IMAGING OF GRANULOMATOUS LESIONS OF THE NECK IN CHILDREN

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Granulomatous lesions of the neck are common in children. The granulomatous response is a generic reaction to the presence of a persistent endogenous or exogenous insoluble irritant, which is dependent on the state of the host's immune system.4 Granulomatous inflammation is a specific type of chronic inflammation characterized by accumulations of modified macrophages called epithelioid cells. Granulomatous lesions are usually infectious in origin and are classified according to the causative organism as bacterial, fungal, or parasitic in nature. Granulomatous inflammation is one of the more common findings in chronically enlarged, surgically excised lymph nodes in children.

In adults tuberculosis (TB), nontuberculous mycobacteria (NTM), sarcoidosis, fungal infections, rheumatoid disease, and foreign body inclusions cause the majority of cases of granulomatous lymphadenitis. Less common causes of granulomatous inflammation include brucellosis, schistosomiasis, syphilis, and leprosy. In children in the United States, NTM infection accounts for most granulomatous lesions of the head and neck.4 Because different organisms (e.g., Mycobacterium tuberculosis and NTM) can cause histologically indistinguishable nodal disease, a thorough history and physical examination are essential diagnostic requirements. Although a presumptive diagnosis can be made based on clinical features, imaging and histopathologic examination, a definitive diagnosis may prove elusive because special stains and culture may fail to demonstrate the causative agent.4 Preoperative imaging is used to evaluate for the extent of mass lesions, to document distortion or narrowing of the airway and vessels, and to delineate osseous involvement.

Section snippets

NTM INFECTION

Mycobacterial infections are usually separated into TB caused by M. tuberculosis and NTM infection caused by all mycobacterial species other than M. tuberculosis. The most common NTM (or atypical mycobacteria) are M. avium-intracellulare, M. scrofulaceum, M. bovis, and M. kansasii. The term scrofula has been applied to cervical lymphadenitis caused by M. tuberculosis and M. bovis, but is currently used to describe any mycobacterial lymphadenitis.33

A wide variety of diseases are caused by NTM,

TB

TB is an unusual cause of cervical lymphadenopathy in children in the United States, and is largely seen in children with AIDS or in immigrants from countries where TB is still a widespread problem.18

TB of the neck usually produces painless bilateral posterior triangle and internal jugular adenitis.26 Involvement of other regions, however, such as the submental and submandibular nodes, may occur. The larynx, pharynx, and thyroid gland are occasionally infected. Unlike NTM adenitis, TB adenitis

CAT-SCRATCH DISEASE

Cat-scratch disease (CSD) is a relatively common granulomatous disease that affects an estimated 2000 people in the United States each year. CSD occurs worldwide without racial or sexual predilection, and is primarily a disease of children. The causative organism is Bartonella henselae, a gram-negative bacillus.6 The spectrum of diseases caused by Bartonella species has expanded and now includes CSD, bacillary angiomatosis, bacillary peliosis, bacteremia, endocarditis, and trench fever.38 A

TULAREMIA

Tularemia is a zoonozis caused by Francisella tularensis, a small gram-negative bacillus. The disease has been described in Europe, Japan, and all parts of the United States.23 The disease is transmitted to humans by direct contact with infected animal material (e.g., from rabbits, hares, or muskrats); by insect bites (e.g., ticks, mosquitoes, or deerflies); by inhalation; or by the oral route (e.g., eating infected rabbit).21, 23

The initial clinical manifestations occur after an incubation

HISTOPLASMOSIS

Histoplasmosis is the most common endemic respiratory mycosis in the United States, where it is most prevalent in the major river valleys of the central and southern states.10, 22 Histoplasmosis is caused by the fungus Histoplasmosis capsulatum. The fungus is associated with avian droppings and is contracted through inhalation of airborne spores. In most patients the primary infection is asymptomatic and the disease is self-limited. When symptoms do occur, they are generally nonspecific and

SARCOIDOSIS

Sarcoidosis is a chronic multisystem noncaseating granulomatous disorder of uncertain cause. Although any organ system can be involved, the lungs, lymph nodes, skin, eyes, and salivary glands are most frequently affected.29 The most common otolaryngologic manifestations are neck masses, parotid masses, and facial nerve palsy.33 Cervical nodes are the most commonly involved peripheral lymph nodes in sarcoidosis. Cervical adenopathy is typically bilateral with mobile, nontender nodes. Involvement

SUMMARY

Cervical lymphadenopathy is the most common presentation of granulomatous inflammation of the neck in children and is usually caused by NTM infection. Although certain granulomatous infections have characteristic imaging features, there is considerable overlap in the imaging appearance of the various disorders. The diagnosis is usually based on a combination of clinical features, histopathologic examination, serologic tests, and culture results.

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    Division of Neuroradiology, Department of Radiology, Children's Hospital; and Harvard Medical School, Boston, Massachusetts

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