Granulomatous Lymphadenitis

Granulomatous inflammation of lymph nodes is the second most common finding in histological examination of peripheral lymph nodes. Reactive hyperplasia accounts for the most common finding. Granulomatous disease accounts for almost one-third of biopsies of cervical masses or lymph nodes in children. They are most commonly identified in the head and neck region. The granulomatous response is a generic reaction to the presence of a persistent endogenous or exogenous insoluble irritant characterized by accumulation of macrophages and dependent of the immune system of the host. Non-tuberculous mycobacteria (NTM) is the etiology of most cases of granulomatous lymphadenitis in children. In developed countries Mycobacterium Avium and Intracellulare accounts for most cases of NTM causing granulomatous lymphadenitis. NTM lymphadenitis in immunocompetent children is best managed with complete excision. Other causes of granulomatous lymphadenitis include tuberculosis, sarcoidosis, fungal infections, rheumatoid disease, Cat's scratch disease and foreign body inclusions. NTM are ubiquitous in the environment existing in soil and water (including tap water) and ingestion of contaminated material has been thought to be the principal route of cervicofacial infection in children. Children with NTM granulomatous lymphadenitis are commonly less than five years in age and more likely have multiple lymph nodes involvement in the preauricular/parotid or submandibular/submental area. Granulomatous inflammation in other sites (axilla and upper extremity, inguinal), or older than age 10 years rarely yielded a cause. Surgical excision of granulomatous lymphadenitis has a high cure rate. Surgical excision is also more effective therapy than prolonged antibiotic oral therapy. The complication rate of children who underwent surgical excision is higher including secondary staphylococcal infection and transient or permanent facial nerve damage reason why some physicians prefer to manage deep cervical lymph nodes with antibiotics and watchful waiting.  

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