General Data

Patient: JS
Age: 17 years old
Sex: Male
Civil Status: Single
Address: Island Garden City of Samal
Nationality: Filipino
Religion: Roman Catholic

Interview Details: July 27, 2017 – Southern Philippines Medical Center

TB-DOTS Clinic
Informant: Patient
Reliability: 90 percent

Chief Complaint: Lateral Neck Mass

History of Present Illness

One year prior to consult, patient noted enlarging mass on the right lateral area of the neck which he
described as about 5 x 3 cms in size, round, smooth, non tender, and movable. There were no other
associated signs and symptoms noted. No consultation was done. No medications were taken.

Six months prior to consult, patient noted onset of intermittent nonproductive cough, often associated
with body malaise and undocumented fever. The mass was also noted to be enlarging, about 6 x 4 cms in
size, round, smooth, nontender and movable. Patient was given by relatives with unrecalled antibiotics
which afforded no relief. No consultation was still done.

One month prior to consult, noted progressive enlargement of the mass, now at about 12 x 6 cms in size,
fixed, smooth, round, and nontender. Patient still noted intermittent non-productive cough. No fever,
night sweats, hemoptysis, or weight loss were noted. At this time, patient noted another enlarging neck
mass at the left lateral neck area, about 4 x 3 cms in size, round, smooth, movable, and nontender, hence
was brought by her Aunt for consultation.

Past Medical History

• No previous medical or surgical admissions
• No known comorbidities or any childhood illnesses
• No history of developmental delay
• No food and drug allergies
• Immunization Status: unknown; (+) BCG mark, right deltoid
• No known exposure to TB

Family History
• Maternal Side: (+) Diabetes Mellitus
• Paternal Side: (+) Hypertension
• (-) Bronchial Asthma
• (-) Thyroid Diseases
• (-) Malignancies
Personal and Social History
• Patient is the eldest among seven siblings. His father works as a Driver while his mother is
currently unemployed. The family has to frequently transfer residence due to his father’s job,
which cause him to often stop from schooling. Currently patient lives with his Aunt in Samal as a
personal choice, where he attends school as a Grade 7 student.
• Patient is non-smoker, non-alcoholic beverage drinker and denies any illicit drug use. Patient
works as a part-time Dishwasher at a nearby carenderia in their area. His hobby includes playing
basketball and hanging out with friends on his spare time. Patient has a male sexual orientation
and has had one sexual partner.

Review of Systems
Pertinent: (+) nonproductive cough
(+) body malaise
(+) fever (undocumented)
(-) weight loss
(-) hemoptysis
(-) night swears

Physical Examination Vital signs Measurement Interpretation

General: Patient is ambulatory, cooperative, coherent, not Heart Rate 86 bpm Normal
in respiratory distress
Respiratory 20 cpm Normal
Skin: Warm and moist with good skin turgor. Nail beds are Rate
pink with capillary refill time of less than 2 seconds. No Temperature 36.5°C Afebrile
jaundice, pallor, cyanosis, scars or ulcerations.
Blood 100/60 mmHg Normal
Head: Hair is black, soft, thick and equally distributed. Skull Pressure
is normocephalic and atraumatic. No infestations and lesions.
Anthropometric Measurement
Eyes: Symmetrical with no opacities or lesions noted. Pinkish Height 165 cm
palpebral conjunctiva. Pupils equally round and briskly
reactive to light and accommodation. Papillary size of 2- Weight 57 kgs
3mm. BMI 20.9
(Normal)
Ears: Pinnae without deformities, lumps, or skin lesions. No
discharges and lesions.

Nose: Nasal mucosa is pink. Nasal septum in midline. No sinus tenderness. Nostrils patent, without nasal
flaring. No nasal polyps, ulcers, or bleeding.

Mouth and Throat: Lips are dry and pink. Oral mucosa pinkish, moist, without ulcers, white patches, or
nodules. Tongue is pink, in the midline. Uvula is in the midline. No tonsillar hypertrophy or pharyngeal
exudates.
Neck: Trachea is in midline, without deviation. Thyroid gland normal in size moves up with swallowing.
Multiple enlarged cervical lymphadenopathies:
 Right: 12 x 6 cm, firm, smooth, movable, nontender
 Left: 4 x 3 cm, firm, smooth, movable, nontender
Chest: Chest is symmetrical, without deformities or retractions. Breathing is spontaneous, no retractions
or use of accessory muscles noted. No tenderness or masses noted. Tactile fremitus equal on all lung
fields. Decreased breath sounds on right lower lung field noted.

Heart: Adynamic precordium. No heaves, thrills noted. PMI at 5th intercostal space, midclavicular line.
Regular heart rate and rhythm, no murmurs noted.

Abdomen: Flat, no lesions, no masses noted. Normoactive bowel sounds. Tympanitic on percussion. No
hepatosplenomegaly noted. No tenderness and masses noted on palpation.
Musculoskeletal. Grossly normal extremities. No lesion s, no masses, no edema noted.

Salient Features

• Pertinent Positives
• 17 y/o, male, Filipino
• Low socio economic status
• Multiple enlarged cervical lymphadenopathies, nontender
• Intermittent nonproductive cough
• Body malaise and fever
• (+) decreased breath sounds, right lower lobe
• Pertinent Negatives
• No weight loss
• No hemoptysis, night sweats

Differential Diagnoses
• Nonspecific lymphadenitis.
• Lymphomas, and chronic lymphatic leukaemia.
• Branchial cyst mimics cold abscess.
• Lymph cyst mimics cold abscess.
• Pulmonary Tuberculosis
• Tuberculous Lymphadenitis

Management Done

PATIENT SEEN AT
OPD – DIAGNOSTIC
REFERRAL
DEPARTMENT OF IMAGING
PEDIATRICS

Patient was initially seen at the Department of Pediatrics – Outpatient Department. He was requested
with laboratory tests, including Chest-Xray and Sputum AFB with the following results:
 Initial Chest Xray: Bilateral Pneumonia with Consolidation,
Right. Cannot entirely rule out pulmonary mass in the right.
Short follow-up interval suggested with PA and Lateral View

DSSM - Negative

Patient followed-up at the Department of Pediatrics and was requested with Repeat Chest Xray and Fine
Needle Biopsy was done with the following results.

Bilateral Pneumonia with Hilar Lymphadenopathies, Right

Cytopathology Report: Acute and Chronic Inflammation with

Granulomatous Inflammation, consider Tuberculosis

Hence, patient was referred to SPMC- TB DOTS Clinic for start of Anti-Kochs Therapy.

FINAL DIAGNOSIS: EXTRA-PULMONARY TB- TUBERCULOUS LYMPHADENITIS

Discussion: Tuberculous Lymphadenitis
TB case notifications 2014, Philippines
• Extrapulmonary TB accounts for 20 percent of
all TB cases Pulmonary, 92,991
• Most common site of extrapulmonary bacteriologically
tuberculosis: Lymphatics, Pleural, and Bones confirmed
• Causative organism : Mycobacterium Pulmonary, clinically 139,950
tuberculosis diagnosed
• Site : Jugulodigastric lymph nodes ( most Extrapulmonary 4,361
common) ; Posterior triangle group of lymph
nodes
• Mode of infection –usually through tonsils, occasionally through blood from lungs

Pathogenesis
Clinical Features:
• The patient has the usual general
manifestations of tuberculosis: evening
pyrexia, cough (maybe from pulmonary
tuberculosis),malaise
• Locally there will be regional
lymphadenopathy

Diagnosis
• Aspiration of the pus in a cold abscess for
cytology (for epithelioid cells), staining
(Ziehl-Neelsen—AFB) and culture
• Raised ESR and CRP
• Mantoux test may be useful; but not very
reliable.
• Chest X-ray to look for pulmonary
tuberculosis.

Treatment:
Based on the 2016 Clinical Practice Guidelines for the Diagnosis, Treatment, Prevention and Control of
Tuberculosis, patient will be started on a 6-months Antikoch’s Therapy.
Management/Plan:

The National TB Program designed a strategic plan to ensure compliance to treatment through a
systematic referral system and surveillance. A diagnosed patient, either bacteriologically confirmed or
clinically diagnosed, will be sent to the Regional TB DOTS Clinic where referral will be made and forwarded
to the local health center accessible to the patient. Once enlisted, patient’s data will be encoded in the
national survey system and will be given free medications. The image below is the actual referral of the
patient to be sent to the local health center of choice.

Health Education
Increasing awareness and knowledge about
the disease
• Understanding of the disease
process
• Transmission/Infectivity
• Possible complications
• Management and Outcomes

Treatment Compliance
• Use of Fixed Dose Combination
• PCT – DOTS
• Monitoring and Tracking (reminder
system, incentives, enables)
• Enhance support (family, friends,
community)
• Follow-ups

Management of Drug-induced Side Effects

• INH-associated Nephropathy
• Visual Impairment ( ETON: Ethambutol-related Toxic Optic Neuropathy)
• Ototoxicity (streptomycin)
• Hyperurecemia (Pyrazinamide)
• Cutaneous drug reactions
• Nephrotoxicity (Rifampicin and Strep)