Fistulas don't tell the whole story: Predicting the need for surgery in pediatric patients with non-tuberculous mycobacterial cervicofacial lymphadenitis

Abstract

Introduction

Cervicofacial lymphadenitis (CFL) in children is commonly caused by non-tuberculous mycobacterium (NTM). NTM presents as lymphadenopathy, which can result in violaceous skin changes, necrosis, and fistulas in later stages. Multiple therapeutic modalities are available, encompassing conservative management, antimicrobial treatment, and surgical procedures of varying complexity, with considerable inter-institutional and intra-institutional practice variation.This study aimed to evaluate whether the radiographic presence of fistulous tracts in patients with NTM CFL is associated with an increased probability of requiring surgery.

Methods

We conducted a retrospective cohort study of patients with clinical or histopathologic diagnosis of NTM at a single tertiary care urban pediatric hospital between 2010 and 2024. Demographic, physical examination, medical and surgical treatment, laboratory findings, and follow-up data were collected. Available imaging was blindly reviewed by pediatric neuroradiologists for the presence of cutaneous fistula (CF). Patients were excluded if they were over 18 years of age, did not have imaging, and had presentation/pathology/culture data inconsistent with NTM. Descriptive statistics, analysis of variance (ANOVA), and logistic regression tests were used for group comparisons.

Results

Sixty-six patients were found to have proven or presumed NTM CFL, available imaging, and disease resolution at the time of chart review. Forty-seven (71.2 %) had evidence of cutaneous fistulas. For those 47 with CF, 15 underwent primary surgical treatment while 32 had primary antibiotic treatment, although ultimately 28 of the latter required surgery. For those with and without CF there were significantly more patients who required surgical treatment for resolution (p < 0.001). There was no significant difference in the likelihood of surgical intervention for disease resolution between patients with CF compared to those without.

Conclusions

While the radiographic presence of CF did not significantly predict the likelihood of requiring surgical intervention, most patients with and without CF ultimately required surgery for disease resolution rather than responding to long-term antibiotic therapy alone. These findings suggest that surgical intervention remains a critical component of NTM CFL management regardless of initial imaging findings. This information can help clinicians counsel families that while medical therapy may be attempted initially, surgical treatment should be anticipated as part of the treatment course for optimal disease resolution.