THE AETIOLOGY OF ACUTE CERVICAL ADENITIS IN CHILDREN: SEROLOGICAL AND BACTERIOLOGICAL STUDIES

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1 1. MED. MICROBI0L.-VOL. 13 (1980), The Pahologcal Socey of Grea Bran and Ireland /80/ $02.00 THE AETIOLOGY OF ACUTE CERVICAL ADENITIS IN CHILDREN: SEROLOGICAL AND BACTERIOLOGICAL STUDIES T. YAMAUCHI*, PATRICIA FERRIERI~ AND B. F. ANTHONY* *Deparmen of Pedarcs, Harbor General Hospal, UCLA School of Medcne, Torrance, Calforna, and he 1 Unversy of Mnnesoa Medcal School, Mnneapols, Mnnesoa, USA ACUTE cervcal adens n chldren connues o be a common problem n paedarc medcne. The bacera mos commonly mplcaed have been group-a srepococc and Saphylococcus aureus. There s, however, some uncerany n decdng whch of hese organsms s he prmary pahogen causng cervcal adens (Dajan, Garca and Wolnsky, 1963; Scobe, 1969; Brook and Wner, 1971; Baron and Fegn, 1974; Wald and Svasubramanan, 1976). Prevous sudes have demonsraed ha he majory of saphylococc solaed n hs llness are ressan o penclln, alhough penclln connues o be he drug of choce for group-a srepococcal nfecons (Breese, 1953; Goodman and Glman, 1958; Sllerman e al., 1960; Breese, Dsney and Talpey, 1965). Ths sudy was underaken o deermne he aeology of acue cervcal adens n chldren because successful anboc herapy depends on knowledge of he specfc suscepbly of he organsms nvolved. MATERIAL AND METHODS Thepaens. The sudy populaon was seleced from chldren 15 years of age or less who were seen n he Acue Care Clnc a Harbor General Hospal wh a hsory of cervcal mass of 72-h duraon or less. Durng a 33-monh perod, 26 chldren me he crera for admsson o he sudy: (1) he presence of an aneror neck mass of a leas 2 cm dameer whch was ender and hough o be flucuan, and (2) he absence of anboc herapy for he 2 weeks before he sudy. A dealed hsory and examnaon was performed and nformed consen was obaned from he paren or guardan of every chld. All chldren had he followng laboraory sudes: nose and hroa culures, nradermal skn ess wh he equvalence of 5 uberculn uns of PPD-S, PPD-B, PPD-G and PPD-Y (wh mycobaceral skn-es angens provded by Dr Lyda Edwards of he Uned Saes Publc Healh Servce), whe blood-cell coun, and eryhrocye sedmenaon rae. In addon, many chldren had blood culures, oher nraderma1 skn ess (coccdodn, hsoplasmn, blasococcn and ca-scrach), ches roengenogram, urnalyss and nfecous mononucleoss slde es (Orho Dagnoscs Inc., Raran, NJ, 08869). Afer lymphnode aspraon, all chldren were reaed wh anbocs for 7-10 days a he Receved 8 Feb. 1979; acceped 4 June f Presen address: Arkansas Chldren s Hospal, 804 Wolfe Sree, Lle Rock, Arkansas 72201, USA. Requess for reprns should be sen o Dr Yamauch a hs address. 37

2 38 T. YAMAUCHI, PATRICIA FERRIERI AND B. F. ANTHONY dscreon of he house saff. Anbocs used ncluded: ampclln (75 mg/kg daly n four dvded doses), cloxaclln (25-50 mg/kg daly n four dvded doses) or penclln (25-75 mg/kg daly n four dvded doses). Two hospalsed chldren receved mehclln ( mg/kg daly n four dvded doses). Needle aspraon of he cenre of a sngle mass, or he larges of several masses, was aemped on every chld ncluded n hs sudy. Needle aspraon and culure. Afer careful preparaon of he overlyng skn wh odne and alcohol and whou anaeshesa, he node was enered wh a serle l+-nch (38 mm) 20-gauge needle aached o a serle 10-ml syrnge. If maeral was no obaned, he needle was rnsed wh hoglycollae broh whch was noculaed ono plaes of sheep blood, chocolae and Sabouraud s agar, no ubes of hoglycollae and bran-hear nfuson broh, and ono Loewensen-Jensen slans. Any aspraon maeral was examned by Gram s and acd-fas srans and noculaed as descrbed above. In addon, sx aspraes were culured for anaerobc organsms wh pre-reduced anaerobc meda (Sco Laboraores). Group-A srepococc were enavely denfed wh bacracn dscs (Hyland Laboraores). All coagulase-posve saphylococc were desgnaed S. aureus. Anboc sensves were esed by he sandardsed dsk mehod of Bauer e al. (1966). The node aspraes and hroa swabs of several chldren were culured for vruses on he followng cell culure lnes: HeLa, green-monkey kdney, human amnon, and WI-38 fbroblass. Serology. Acue and convalescen sera from 19 chldren were examned for anbodes o one or more srepococcal angens. Ansrepolysn-0 was measured by a modfcaon of he mcromehod of Edwards (1964), andeoxyrbonuclease B (an-dnaase B) by he mehod of Nelson, Ayoub and Wannamaker, 1968) and annconamde adenne dnucleodase (an- NADase) by he echnque of Kellner, Freeman and Carlson (1958), as modfed by Ayoub and Wannamaker (1962) and Ayoub and Ferre (1966). Boh serum samples from each paen were esed smulaneously. Sngle res above 240 were consdered elevaed, and a sgnfcan rse n anbody re was defned as wo or more dluon ncremens n seral bleedngs. RESULTS Bacerologcal sudes The resuls of he bacerologcal sudy of maeral obaned by needle aspraon of cervcal lymph nodes are shown n able I. Only hree of 26 lymph nodes were culure negave. S. aureus or group-a srepococc or boh were solaed from 22 (84.6%) of 26 nodes. S. aureus was solaed n pure culure from he lymph nodes of 17 chldren (654%). Group-A srepococc were solaed as a sngle solae n only four cases (15.4%). One asprae yelded S. aureus and group-a srepococc. Of he 18 saphylococcal solaes, TABLE I Bacerologcal culure of needle aspraes from 26 cervcal lymph nodes GroupA srepococc 4 ( 15.4) S. aueus and group-a srepococc l(3-8) Mycobacerum kansas lj3.8) No growh 3 (11.5) Toal 26 I

3 TABLE I1 Resuls* of srepococcal anbody sudes Organsm solaed from lymph node Paen Saphylococcus aureus Group-A srepococcus 7-monh male 1 -year female +-year male 5-monh male 3-year male 5-year male 2$-year male 3-year male +year male 2-year female 6-year male I Tre of ansrepolysn-0 Tre of an-dnaase B Tre of an-nadase Acue Convalescen Acue Convalescen Acue Convalescen I * Sx chldren had no anbody elevaon or change on seral deermnaon; four chldren dd no provde convalescen sera. One chld, whose lymph-node asprae yelded no growh, had a rased re of ansrepolysn-0 a he me of aspraon. T = Elevaed or sgnfcan rse.... = No esed.

4 40 T. YAMAUCHI, PATRICIA FERRIERI AND B. F. ANTHONY 15 were ressan o penclln. No anaerobc organsm was solaed from he sx aspraes suded. Mycobacerum kansas was found n one asprae. Gram-posve cocc were demonsraed n saned smears n 14 (63.6%) of 22 lymph-node aspraes. Bacera were always solaed by culure when organsms were seen on he saned smears. On several occasons, as expeced, aspraes ha faled o exhb organsms by gram san subsequenly yelded organsms n culure. The aypcal mycobacerum was nally demonsraed by acd-fas sanng and was laer obaned n culure. Only wo of he 26 hroa culures yelded group-a srepococc. One of hese chldren also yelded group-a srepococc from an nfeced lymph node and he oher had S. aureus n he lymph-node asprae. Vrologcal sudes Vrus was solaed from he hroa of wo chldren n whom S. aureus was solaed from node aspraes, nfluenza A from one and respraory syncyal vrus from he oher. Sx node aspraes culured for vruses were negave. Serologcal sudes All four chldren whose nodes yelded only group-a srepococc had a sgnfcan elevaon, or change on seral esng, of a leas one of he srepococcal anbodes. I s of greaer neres ha seven of 17 paens wh S. aureus n aspraes exhbed an mmune response o one or more srepococcal angens (able 11); sx ohers had no anbody elevaon or change on seral deermnaons; convalescen sera were no obaned from he remanng four paens. Neher he chld wh mxed saphylococcal and srepococcal node solaes nor he chld wh aypcal mycobaceral nfecon had elevaed AS0 res a he me of aspraon. Addonal sera for srepococcal anbodes were no obaned from eher of hese paens. Of he hree paens wh serle node aspraes one had a srepococcal anbody response. Clncal jndngs The clncal fndngs n chldren wh culure-proven S. aureus or srepococcal nfecons of lymph nodes were no dfferen. Temperaure, whe blood-cell coun and eryhrocye sedmenaon rae were all elevaed. DISCUSSION Earler sudes on he pahogeness of cervcal adens n chldren ndcaed ha group A-srepococc were he mos commonly solaed organsms (Powers and Bosver, 1944; Adamson, 1949; Dajan e al., 1963). More recenly, clncal nvesgaors have quesoned he srepococcal aeology of cervcal adens n chldren. Scobe (1969) revewed 946 cases of acue suppurave adens n chldren and arbued 67% o saphylococc. He con-

5 BACTERIOLOGY OF ACUTE CERVICAL ADENITIS 41 cluded from hese observaons ha he saphylococcus had replaced he srepococcus as he mos common nfecng organsm causng nflammaory lymph-node dsease. More recenly, Baron and Fegn (1974), repored 76 cases of cervcal adens, wh S. aureus n 36% of lymph-node aspraes and only 25% arbuable o srepococcal dsease. In he sudes of Scobe and of Baron and Fegn, pror anboc herapy had been gven o some paens and neher sudy rounely sough serologcal evdence of srepococcal nfecon. In our repor, 19 of he 26 chldren had serologcal sudes n addon o culure of lymph-node aspraes. Because he AS0 re alone may no accuraely reflec recen srepococcal nfecon, mulple seral anbody deermnaons were performed n mos of our paens. The dagnosc value of srepococcal anbodes has been well defned n he leraure (Sollerman e al., 1956; Kaplan e al., 1971; Bsno e al., 1973; Dllon and Reeves, Alhough n hs seres we repor only four cases of pure group A-srepococcal culure from lymph nodes, all four chldren had eher a sgnfcan elevaon of srepococcal anbody nally, or a sgnfcan change of re of one or more of he srepococcal anbodes durng he course of reamen. More neresngly, alhough S. aureus was he only solae n 17 cases (65.6%), seven of hese chldren (able 11) had serologcal evdence of a recen srepococcal nfecon. Thus, by employng boh bacerologcal and serologcal crera for esablshng he aeology of cervcal adens we found ha group-a srepococc were concerned n 13 (50%) of he nfecons: four pure baceral culures, one mxed culure and egh posve by serology. The recovery of nfluenza A from one chld wh cervcal adens and respraory syncyal vrus from anoher rases he possbly ha vruses may have a role n he aeology of hs dsease. Several vruses have already been mplcaed n he pahogeness of lymphadenopahy (Krugman, 1965; Debre and Celers, 1970; Henle and Henle, 1973). Alhough we were unable o solae vrus from several lymph-node aspraes, hs remans an neresng area of speculaon and needs furher nvesgaon. The majory of paens n hs sudy were reaed wh penclln or ampclln (Krugman, 1965; Dllon and Reeves, 1974), and despe he hgh prevalence of penclln-ressan saphylococc almos all chldren mproved clncally wh hs herapy. Ths fndng s conssen wh he work of Markowz and Dllon (Markowz e al., 1965; Dllon, 1970), who repored unformly effecve reamen of srepococcal mpego wh penclln despe he presence of penclln-ressan saphylococc. An analogy can be made wh he exensve epdemologcal sudes of nonbullous mpegnous lesons whch sugges ha alhough srepococc and saphylococc may coexs n lesons, he saphylococc play a subsdary role as secondary nvaders. Dajan e al. (1963) also repored solaon of pencllnressan saphylococc alone and n combnaon wh srepococc from paens wh cervcal adens and suggesed ha he saphylococcus was a co-nvader. I s dffcul o deermne he exac role of saphylococc n hese cervcal lymph-node nfecons. In hs sudy, sx chldren yelded S. aureus from her cervcal lymph nodes and had no change of srepococcal anbody re on

6 42 T. YAMAUCHI, PATRICIA FERRIERI AND B. F. ANTHONY seral deermnaon. A relable saphylococcal-anbody es would be useful n deermnng he sgnfcance of hese culures. One mgh speculae ha he S. aureus was ranspored from he hroa va lymphacs, hereby causng suppuraon and nfecons of he lymph nodes. S. aureus has no, however, been relaed o onslls-pharyngs n he hos. Moreover, he chldren n hs sudy wh saphylococcal dsease, hough few, dd no have respraory sympoms precedng her cervcal adens. In conras, he majory of chldren wh srepococcal cervcal lymph-node nfecons had respraory sympoms. By needle aspraon, culure and seral serologcal esng, we found ha 13 (50%) of he 26 cases n hs repor were assocaed wh srepococc. In sx of he chldren S. aureus was he only organsm recovered and appeared o be he aeologcal agen responsble for cervcal lymph-node nfecons. SUMMARY Acue cervcal adens was nvesgaed n 26 chldren over a 33-monh perod. Lymph nodes were aspraed and culured o yeld Saphylococcus aureus or group-a srepococc or boh from 22 (84.6%) of he aspraes. Mycobacerum kansas was solaed from one chld. By combned culure and seral serologcal ess (ansrepolysn-0, an- DNAase B, and an-nadase), 50% of he cases were found o be assocaed wh srepococcal nfecon. In a few chldren, S. aureus was he only organsm recovered, and appeared o be he aeologcal agen. Ths sudy was sponsored n par by Tranng Gran no. TolA from he Naonal Insue of Allergy and Infecous Dsease, a General Research Suppor Gran o he Professonal Saff Assocaon; Harbor General Hospal, from he Uned Saes Publc Healh Servce; and a research gran from he Uned Saes Publc Healh Servce, AI Dr Ferrer was suppored n par by gran no. HL from he Uned Saes Publc Healh Servce. REFERENCES ADAMSON, C. A Bacerologcal sudy of lymph nodes: analyss of posmorem specmens wh parcular reference o clncal, serologcal and hsopahologcal fndngs. Aca med. scand., 133 (suppl. 227), 1. AYOUB, E. M. AND FERRETTI, J. J Use of bsulfe n he srepococcal annconamde adenne dnucleodase es. Appl. Mcrobol., 14,391. AYOUB, E. M. AND WANNAMAKER, L. W Evaluaon of he srepococcal desoxyrbonuclease B and dphosphopyrdne nucleodase anbody ess n acue rheumac fever and acue glomerulonephrs. Pedarcs., 29,527. BARTON, L. L. AND FEIGIN, R. D Chldhood cervcal lymphadens: a reapprasal. J. Peda., 84,846. BAUER, A. W., KIRBY, W. M. M., SHERRIS, J. C. AND TURCK, M Anboc suscepbly esng by a sandardzed sngle dsc mehod. Am. J. dn. Pah., 45,493. BISNO, A. L., NELSON, K. E., WAYTZ, P. AND BRUNT, J Facors nfluencng serum anbody responses n srepococcal pyoderma. J. lab. dn. Med., 81,410. BREESE, B. B Treamen of bea-hemolyc srepococcc nfecons n home: relave value of avalable mehods. J. Am. med. Ass., 152, 10.

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