TUBERCULOUS LYMPHADINITIS

Prof. Abdul Majeed Chaudhry

FRCS(E), FRCS(G). FCPS, MHPE(Holland))

Head of Department of Surgery SIR GANGA RAM HOSPITAL, Lahore

LYMPHADENITIS
Lymphadenitis is the inflammation and/or enlargement of a lymph node as a result of infection acquired of MBT from the draining area or directly as a lymphatogenous infection from a distant tubercle. The increased size of a node may be caused by the following:

Inflammatory enlargement of the lymph nodes Multiplication of cells within the node, including lymphocytes, plasma cells, monocytes, or histiocytes and central caseation necrosis

Cervical group of L.Ns is the commonest site among other L.Ns in the body.

LYMPH NODESMated together

POPULATION AT RISK

i. ii.

Low socioeconomic group Immunocompromised

Diabetics On corticosteroids HIV

iii.

Young and old age group Excessive consumption of milk and dairy products

EXTRAPULMONARY SITES

Abdominal TB Cervical L.N. Mediastinal L.N. Skeletal (Spine, bones & joints) Skin Meningies Surgical sites Urogenital TB. Axillary L.N. Inguinal L.N.

MODES OF INFECTION
Aerosolization of organisms Ingestion of contaminated food Inoculation Reactivation of old lesion

MODE OF SPREAD
Lymphatogenous Haematogenous Local erosion

TUBERCULAR BACILLI

TONSIL

LYMPHADENOPATHY

CLINICAL FEATURES
Low grade fever Anorexia and weight loss Night sweats and lethargy Single or multiple neck swellings Feature associated to the primary lesions Single or multiple neck sinuses

PRESENTATION
Acute and chronic lymphadenopathy Discharging sinus Cold and collar stud abscess As a differential diagnosis of neck masses

DIAGNOSIS
History & Clinical Examination FBC, ESR, x-Ray Chest & Neck, PPD (tuberculin skin test) Fine needle aspiration cytology/Excision biopsy M. tuberculosis (MTB) culture. PCR of blood and lymph node

CYTOLOGY
The diagnosis of T.B.Lymphadenopathy is routinely performed by lymph node cytology or excision biopsy. -However It lack specificity due to the difficulty of distinguishing other granulomatous pathologies in the absence of acid-fast bacilli, The process of biopsy is invasive

PCR
The PCR is routinely used in specimen from the site of infection, such as sputum for pulmonary T.B. cerebrospinal fluid for tuberculous meningitis, and Lymph node material for T.B.Lymphadenitis (LN-PCR)

PBMC-PCR
An alternative approach is the detection of M. tuberculosis or M. avium DNA with a PCR in peripheral blood mononuclear cells (PBMC-PCR) of patients with pulmonary TB. The hypothesis is that patients with active infection harbor mycobacterial DNA in peripheral scavenging cells such as macrophages.

DIAGNOSIS OF TUBERCULOSIS LYMPHADENITIS USING A POLYMERASE CHAIN REACTION ON PERIPHERAL BLOOD MONONUCLEAR CELLS SHAPER MIRZA, BLANCA I. RESTREPO, JOSEPH B. McCORMICK, AND SUSAN P. FISHER-HOCH Department of Pathology, Aga Khan Hospital, Karachi, Pakistan; University of Texas Health Science Center Houston School of Public Health, Brownsville, Texas

TUBERCULOUS LYMPHADENITIS: CLINICAL CHARACTERISTICS AND OUTCOME IN A COMMUNITY HOSPITAL

Tapan K. Gayen, MD*, Ravindra Hanumaiah, MD, Vijay Rupanagudi, MD, Karthikeyan Kanagarajan, MD and Santi Dhar, MD Coney Island Hospital, Brooklyn, NY

Foreign born particularly immigrants from Indian subcontinent constituted the predominant patient subgroups with TB lymphadenitis. Cervical lymphadenopathy constituted predominant lymph node group involved. PPD was positive in only 60%, while only 8% had sputum growing MTB. 72% of patients had positive lymph node culture for MTB and in others pathology showing caseating granulomas was needed to establish diagnosis. 6 months of treatment was adequate in most of the patients.

TREATMENT

High protein diet Excision of lesion followed by 9-12 months of antituberculous chemotherapy. Cold abscess requires repeated aspirations with chemotherapy Very large and mated lymph nodes may require neck dissection preserving sternomastoid, accessory nerve and jugular vein if possible followed by chemotherapy. Chronic sinuses heal spontaneously on antituberculous chemotherapy. Treatment of primary lesion

CONCLUSION
In our setup patients with subacute to chronic lymphadenitis , TB should be strongly considered even if PPD is negative and sputum is negative for MTB. Lymph node pathology showing caseating granuloma establishes the diagnosis even if culture is negative. Uncomplicated tuberculous cervical lymphadenitis resolve completely on effective ATT for appropriate duration. Disease can be well controlled by better vaccination, public education and consuming pasteurized milk

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