November 2005

A 16-year-old boy presents to the pediatric infectious disease clinic for evaluation and treatment of a draining lesion on his neck. He first noticed some swelling about three to four months earlier that was just to the right of the midline at the base of the anterior neck. About two months later, as the mass got larger, it began to be painful and fluctuant. His primary provider referred him to a pediatric surgeon, who ordered a computed tomography (CT) scan of the neck and thorax as shown in figures 1 and 2. Two days later, he performed an incision and drainage (I and D), which revealed about 10 mL of pus, which was stained for bacteria, fungi and acid-fast bacilli (AFB), all of which were negative; corresponding cultures are pending. The I and D site has been draining since. On further questioning, he denied any trauma or even scratches anywhere about the neck or surrounding area.

His past medical history is significant for living in the Philippines for the first 11 years of his life. Otherwise, he has led a fairly unremarkable childhood with no known exposures to tuberculosis or those at high risk. There has been no recent travel, tick or other insect exposure or significant animal exposure, including cats. His immunizations are up-to-date and he lives with both parents and three siblings (all healthy). He is a good student in the ninth grade and participates in sports, but again, there is no history of trauma. His review of symptoms includes the chief complaint and intermittent low back pain for the last several years, but mild enough not to require investigation or therapy.

Examination revealed a healthy-appearing 16-year-old boy in no distress and normal vital signs. His growth parameters were normal for his age, with no weight loss. The only positive finding was the subject of the chief complaint: a firm, moderately painful mass at the base of the anterior neck just to the right of the midline, with an open lesion that has some yellowish drainage (figure 3) that is kept covered with a bandage. There were no other masses nor adenopathy felt or any other positive findings on exam.

Laboratory tests have been unremarkable except the AFB culture taken several weeks earlier appears to now be growing something.

What’s Your Diagnosis?

1. Cat Scratch Disease
2. Tuberculous lymphadenitis
3. Thyroglossal duct abscess
4. Nontuberculous lymphadenitis

Answer

The answer is B. The AFB culture grew Mycobacteria tuberculosis that was eventually shown to be pan-sensitive against all the anti-tuberculous drugs tested. He was treated according to the recommendations in the Red Book, starting out with four-drug therapy (isoniazid, rifampin, ethambutol and pyrazinamide).

The ethambutol was discontinued after one month when sensitivities were known, and the pyrazinamide was discontinued after two months. The isoniazid and rifampin were continued for a total of six months with resolution of the drainage and improvement as shown on the repeat CT scan of the area four months later (figure 4). The right-sided paratracheal mediastinal adenopathy shown in figure 2 also resolved as shown in figure 5. A contact investigation by the local health department never found the source of exposure. By the way, the intermittent low back pain turned out to be related to his sports activity, with a normal spinal MRI. Obviously, vertebral tuberculosis (TB) should come to mind in such a patient as well.

Cervical tuberculous lymphadenitis has been referred to in the past as scrofula. This term is from the Latin word for “brood sow,” presumably for the appearance of the patient with an advanced case, causing the neck to resemble having jowls. Nontuberculous mycobacteria lymphadenitis may cause similar manifestations, but is more likely to occur in younger children, usually younger than 5. These cases (nontuberculous lymphadenitis) are best treated with surgical excision of the infected node(s). However, I and D should be avoided in both.

Cat scratch disease (CSD) lymphadenitis can certainly result in a chronic draining sore at an I and D site (figure 6); however, involvement of deep cervical nodes at the base of the neck would be an unusual location. Additionally, the patient had no cat exposure by history. Of course we all know that a negative exposure history dose not rule out CSD. Caused by Bartonella henselae, CSD is not routinely cultured, but rather diagnosed clinically and supported serologically. Another clue against CSD was the growth of an AFB organism. CSD nodes are best left alone. Even if they suppurate, it is considered best to watch and wait unless it is obvious that the node is going to drain. Then most experts recommend using needle aspiration rather than I and D to try to avoid chronic drainage, which was the history of the child in figure 6.

An infected thyroglossal duct cyst may present with some spontaneous drainage, but should present as a soft, fluctuant mass with discrete swelling in the midline of the lower part of the anterior neck as shown in figure 7. After drainage and clearance of the bacterial infection, these lesions need to be surgically ablated, otherwise there is a high probability of recurrence. The patient pictured in figure 7 was in for the second time in two years with the same problem due to not following up after the first episode.

As usual, if you want to read about TB in children, I recommend Jeffrey R. Starke’s TB chapter in Feigin and Cherry’s Textbook of Pediatric Infectious Diseases, 5th Edition (2004), Chapter 101, page 1337. Everything you would want to know is there. Dr. Starke, another very talented physician at Baylor College of Medicine, also happens to write the chapter on infective endocarditis in the same text.

Commentary

It’s often a cliché to make reference to people as pioneers, but sometimes it is appropriate. At any given time, pioneers in various fields die, and pioneers-to-be are born. But at this particular time in history, we are regularly witnessing the passing of true pioneers who were instrumental in shaping the field of pediatric infectious diseases and the founding of the first pediatric infectious disease training programs. I have mentioned several of these outstanding individuals in this column in the last few years, and unfortunately it is time to honor another.

To my regret, I never met Dr. Martha Dukes Yow Roessler, but my mentor, Jim Bass (1930–2001) made sure I knew who Dr. Yow was during my fellowship training by discussing her research and reputation. Dr. Yow’s outstanding career began with her undergraduate studies at the University of South Carolina, which ultimately honored her with their Distinguished Alumna Award. She received her medical education at the Medical College of South Carolina (now the Medical University of South Carolina). She began her postgraduate training in Ob/Gyn, which apparently is where she developed her interest in congenital, perinatal and neonatal infectious diseases.

She subsequently pursued this field at Duke University and obtained a position at Baylor College of Medicine in 1955. Within a few years, she and her first husband, Ellard Yow, MD, (who died in 1965) worked together to help contain and eradicate an outbreak of penicillin-resistant Staphylococcus aureus infections. Her other areas of interest and work included group B strep, congenital cytomegalovirus and rubella. In 1967, Dr. Yow established one of the country’s first pediatric infectious diseases sections and subsequently, fellowship training at Baylor. Another leader in the field, Carol J. Baker, MD, who also trained in pediatric infectious diseases at Baylor, currently holds the position. Baker is also a modern day pioneer in advancing the science of preventing and treating neonatal infections. From 1970 to 1978, Dr. Yow was a member of the prestigious Committee on Infectious Diseases of the AAP, which she chaired from 1976 to 1978. She went on to serve on committees at the NIH and functioned as editor in chief of The Journal of Infectious Diseases from 1984 to 1989, and received the Infectious Diseases Society of America’s (IDSA) Society Citation in 1988. In 1997, Dr. Yow published her memoirs, Balancing Act: Memoirs of a Southern Woman Doctor, which can still be purchased on Amazon.com.

Dr. Yow died on May 29 of this year secondary to complications of Parkinson’s disease. She is survived by her husband, Dr. Robert Roessler, three children, two stepchildren and several grandchildren and step-grand children. She is also survived by the many pediatricians and pediatric infectious disease specialists who were trained and/or influenced by her teaching, and the countless patients who benefited by her touch. Memorials can be sent to the Ellard Yow Memorial Library Fund, The Methodist Hospital, 6565 Fannin, MS D204, Houston, Texas 77030, c/o Linne Girouard, MLIS, AHIP, or phone 713-441-2229.

Most of the above information on Dr. Yow was obtained from the AAP and the IDSA.

Lastly, I feel compelled to point out that there are literally dozens of Army pediatricians on the ground in Iraq and Afghanistan, most of whom are recently trained, practicing in very austere conditions.

Getting an exact count is difficult due to security reasons, and I have no idea how many Navy and Air Force pediatricians are deployed. But I think it is safe to say that there are many, highly qualified pediatricians from all three services working there. The same can be said of the surgeons, internists, obstetricians, family physicians, dermatologists and more. Little do the civilian parents of the sick and injured know that their children are receiving care from some of the brightest young doctors in the world, many of whom will return to pursue outstanding careers, which we will be reading about for decades to come. Perhaps there is a developing pioneer or two in the group. I still receive many letters each month with stories from the war. Some are literally heartbreaking and hard to read, but I still hope to continue getting the feedback. So, please keep in touch.

Follow-up: The Uniformed Services Pediatric Seminar, which was to be in Biloxi, Miss. will now be in mid-March in Portsmouth, Va. More to come.