive tuberculin skin test (i.e., Mantoux test). The finding or with extensive skin necrosis, curettage can be performed as an alter-
of nontender, painless, unilateral cervical lymph nodes on physical native to total excision as the initial procedure. This is usually part of
examination further strengthens this suspicion. Objective diagnosis is a staged process followed by subsequent excision and wound closure.
then fairly difficult and relies on cervical lymph node sampling. Immunocompetent patients with nontuberculous cervical
Particular difficulties exist in making a clinical diagnosis in children lymphadenitis do, however, appear to show some response to medical
with HIV disease, who may have atypical presentations. When clinically therapy alone. A recent study of 92 immunocompetent children
2
indicated, screening for pulmonary and laryngeal disease depends with nontuberculous mycobacterial lymphadenopathy (90% M. avium
heavily on lymph node sampling. Fine needle aspiration (FNA) with complex or M. hemophilum) showed a natural history of violaceous
culture or polymerase chain reaction (PCR)–based identification are skin changes with discharge of pus for 3–8 weeks. The infection then
rapidly overtaking the more conventional methods of diagnosis, with seemed to settle, with 71% achieving total resolution within 6 months
the more traditional method of excisional biopsy being reserved for and resolution of the remaining 29% within 9–12 months. This raises
selected cases. the question of a possible conservative approach to nontuberculous
Nontuberculous Mycobacterial Infections mycobacterial infestations of the cervicocranial region.
Cervical lymphadenopathy caused by nontuberculous mycobacteria
BCG lymphadenitis can thus be managed by a variety of therapeutic options in
A special situation exists in lymphadenopathy related to the Danish immunoincompetent children, with infection resolution being the
strain of bacille Calmette-Guérin (BCG; Figure 37.3), which is estimat- eventual outcome regardless of management option selected. The
ed to occur at the rate of 36 per 1,000 vaccinations. This may be partly best management option in this group appears to be an individualised
strain specific, and the association of the current Danish-strain BCG approach with excisional biopsy as the recommended option; its
and regional lymphadenitis has been recognised especially in HIV- feasibility is determined by the length of history, the danger of facial
positive children. Similarly, disseminated BCG disease occurs almost nerve injury (due to position), and the presence of hypertrophic scarring.
exclusively in immunocompromised children and has an extremely In immunocompromised (e.g., HIV-affected) children, the
high mortality. In HIV-positive children with suspected BCG-regional management option may change depending on the CD4 count. The
axillary lymphadenitis, the diagnosis should be confirmed by means of potential for systemic disease in these patients remains (see the
FNA, pus swab, or gastric washout. The investigative protocol in these preceding section on bacille Calmette-Guérin lymphadenitis).
patients should include a chest radiograph to exclude disseminated Other Causes of Chronic Granulomas in Lymph Nodes
mycobacterial disease. If a positive BCG mycobacterium is cultured
from the lymph nodes, initial treatment should be by means of tubercu- Rosai-Dorfman disease
lostatics, and surgery should be avoided and reserved for complicated Rosai-Dorfman disease, or sinus histiocytosis with massive lymphade-
patients and cases where diagnostic doubt exists. nopathy (SHML), is an uncommon but well-defined cause of chronic
In BCG adenitis, if the lymph nodes are <3 cm in size, the diagnostic lymphadenopathy in childhood. It is a histiocytic proliferative disease.
FNA should be followed by a “wait and see” policy, which avoids Patients may present with a low-grade fever and cervical lymphade-
the use of ineffective tuberculostatics, with the inherent problem of nopathy. It is a benign self-limiting disorder. Histological features
acquired drug resistance, as well as affording a lower incidence of include numerous large histiocytes with prominent emperipolesis (a
surgically related complications. In nodes >3 cm in size with a negative halo observed around the cell), fine vacuoles in the cytoplasm, and
FNA culture, other concerns of underlying disease need to be taken into lymphocytes and plasma cells in the background.
account in evaluating surgical intervention. This is especially so if the Diagnosis has successfully been made with a FNA biopsy in a
patient is not responding to conventional therapy. number of reports demonstrating the characteristic SHML features,
Mycobacteria other than tuberculosis namely, large histiocytes with abundant pale, eosinophilic cytoplasm
Mycobacteria other than tuberculosis can be a cause of chronic localised containing well-preserved lymphocytes and occasional plasma cells
cervicofacial lymphadenitis. Due to MOTT’s perceived resistance to and granulocytes. Additional immunostaining may demonstrate typical
positive S-100 protein and alpha-1-antichymotrypsin staining, but no
reaction when stained for lysozyme.
Cat scratch disease
Cat scratch disease is caused by infection by the Bartonella henselae
organism. Cat scratch disease occurs in many countries (including
some developing ones), but may be difficult to diagnose in children. It
is a self-limiting zoonotic condition that may occur at any age, but it
is most common among children and adolescents. It usually involves
enlargement of only a single node regionally, which is usually the cer-
vical or axillary and very rarely inguinal lymph nodes. It is diagnosed
on careful history taking and specific serological test and histopatho-
logical examination.
Castleman disease
Castleman disease (angiofollicular lymph node hyperplasia) has been
reported in Africa both in the cervicofacial area and intraabdominally.
Although presentation as an asymptomatic neck mass is not uncom-
Figure 37.3: BCG ulcer (small arrow) and axillary lymphadenopathy (large mon, it most frequently presents with mediastinal lymphadenopathy.
arrow) in a neonate.