Indistinct skin lesion on the cheek of a two-year-old

Introduction Atypical mycobacterioses are infections caused by non-tuberculous mycobacteria. In children, the cervical lymph nodes are most commonly affected, but also manifest submandibular or preauricular nodes can be involved. However, the diagnostic and therapeutic management can be challenging.

Methods A two-year-old patient, healthy except for atopic dermatitis, presented with a livid, centrally exulcerated left preauricular skin lesion that had been present for about 6 months. Sonographically, the lesion was echoinhomogeneous and subcutaneously located. Magnetic resonance imaging revealed a swelling of the cutis with a narrow fistula extending towards the parotid gland with subtle contrast enhancement.

Results Intraoperatively, the altered skin was circumcised under monitoring of the facial nerve. The fistula was dissected up to a lymph node, that was in contact with the facial nerve. The tissue was completely excised. Histologically, a chronic, granulomatous, epithelioid cell lymphadenitis with formation of a fistula to the cutis was found. Ziehl-Neelsen staining and PCR showed no evidence of mycobacteriosis. However, the microbiological examination revealed an infection with wild-type Mycobacterium avium.

Discussion Complete removal of all affected lymph nodes is the treatment of choice for atypical mycobacteriosis. In this case, a preauricular infection was found. Despite the close proximity to the facial nerve, complete excision of the tissue with preservation of the facial nerve was successful without recurrence.

Publication History

Article published online:
13 May 2024