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Tubercular lymphadenitis

      Case presentation

      A 46-year-old male presented with gradually progressive swelling and discharge from both sides of his neck of 2 months duration. He also had a history of intermittent low-grade fever and weight loss for 2 months. Examination revealed multiple matted, firm to soft swellings on both sides of the neck associated with discharging sinuses bilaterally (Figure 1). Ziehl-Neelson staining of the discharge revealed acid-fast bacilli. The lymph node along with the sinus tracts and overlying skin were excised and post histopathology of the specimen showed epithelioid cell cluster (white arrow) and multinucleated giant cells (black arrow) surrounded by lymphoid cells, confirmatory of tubercular lymphadenitis (Figure 2). The patient was started on anti-tubercular drugs, which continued for 6 months and he is asymptomatic at 1-year follow-up.
      Tuberculous lymphadenitis is the most common extra pulmonary manifestation of tuberculosis, most commonly caused by Mycobacterium tuberculosis.1  Cervical lymph nodes are the most common site of involvement and are reported in 60% to 90% of patients with tubercular lymphadenitis.
      • Gupta V
      • Bhake A.
      Clinical and cytological features in diagnosis of peripheral tubercular lymphadenitis - A hospital-based study from central India.
      Children and young adults are mostly affected and there is a female preponderance. Patients with HIV have an increased frequency of lymphadenitis. Cervical lymph node involvement may either be due to spread from a pulmonary focus or a focus in the tonsils or adenoids.
      • Gupta V
      • Bhake A.
      Clinical and cytological features in diagnosis of peripheral tubercular lymphadenitis - A hospital-based study from central India.
      Classically, patients present with low-grade fever, weight loss, fatigue, and night sweats.
      Jones and Campbell classified peripheral tuberculous lymph nodes into five stages; stage 1, enlarged, firm, mobile, discrete nodes showing non-specific reactive hyperplasia; stage 2, large rubbery nodes fixed to surrounding tissue owing to periadenitis; stage 3, central softening due to abscess formation;  stage 4, collar-stud abscess formation and stage 5, sinus tract formation. The differential diagnosis includes various lymphadenitis like viral, bacterial or fungal, neoplasm like lymphoma or metastatic lymph nodes, sarcoidosis, toxoplasmosis, etc.
      • Gupta V
      • Bhake A.
      Clinical and cytological features in diagnosis of peripheral tubercular lymphadenitis - A hospital-based study from central India.
      ,
      • Rai DK
      • Kumar R
      • Ahmad S.
      Clinical characteristics and treatment outcome in Tubercular lymphadenitis patients- A prospective observational study.
      The diagnosis can be made by smears obtained from a draining sinus or by FNA. Ziehl-Neelsen staining of the smears may reveal mycobacteria.
      • Rai DK
      • Kumar R
      • Ahmad S.
      Clinical characteristics and treatment outcome in Tubercular lymphadenitis patients- A prospective observational study.
      Biopsy of the nodes may be required if FNA is not conclusive, which will show typical tuberculous granuloma consisting of giant multinucleated cells (Langhans cells), surrounded by epithelioid cells and central caseating necrosis.
      • Gupta A
      • Kunder S
      • Hazra D
      • et al.
      Tubercular lymphadenitis in the 21st century: A 5-Year single-center retrospective study from South India.
      • Gupta V
      • Bhake A.
      Clinical and cytological features in diagnosis of peripheral tubercular lymphadenitis - A hospital-based study from central India.
      • Rai DK
      • Kumar R
      • Ahmad S.
      Clinical characteristics and treatment outcome in Tubercular lymphadenitis patients- A prospective observational study.
      The treatment is mainly by administering antitubercular drugs for 6 months, although a longer duration may be required in some cases.
      • Gupta A
      • Kunder S
      • Hazra D
      • et al.
      Tubercular lymphadenitis in the 21st century: A 5-Year single-center retrospective study from South India.
      • Gupta V
      • Bhake A.
      Clinical and cytological features in diagnosis of peripheral tubercular lymphadenitis - A hospital-based study from central India.
      • Rai DK
      • Kumar R
      • Ahmad S.
      Clinical characteristics and treatment outcome in Tubercular lymphadenitis patients- A prospective observational study.
      Surgical therapy is limited to incision and drainage of abscess, a biopsy of lymph nodes, and surgical excision of affected lymph node and sinus tract.

      Source of Funding

      None.

      Conflicts of Interst

      None.

      References

        • Gupta A
        • Kunder S
        • Hazra D
        • et al.
        Tubercular lymphadenitis in the 21st century: A 5-Year single-center retrospective study from South India.
        Int J Mycobacteriol. 2021; 10: 162-165https://doi.org/10.4103/ijmy.ijmy_66_21
        • Gupta V
        • Bhake A.
        Clinical and cytological features in diagnosis of peripheral tubercular lymphadenitis - A hospital-based study from central India.
        Indian J Tuberc. 2017; 64: 309-313https://doi.org/10.1016/j.ijtb.2016.11.032
        • Rai DK
        • Kumar R
        • Ahmad S.
        Clinical characteristics and treatment outcome in Tubercular lymphadenitis patients- A prospective observational study.
        Indian J Tuberc. 2020; 67: 528-533https://doi.org/10.1016/j.ijtb.2020.07.021