Letters to the Editor / International Journal of Pediatric Otorhinolaryngology 75 (2011) 721–724
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means of a framework of actions aging at a national level as well as at international ones. Reference [1] D. Gregori, The Susy Safe Project. A web-based registry of foreign bodies injuries in children, Int. J. Pediatr. Otorhinolaryngol. 70 (2006) 1663–1664.
Francesca Foltran Dario Gregori* Laboratories of Epidemiological Methods and Biostatistics, Department of Environmental Medicine and Public Health, University of Padova, Via Loredan 18, 35131 Padova, Italy Desiderio Passali Department of Otolaryngology, University of Siena, Italy *Corresponding author. Laboratories of Epidemiological Methods and Biostatistics, Department of Environmental Medicine and Public Health, University of Padova, Padova, Italy Tel.: +39 02 00612711; fax: +39 02 700445089 E-mail addresses:
[email protected] [email protected] (Dario Gregori) 17 April 2010 Available online 26 May 2010 doi:10.1016/j.ijporl.2010.04.013
Fig. 1. Incidence of acute mastoiditis per year. Blue line refers to a previous study, orange line refers to new cases. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of the article.)
years old, who are commonly affected by acute otitis media; difficulties in organizing it are not so rare. A largely shared study on the treatment of acute otitis media is necessary. References [1] M.B. Benito, B.P. Gorricho, Acute mastoiditis: increase in the incidence and complications, Int. J. Pediatr. Otorhinolaryngol. 71 (7) (2007) 1007–1011. [2] A.B. Salgueiro, M.J. Brito, C. Luis, M. Do Ceu Machado, Mastoiditis in the pediatric age, Acta Pediatr. Port. 38 (2007) 257–261.
S. Palma* ENT Department, University Hospital Modena
Letter to the Editor
E. Desiderio E. Fiumana Department of Paediatrics, University Hospital Ferrara
Acute mastoiditis in children. An increasing entity? Recent papers suggest [1,2] a renewed increase in the incidence of acute mastoiditis in children over the last few years. A retrospective study was carried out with the aim to investigate the incidence in our country: all the case sheets of the children admitted to Paediatrics, at the University Hospital of Ferrara from January 1994 to December 2008 (Fig. 1) were examined. In our county infant population has been quite stable during the last few years, around 13.000 resident children (with age from 0 to 14 years), the incidence resulted 0.13:1000. Thompson et al. in a similar period of observation reported 0.2:1000. On the basis of the results our study cannot confirm a real increase of the incidence of acute mastoiditis, a cycling transmission of the strains can explain the ongoing of the graphics. Although the decrease of acute mastoiditis in the industrialized countries since the introduction of antibiotics, the morbidity and mortality rate still are unaltered as levels of resistance are present. In some countries, probably due to local habits or to a diffusion of certain particularly resistant bacterial strains, it seems to be on the increase. Starting from the point that more data are necessary to better understand the phenomenon, small differences in calculating the incidence can be explained since most are retrospective studies; moreover immigration can cause large amount of infant population in relatively short time. The problem seems to be still an appropriate use of antibiotics. Benito suggests that tympanocentesis for middle ear culture could be more frequently used, but it is often difficult for parents to accept the necessity of such a procedure in children below two
R. Bovo M. Rosignoli Audiology Department, University Hospital Ferrara A. Martini ENT Department, University Hospital Padova *Corresponding author. Tel.: +39 0594222402; fax: +39 051490115 E-mail address:
[email protected] (S. Palma) Available online 15 December 2010 doi:10.1016/j.ijporl.2010.10.024
Letter to the Editor Cervicofacial lymphadenitis caused by nontuberculous mycobacteria; host, environmental or bacterial factors? Sir, In a recent issue of the Journal, Dr. Haverkamp and colleagues presented an interesting study on host immunity genes and their potential importance in cervicofacial lymphadenitis caused by
Letters to the Editor / International Journal of Pediatric Otorhinolaryngology 75 (2011) 721–724 c
Table 1 Mean age of patients with NTM lymphadenitis, by species. Species/complex
Mean age (months)
M. kansasii (n = 12) M. avium (n = 178) MAC-X (n = 31) M. malmoense (n = 14) M. haemophilum (n = 39) Total (n = 274)
31 20 34 20 38 21 40 19 69 42 40 27
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Department of Pulmonary Diseases, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
*Corresponding author at: Department of Clinical Microbiology, Radboud University Nijmegen Medical Center, Geert Grooteplein 21, PO Box 9101, 6500 HB Nijmegen, The Netherlands. Tel.: +31 24 3616484 E-mail address:
[email protected] (J. van Ingen). 13 December 2010 Available online 5 March 2011
nontuberculous mycobacteria (NTM). They concluded that environmental factors may be more important than genetic constitution. In addition, they stated that the observed association between the +3953TT mutation in the IL1b gene and NTM lymphadenitis and periodontitis suggests that oral exposure to mycobacteria during eruption of teeth may play a role in the etiology of cervicofacial NTM lymphadenitis [1]. What is left out of the equation here is the bacteriological factor; age related risk factors (such as eruption of teeth) interplay with age-dependent environmental exposures. The species diversity and virulence of NTM met in these environments (water, soil, pets, etc.) are likely to determine whether infection is established and by which organism. To find evidence for this hypothesis, we have retrieved all primary NTM isolates from cervicofacial lymph nodes in children aged 12 years or younger from the years 2000 through 2009 from our reference laboratory database in the Netherlands. We divided these isolates by species and compared the mean ages (in months) of the patients involved. We found a total of 293 patients; Mycobacterium avium (n = 178), M. avium complex isolates other than M. avium, Mycobacterium intracellulare or Mycobacterium chimaera (MAC-X, n = 31), Mycobacterium haemophilum (n = 39), Mycobacterium malmoense (n = 14) and Mycobacterium kansasii (n = 12) were the most frequent causative agents and rapid growers were isolated from seven patients only (3 Mycobacterium fortuitum, 2 Mycobacterium chelonae, 2 Mycobacterium abscessus; total 2.4%). For the five most frequent causative agents, mean patient age differs significantly (see Table 1). Patients with M. avium lymphadenitis are significantly younger than those with M. haemophilum, the second most common causative agent (2 yr 10 mo vs. 5 yr 9 mo; t = 10.9; 95%CI 2.46–3.54; p < 0.00001); MAC-X is a grouping, rather than a species. We conclude that the bacteriological factor should be considered in the etiology of NTM lymphadenitis; the predominance of slow growing NTM hints at the importance of bacterial (virulence) factors. Moreover, different species cause lymphadenitis in children of different ages. Age-related environmental exposures likely determine the causative agent. If eruption of teeth is a risk factor, it is less likely to pertain to M. haemophilum, as this species infects children above the teething age. The etiologies of NTM lymphadenitis differ by species. Reference [1] M.H. Haverkamp, J.A. Lindeboom, A.W. de Visser, D. Kremer, T.W. Kuijpers, E. van de Vosse, et al., Nontuberculous mycobacterial cervicofacial lymphadenitis in children from the multicenter, randomized, controlled trial in The Netherlands: relevance of polymorphisms in candidate host immunity genes, Int. J. Pediatr. Otorhinolaryngol. 74 (2010) 752–754.
Jakko van Ingena,b,c,*, Dick van Soolingena,b,c National Mycobacteria Reference Laboratory, National Institute for Public Health and the Environment, Bilthoven, The Netherlands b Department of Clinical Microbiology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands a
doi:10.1016/j.ijporl.2011.01.032
Letter to the Editor Reply to: Nontuberculous mycobacterial cervicofacial lymphadenitis in children from the multicenter, randomized, controlled trial in the Netherlands: Relevance of polymorphisms in candidate host immunity genes Dear Sir, We agree fully with the remark of Dr. van Ingen and Dr. van Solingen that bacterial virulence determinants may play a role in the pathogenesis of nontuberculous mycobacterial (NTM) infections in children, aside from environmental and genetic factors. They indicate that slow-growing mycobacteria cause the majority of NTM infections in children and that the mean age of children with M. avium lymphadenitis differs significantly from that of children with M. haemophilum. From the set of data they present, it strikes us that the mean age of children with lymphadenitis due to NTM infection other than M. haemophilum is quite similar. Importantly, the M. haemophilum patients alluded to in the letter constitute Dutch children from a specific, as yet enigmatic, outbreak in the Netherlands that took place in 2004 in a limited geographical area (Amsterdam and surrounding areas). This group was described by Lindeboom et al. who highlighted the age difference between the children infected with M. haemophilum and those infected with M. avium. [1] Although we agree with the authors that in mycobacterial lymphadenitis, bacterial factors likely act in concert with host genetic and environmental conditions, we question whether the higher age at infection in this unique and selected group of M. haemophilum infected children offers best proof for a differential age-related susceptibility to pediatric NTM infection, and could be regarded as in disagreement with our hypothesis. Although teething occurs around the age of 2, most commonly cited for NTM lymphadenitis, the shedding of milk-teeth starts at age 5 or 6 and thus could provide a porte d’entre´e for other infections, such as caused by M. haemophilum. As of yet, little is known for certain regarding the factors leading to NTM lymphadenitis in children. Indeed, the finding that slow-growing NTM outnumber rapidgrowers in pediatric lymphadenitis, [2] might relate to differences among these strains in invasive bacterial virulence characteristics, or, just as likely, to their specific ability to trigger an inflammatory proliferative response at the center of the host’s immune system, a lymphnode. References [1] J.A. Lindeboom, J.M. Prins, E.S. Bruijnesteijn van Coppenraet, R. Lindeboom, E.J. Kuijper, Cervicofacial lymphadenitis in children caused by Mycobacterium haemophilum, Clin. Infect Dis. 41 (2005) 1569–7155.