Tuber&
and Lung Disease (1992) 73.362-361
0 1992 Longman
GroupUK
Ltd
Tubercleand LungDisease
Mycobacterial lymphadenitis in Western Australia S. C. Pang Chest and Tuberculosis
Services, Health Department
of Western Australia, Perth, Australia
S UMMA R Y. The records of 172 patients with culture-positive mycobacterial lymphadenitis in Western Australia between January 1972 and December 1989 inclusive have been reviewed. Of the 118 children under 7 years of age, the disease was caused by kf. tuberculosis in 4%) the M. avium complex in 74 % and M. scrofulaceum in 20%, whereas in the 54 adults aged 15 years and over, the same organisms were responsible for 89%) 2% and 4% respectively of their diseases. Tuberculous (TBC) lymphadenitis affected mainly adult Asian migrants (71%), while non-tuherculous mycobacterial (NTM) lymphadenitis predominantly affected non-Aboriginal Australian children (92%). The two conditions differed significantly in their distribution of disease in the lymph nodes (PC 0.001). Patients with the TBC disease had a longer (P c 0.001) duration of symptoms before diagnosis but less common (P < 0.02) local complications at presentation than those with the NTM disease. The response of TBC lymphadenitis to medical treatment was excellent with no failure or relapse in the 43 patients followed up to 12 months. Total excision was curative for NTM lymphadenitis although in 10% a second excision was needed because of relapse or residual disease. In a selected group of children, the double Mantoux test was shown to have a 79% sensitivity and a 69% specificity in the diagnosis of the NTM disease. Over the last decade, the prevalence of NTM lymphadenitis in Western Australia decreased while that of TBC lymphadenitis remained steady. R &S U Mk
. Les dossiers de 172 malades atteints d’une lymphadenite mycobactkienne avec culture positive et repertories en Australie de 1’Ouest entre janvier 1972 et decembre 1989 inclus ont ete revus. Chez les 118 enfants QgCsde moins de 7 ans, la maladie Ctaitdue a Mycobactetium tuberculosis dans 4% des cas, au complexe M. avium (MAC) dans 74% des cas et a M. scrofuluceum dans 20% des cas, tandis que chez les 54 adultes Pges de 15 ans et plus, les m&mesorganismes ont ete responsables respectivement de 89%, 2% et 4% des cas pathologiques. Une lymphad&tite tuberculeuse (TBC) affectait principalement des migrants asiatiques adultes (71%), tandis que la lymphadenite mycobactkienne non-tuberculeuse (NTM) affectait principalement des enfants australiens nonaborigenes (92%). Les 2 conditions avaient une difference significative dans la distribution de la maladie au niveau des ganglions lymphatiques (P < 0,001). Les malades atteints de TBC avaient une anciennete superieure (P < 0,001) des symptGmes avant diagnostic, mais ils avaient aussi moms communement de complications locales (P < 0,02) a la presentation par comparaison avec ceux atteints de NTM. La reponse de la 1ymphadeniteTBC au traitement medical etait excellente: aucun echec ni rechute parmi les 43 malades suivis jusqu’a 12 mois. L’excision totale a CtCcurative pour la lymphad&tite NTM, bien que dans 10% des cas une deuxieme excision ait ete nkessaire en raison d’une rechute ou d’une maladie residuelle. Dans un groupe dlectionne d’enfants, le double test de Mantoux a montre une sensibilite de 79% et une specificite de 69% pour le diagnostic de la maladie NTM. Au tours de la derniere decemde la prevalence de la 1ymphadCnit.eNTM en Australie de 1’Ouest a dhninue, tandis que celle de la lymphadenite TBC est demeuree co&ante. R ES UM E N . Se revisaron las fichas clfnicas de 172 pacientes que presentaron una linfadenitis micobacteriana
con cultivo positivo, diagnosticada en el oeste de Australia entre enero de 1972 y diciembre de 1989 inclusive. En 118 niiios de menos de 7 aiios de edad, la enfermedad se debia a M. tuberculosis en e14 % de 10s cases, a M. avium (MAC) en el74% y a M. scrofuluceum en el20%, mientras que en 54 adultos de mais de 15 aiios de edad 10s mismos microorganismos eran responsables de 89%) 2 % y 4 % de 10s cases, respectivamente. La linfadenitis tuberculosa (TBC) afectaba principalmente a 10s migrantes asiaticos adultos (71%), mientras que la linfadenitis micobacteriana no tuberculosa (NTM) afectaba principahnente a 10s niiios australianos no aborigenes (92%). Las dos condiciones tenian una diferencia signiflcativa en lo referente a la distribution en 10s ganglios linfaticos
Correspondence to: S. C. Pang, Chest and Tuberculosis Services, Health Department of Western Australia, 17 Murray Street, Perth, Western Australia 6000. 362
Mycobactetial
lymphadenitis
in Western Australia
363
0,001). Los enfermos con enfermedad TBC habian tenido un period0 m8s largo (PcO,OOl) con sintomas antes de1 diagmktico, pero presentaron complicaciones locales con menor frecuencia (P < 0,02) que aqubllos con enfermedad NTM. La respuesta de la linfadenitis TBC al tratamiento con medicamentos era excelente: sin fracasos ni recaidas en 10s 43 pacientes sequidos hasta 12 meses. La eseisidn total fue curativa para la linfadenitis NTM, aunque en el 10% de 10s cases se necesit6 una segunda escisibn, debido a una recaida o a una enfermedad residual. En un grupo seleccionado de niiios, el doble test de Mantoux mostr6 una sensibilidad de 79% y una especificidad de 69% para el diagmktico de la enfermedad NTM. La prevalencia de linfadenitis NTM ha disminuido en el curso de la liltima dCcada en el oeste de Australia, mientras que la prevalencia de linfadenitis TBC ha permanecido constante. (PC
INTRODUCTION Tuberculous (TBC) lymphadenitis has been the commonest extrapulmonary tuberculosis in Australia.‘.* It was reported to make up 9% of tuberculosis notifications in children under 17 years of age in Victoria for the period 1970-l 986” and 11.7% of all tuberculosis notifications in New South Wales in 1986.’ Yet between 1976 and 1985, Joshi et al’ could only find 5 children presenting to the Royal Children’s Hospital in Melbourne with tuberculous as against 86 with non-tuberculous mycobacterial (NTM) lymphadenitis, commenting that lymphadenitis due to M. tuberculosis was rare in the community. Similar findings were reported for Western Australia.6,7 All included culture-negative diseases, and no study on communitywide mycobacterial lymphadenitis in Australia has ever been published. Western Australia with its relative geographical isolation, a single Mycobacteria Reference Laboratory Service and a central Chest and Tuberculosis Control Branch, both under the State Health Department, provides unique conditions for such studies. This paper reports on the I8-year findings between 1972 and 1989 inclusive.
MATERIALS AND METHODS General data All records of patients notified to the Chest and Tuberculosis Services at the Perth Chest Clinic (PCC) for mycobacterial lymphadenitis from January 1972 to December 1989 were reviewed. NTM disease is not notifiable but in Western Australia the State Mycobacteria Reference Laboratory (SMRL), which is solely responsible for all mycobacteriological studies, reports every mycobacterial identification by culture or smear from clinical specimens to the PCC where volunteer notification is encouraged and solicited for surveillance and statistical purposes. Those whose diagnoses were based on histology or clinical grounds, would only be noti tied through the clinicians’ volition. Undernotification of this group was inevitable but the number is estimated to be small because of the clustering of patients at the Princess Margaret Hospital for Children where special interest in the disease was well known.6-s Information about each patient was recorded on
predesigned data collection forms for demographic and clinical details which were then analysed using simple descriptive statistical methods including x’ test for probability values. Children are defined in this study as persons under the age of 15 years. The period of followup assessment was set at 12 months after completing medical or surgical treatment.
Double Mantoux test The tuberculins used for the Mantoux test over this period varied from purified protein derivative (PPD)-B (Battey), PPD-A (avium) to PPD-I (intracellulare) for the non-tuberculous mycobacteria, and from PPD-S (Seibert) to PPD-H (human) for M. tuberculosis. For clarity they are collectively referred to as B and H respectively in the results. The dose was 5 iu for children and 10 iu for adults. To assess the value of the double Mantoux test, ’ the results from the non-Aboriginal Australian children with diseases caused by the M. avium complex or M. scrojiilaceum were analysed. All would not have had BCG vaccinations and were most unlikely to have been simultaneously infected by M. tuberculosis. The sensitivity and specificity were calculated according to the following definitions: I. when the induration from PPD-B is greater than that from PPD-H by 3 mm or more, the double Mantoux test in the patient is categorized as both TP (truepositive, for NTM infection) and TN (true-negative, for TBC infection); 2. when the induration from PPD-B is less than that from PPD-H by 3 mm or more, the test is categorized as both FN (false-negative, for NTM infection) and FP (false-positive, for TBC infection); and 3. when the two indurations are within 3 mm of each other, the test is (i) TN if the PPD-H induration is under 5 mm, FP if over 4 mm, and (ii) FN if the PPD-B induration is under 5 mm, TP if over 4 mm. The cut-off point for significant difference between the indurations in the double test is difficult to determine as there is no uniform or generally accepted standard in the literature.7-‘0 A minimum of 3 mm is adopted here as this probably represents the limit of accuracy from technical and observer errors.“,‘2 In the small number of patients who had the test repeated after an interval, the
364
Tubercle and Lung Disease
results from the second test were considered separately if the categorization had changed and discarded if not. Similar calculations were not applied to the other groups of patients due to the small number of data available.
Table 1. Source of bacteriological Source
RESULTS
Exclusions A total of 274 patients were found to have mycobacterial lymphadenitis during the period and, of these, 102 had culture-negative disease. 95 of the latter had histological evidence of caseating or necrotizing granulomata with or without positive microscopy for acid-fast bacilli. They were excluded from all analyses but included in the histograph (Figure) to indicate the 3-yearly prevalence of the condition in Western Australia. This left a total of 172 patients with culture-positive disease in the study, consisting of 53 with TBC and 119 with NTM lymphadenitis.
diagnosis
No. of patients Tuberculous
Total Non-tuberculous mycobacterial
Excisional biopsy Needle aspiration Sterile swab Sputum or gastric washing
39 7 3 4
112 0 7 0
151 7 10 4
Total
53
119
172
lymphadenitis. The bacteriological diagnosis is shown in Table 1, while the distribution of the different mycobacterial species in the patients is shown in Table 2.
Tuberculosis and non-tuberculous mycobacterial lymphadenitis Certain demographic features and the anatomical sites of the two diseases are presented separately for adults and children in Table 3 to highlight their differences. The results from the two age groups in each disease, however, have been combined for statistical analyses due to the small number of patients in the childhood TBC and adult NTM subgroups. There was an overall male:female ratio of about 2:3 in both conditions. TBC lymphadenitis was mainly an adult infection of the Asian migrants (71%) and NTM lymphadenitis predominantly a childhood condition of the non-Aboriginal Australians (92%). The anatomical distribution of the two diseases in the various lymph nodes was significantly different (P Two patients who stopped treatment at 3 (RH plus pyrazinamide) and 6 months (RH) because of drug intolerance and default respectively remained well when assessed 12 months later. Both had their lymph
and complications
at presentation
Duration of symptoms in months O-3 >3 No data TBC NTM TBC NTM TBC NTM
Total TBC
NTM
Skin inflammation Abscess formation Cutaneous sinus
0 5 2
I4 22 2
0 0
0
0
I
I
I
3 I
I 9 2
0 8 4
15 32 6
Present Absent
7 6
38 37
1 16
2 3
4 19
12 27
12* 41’
52’ 67’
13’
751
17+
5’
23
39
53
Total
II3 46 67 1.1.5
18-83 35.7 16
P value*
NTM lymphadenitis Adults Children
1.1.7
Age in years Range Mean SD
and outcome
Table 4.
48 17 31
No. of patients Male Female Overall M:F ratio
and in particular its predilection for the upper cervical nodes and the absence of primary infection in the lung. No abdominal lymphadenitis from either cause was diagnosed. All children with the NTM disease had normal chest X-rays. Of the 119 patients with NTM lymphadenitis, 113 (95%) were children with a mean age of 2.8 (range l-6) years. Almost 88% of them had the disease in the cervical nodes and invariably the upper (pre-auricular, submental, submandibular and jugulo-digastric). 13 involved the inguinal nodes compared with 1 the axillary. These further support the view of MacKellar’ that, in children at least the portal of entry is either oropharyngeal or through a skin injury in the limb. The duration of symptoms before diagnosis was generally longer but the complications of skin inflammation, abscess formation and cutaneous sinus were less common in the patients with the TBC than in those with the NTM disease (Table 4). Both were statistically significant. The results of the double Mantoux test and its sensitivity and specificity in differentiating the NTM from the TBC disease are given in Table 5.
Treatment
365
Tuberculous (TBC) and non-tuberculous mycobacterial (NTM) lymphadenitis in Western Australia 1972-1989
5 (4.2%) 87 (73.7%) 23 (19.5%)
! (I .9%) I (I .9%) I(l.9%) 0
in Western Australia
Table 3.
in Western
Children
0
lymphadenitis
*The difference between the two groups is significant
(P2 mm: 10 Total number of tests where PPD-B and PPD-H indurations differ by
and Lung Disease (1992) 73.362-361
0 1992 Longman
GroupUK
Ltd
Tubercleand LungDisease
Mycobacterial lymphadenitis in Western Australia S. C. Pang Chest and Tuberculosis
Services, Health Department
of Western Australia, Perth, Australia
S UMMA R Y. The records of 172 patients with culture-positive mycobacterial lymphadenitis in Western Australia between January 1972 and December 1989 inclusive have been reviewed. Of the 118 children under 7 years of age, the disease was caused by kf. tuberculosis in 4%) the M. avium complex in 74 % and M. scrofulaceum in 20%, whereas in the 54 adults aged 15 years and over, the same organisms were responsible for 89%) 2% and 4% respectively of their diseases. Tuberculous (TBC) lymphadenitis affected mainly adult Asian migrants (71%), while non-tuherculous mycobacterial (NTM) lymphadenitis predominantly affected non-Aboriginal Australian children (92%). The two conditions differed significantly in their distribution of disease in the lymph nodes (PC 0.001). Patients with the TBC disease had a longer (P c 0.001) duration of symptoms before diagnosis but less common (P < 0.02) local complications at presentation than those with the NTM disease. The response of TBC lymphadenitis to medical treatment was excellent with no failure or relapse in the 43 patients followed up to 12 months. Total excision was curative for NTM lymphadenitis although in 10% a second excision was needed because of relapse or residual disease. In a selected group of children, the double Mantoux test was shown to have a 79% sensitivity and a 69% specificity in the diagnosis of the NTM disease. Over the last decade, the prevalence of NTM lymphadenitis in Western Australia decreased while that of TBC lymphadenitis remained steady. R &S U Mk
. Les dossiers de 172 malades atteints d’une lymphadenite mycobactkienne avec culture positive et repertories en Australie de 1’Ouest entre janvier 1972 et decembre 1989 inclus ont ete revus. Chez les 118 enfants QgCsde moins de 7 ans, la maladie Ctaitdue a Mycobactetium tuberculosis dans 4% des cas, au complexe M. avium (MAC) dans 74% des cas et a M. scrofuluceum dans 20% des cas, tandis que chez les 54 adultes Pges de 15 ans et plus, les m&mesorganismes ont ete responsables respectivement de 89%, 2% et 4% des cas pathologiques. Une lymphad&tite tuberculeuse (TBC) affectait principalement des migrants asiatiques adultes (71%), tandis que la lymphadenite mycobactkienne non-tuberculeuse (NTM) affectait principalement des enfants australiens nonaborigenes (92%). Les 2 conditions avaient une difference significative dans la distribution de la maladie au niveau des ganglions lymphatiques (P < 0,001). Les malades atteints de TBC avaient une anciennete superieure (P < 0,001) des symptGmes avant diagnostic, mais ils avaient aussi moms communement de complications locales (P < 0,02) a la presentation par comparaison avec ceux atteints de NTM. La reponse de la 1ymphadeniteTBC au traitement medical etait excellente: aucun echec ni rechute parmi les 43 malades suivis jusqu’a 12 mois. L’excision totale a CtCcurative pour la lymphad&tite NTM, bien que dans 10% des cas une deuxieme excision ait ete nkessaire en raison d’une rechute ou d’une maladie residuelle. Dans un groupe dlectionne d’enfants, le double test de Mantoux a montre une sensibilite de 79% et une specificite de 69% pour le diagnostic de la maladie NTM. Au tours de la derniere decemde la prevalence de la 1ymphadCnit.eNTM en Australie de 1’Ouest a dhninue, tandis que celle de la lymphadenite TBC est demeuree co&ante. R ES UM E N . Se revisaron las fichas clfnicas de 172 pacientes que presentaron una linfadenitis micobacteriana
con cultivo positivo, diagnosticada en el oeste de Australia entre enero de 1972 y diciembre de 1989 inclusive. En 118 niiios de menos de 7 aiios de edad, la enfermedad se debia a M. tuberculosis en e14 % de 10s cases, a M. avium (MAC) en el74% y a M. scrofuluceum en el20%, mientras que en 54 adultos de mais de 15 aiios de edad 10s mismos microorganismos eran responsables de 89%) 2 % y 4 % de 10s cases, respectivamente. La linfadenitis tuberculosa (TBC) afectaba principalmente a 10s migrantes asiaticos adultos (71%), mientras que la linfadenitis micobacteriana no tuberculosa (NTM) afectaba principahnente a 10s niiios australianos no aborigenes (92%). Las dos condiciones tenian una diferencia signiflcativa en lo referente a la distribution en 10s ganglios linfaticos
Correspondence to: S. C. Pang, Chest and Tuberculosis Services, Health Department of Western Australia, 17 Murray Street, Perth, Western Australia 6000. 362
Mycobactetial
lymphadenitis
in Western Australia
363
0,001). Los enfermos con enfermedad TBC habian tenido un period0 m8s largo (PcO,OOl) con sintomas antes de1 diagmktico, pero presentaron complicaciones locales con menor frecuencia (P < 0,02) que aqubllos con enfermedad NTM. La respuesta de la linfadenitis TBC al tratamiento con medicamentos era excelente: sin fracasos ni recaidas en 10s 43 pacientes sequidos hasta 12 meses. La eseisidn total fue curativa para la linfadenitis NTM, aunque en el 10% de 10s cases se necesit6 una segunda escisibn, debido a una recaida o a una enfermedad residual. En un grupo seleccionado de niiios, el doble test de Mantoux mostr6 una sensibilidad de 79% y una especificidad de 69% para el diagmktico de la enfermedad NTM. La prevalencia de linfadenitis NTM ha disminuido en el curso de la liltima dCcada en el oeste de Australia, mientras que la prevalencia de linfadenitis TBC ha permanecido constante. (PC
INTRODUCTION Tuberculous (TBC) lymphadenitis has been the commonest extrapulmonary tuberculosis in Australia.‘.* It was reported to make up 9% of tuberculosis notifications in children under 17 years of age in Victoria for the period 1970-l 986” and 11.7% of all tuberculosis notifications in New South Wales in 1986.’ Yet between 1976 and 1985, Joshi et al’ could only find 5 children presenting to the Royal Children’s Hospital in Melbourne with tuberculous as against 86 with non-tuberculous mycobacterial (NTM) lymphadenitis, commenting that lymphadenitis due to M. tuberculosis was rare in the community. Similar findings were reported for Western Australia.6,7 All included culture-negative diseases, and no study on communitywide mycobacterial lymphadenitis in Australia has ever been published. Western Australia with its relative geographical isolation, a single Mycobacteria Reference Laboratory Service and a central Chest and Tuberculosis Control Branch, both under the State Health Department, provides unique conditions for such studies. This paper reports on the I8-year findings between 1972 and 1989 inclusive.
MATERIALS AND METHODS General data All records of patients notified to the Chest and Tuberculosis Services at the Perth Chest Clinic (PCC) for mycobacterial lymphadenitis from January 1972 to December 1989 were reviewed. NTM disease is not notifiable but in Western Australia the State Mycobacteria Reference Laboratory (SMRL), which is solely responsible for all mycobacteriological studies, reports every mycobacterial identification by culture or smear from clinical specimens to the PCC where volunteer notification is encouraged and solicited for surveillance and statistical purposes. Those whose diagnoses were based on histology or clinical grounds, would only be noti tied through the clinicians’ volition. Undernotification of this group was inevitable but the number is estimated to be small because of the clustering of patients at the Princess Margaret Hospital for Children where special interest in the disease was well known.6-s Information about each patient was recorded on
predesigned data collection forms for demographic and clinical details which were then analysed using simple descriptive statistical methods including x’ test for probability values. Children are defined in this study as persons under the age of 15 years. The period of followup assessment was set at 12 months after completing medical or surgical treatment.
Double Mantoux test The tuberculins used for the Mantoux test over this period varied from purified protein derivative (PPD)-B (Battey), PPD-A (avium) to PPD-I (intracellulare) for the non-tuberculous mycobacteria, and from PPD-S (Seibert) to PPD-H (human) for M. tuberculosis. For clarity they are collectively referred to as B and H respectively in the results. The dose was 5 iu for children and 10 iu for adults. To assess the value of the double Mantoux test, ’ the results from the non-Aboriginal Australian children with diseases caused by the M. avium complex or M. scrojiilaceum were analysed. All would not have had BCG vaccinations and were most unlikely to have been simultaneously infected by M. tuberculosis. The sensitivity and specificity were calculated according to the following definitions: I. when the induration from PPD-B is greater than that from PPD-H by 3 mm or more, the double Mantoux test in the patient is categorized as both TP (truepositive, for NTM infection) and TN (true-negative, for TBC infection); 2. when the induration from PPD-B is less than that from PPD-H by 3 mm or more, the test is categorized as both FN (false-negative, for NTM infection) and FP (false-positive, for TBC infection); and 3. when the two indurations are within 3 mm of each other, the test is (i) TN if the PPD-H induration is under 5 mm, FP if over 4 mm, and (ii) FN if the PPD-B induration is under 5 mm, TP if over 4 mm. The cut-off point for significant difference between the indurations in the double test is difficult to determine as there is no uniform or generally accepted standard in the literature.7-‘0 A minimum of 3 mm is adopted here as this probably represents the limit of accuracy from technical and observer errors.“,‘2 In the small number of patients who had the test repeated after an interval, the
364
Tubercle and Lung Disease
results from the second test were considered separately if the categorization had changed and discarded if not. Similar calculations were not applied to the other groups of patients due to the small number of data available.
Table 1. Source of bacteriological Source
RESULTS
Exclusions A total of 274 patients were found to have mycobacterial lymphadenitis during the period and, of these, 102 had culture-negative disease. 95 of the latter had histological evidence of caseating or necrotizing granulomata with or without positive microscopy for acid-fast bacilli. They were excluded from all analyses but included in the histograph (Figure) to indicate the 3-yearly prevalence of the condition in Western Australia. This left a total of 172 patients with culture-positive disease in the study, consisting of 53 with TBC and 119 with NTM lymphadenitis.
diagnosis
No. of patients Tuberculous
Total Non-tuberculous mycobacterial
Excisional biopsy Needle aspiration Sterile swab Sputum or gastric washing
39 7 3 4
112 0 7 0
151 7 10 4
Total
53
119
172
lymphadenitis. The bacteriological diagnosis is shown in Table 1, while the distribution of the different mycobacterial species in the patients is shown in Table 2.
Tuberculosis and non-tuberculous mycobacterial lymphadenitis Certain demographic features and the anatomical sites of the two diseases are presented separately for adults and children in Table 3 to highlight their differences. The results from the two age groups in each disease, however, have been combined for statistical analyses due to the small number of patients in the childhood TBC and adult NTM subgroups. There was an overall male:female ratio of about 2:3 in both conditions. TBC lymphadenitis was mainly an adult infection of the Asian migrants (71%) and NTM lymphadenitis predominantly a childhood condition of the non-Aboriginal Australians (92%). The anatomical distribution of the two diseases in the various lymph nodes was significantly different (P Two patients who stopped treatment at 3 (RH plus pyrazinamide) and 6 months (RH) because of drug intolerance and default respectively remained well when assessed 12 months later. Both had their lymph
and complications
at presentation
Duration of symptoms in months O-3 >3 No data TBC NTM TBC NTM TBC NTM
Total TBC
NTM
Skin inflammation Abscess formation Cutaneous sinus
0 5 2
I4 22 2
0 0
0
0
I
I
I
3 I
I 9 2
0 8 4
15 32 6
Present Absent
7 6
38 37
1 16
2 3
4 19
12 27
12* 41’
52’ 67’
13’
751
17+
5’
23
39
53
Total
II3 46 67 1.1.5
18-83 35.7 16
P value*
NTM lymphadenitis Adults Children
1.1.7
Age in years Range Mean SD
and outcome
Table 4.
48 17 31
No. of patients Male Female Overall M:F ratio
and in particular its predilection for the upper cervical nodes and the absence of primary infection in the lung. No abdominal lymphadenitis from either cause was diagnosed. All children with the NTM disease had normal chest X-rays. Of the 119 patients with NTM lymphadenitis, 113 (95%) were children with a mean age of 2.8 (range l-6) years. Almost 88% of them had the disease in the cervical nodes and invariably the upper (pre-auricular, submental, submandibular and jugulo-digastric). 13 involved the inguinal nodes compared with 1 the axillary. These further support the view of MacKellar’ that, in children at least the portal of entry is either oropharyngeal or through a skin injury in the limb. The duration of symptoms before diagnosis was generally longer but the complications of skin inflammation, abscess formation and cutaneous sinus were less common in the patients with the TBC than in those with the NTM disease (Table 4). Both were statistically significant. The results of the double Mantoux test and its sensitivity and specificity in differentiating the NTM from the TBC disease are given in Table 5.
Treatment
365
Tuberculous (TBC) and non-tuberculous mycobacterial (NTM) lymphadenitis in Western Australia 1972-1989
5 (4.2%) 87 (73.7%) 23 (19.5%)
! (I .9%) I (I .9%) I(l.9%) 0
in Western Australia
Table 3.
in Western
Children
0
lymphadenitis
*The difference between the two groups is significant
(P2 mm: 10 Total number of tests where PPD-B and PPD-H indurations differ by
