Clinical characteristics and treatment outcome in Tubercular lymphadenitis patients- A prospective observational study.

BACKGROUND: Tuberculous lymphadenitis is the most common form of extrapulmonary tuberculosis. This study was primarily designed to assess clinical characteristics of Peripheral tubercular lymphadenitis and incidence of Paradoxical reaction. MATERIALS & METHODS: It is a prospective observational study for 130 peripheral Lymph node tuberculosis patients diagnosed and treated between 1st Jan 2018 to 31st Dec 2019. All statistical analyses were performed using statistical software SPSS version 20 (SPSS Inc, Chicago, USA). A P value of <0.05 is considered significant. RESULTS: Out of 130 study patients, 54 were male, and 76 were female, with a sex ratio of 1:1.4. The mean age of the patients was 28.01 years (±12.41). Almost one-fourth of study patients (25.38%) had symptoms for more than one years before the diagnosis of tubercular lymphadenitis. Of the 130 patients, 62 (47.69%) were classified as having confirmed TB based on AFB positivity in FNAC sample. More than half of study patients (55.38%) received homoeopathic treatment before initiation of anti-tubercular treatment. The most common Lymph node involved was cervical (66.15%). Forty-six (35.38%) patients developed Paradoxical reaction, and most of this occurred in the first two months of the initiation of Anti-tubercular treatment. Fifty-eight patients (44.61%) had a residual Lymph node of size more than one centimetre after six months of treatment. Only 9 patients out of 54 patients had significant reduction in the size of the lymph node with 9 months of treatment. CONCLUSION: Significant number of patients had residual lymph node at the end of 6 months of treatment, but extending the treatment to 9 months was not beneficial. More than half of patients had history of homoeopathic treatment that could lead to delayed presentation. The paradoxical reaction is very common but most of it subsided spontaneously.

Tuberculous mediastinal lymphadenopathy presenting with left vocal cord palsy: A rare entity.

A 23-year-old-male student, never-smoker presented to our hospital outpatient department with complaints of loss of appetite, unintentional weight loss, fatigue and low-grade fever for two months, hoarseness of voice (HOV) for two weeks. He was evaluated for HOV with video laryngoscopy which demonstrated left vocal cord palsy. Contrast enhanced CT Chest (CECT) was performed for evaluation of mediastinal lesions which revealed multiple peripheral enhancing conglomerate mediastinal lymph nodes. EBUS-trans bronchial needle aspiration (TBNA) and endobronchial biopsy were performed and specimens sent for smear and culture for AFB, Xpert MTB/RIF assay and histopathology. Results were consistent with Mycobacterium tuberculosis (MTB) infection and culture was positive for M. tuberculosis complex. Patient had been started on anti tubercular therapy (ATT) and during his 4th month follow up he showed clinicoradiological improvement without recovery of recurrent laryngeal nerve palsy.

A 21-Year-Old Immune-Competent Man With Recurrent Cough.

CASE PRESENTATION: A 21-year-old Chinese man presented with a nonproductive cough for the past 5 months. He denied fevers, chills, night sweats, chest pain, dyspnea, hemoptysis, or weight loss. He was an undergraduate with an unremarkable medical history. He denied any sick contacts and he never smoked. Laboratory tests showed a leukocyte count of 11,200/µL (normal range, 3,500-9,500/µL) with a high neutrophil count and a raised erythrocyte sedimentation rate of 81 mm/h. The purified protein derivative skin test result was positive, and a TB test (T.SPOT.TB; Oxford Immunotec) produced a positive result. The HIV test result was negative. The lung window of the patient's thoracic CT scan showed mottled, patchy opacification in the right lower lobe, and enlarged mediastinal and right hilar lymph nodes (Fig 1A). Bronchoscopy showed mucosal swelling and congestion (Fig 1B). A lymph node (station 11R) biopsy, obtained by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) (Fig 1C), showed nonspecific necrosis. An acid-fast bacillus smear of bronchial secretion produced negative results. He was administered empiric anti-TB therapy (ethambutol, isoniazid, pyrazinamide, and rifapentine). But his cough had not improved by 4 months later. Thus he came to our hospital for a second opinion.

Extrapulmonary Tuberculosis: Pathophysiology and Imaging Findings.

Extrapulmonary tuberculosis (TB) represents approximately 15% of all TB infections. It is difficult to diagnose on the basis of imaging characteristics and clinical symptoms, and biopsy is required in many cases. Radiologists must be aware of the imaging findings of extrapulmonary TB to identify the condition in high-risk patients, even in the absence of active pulmonary infection. In extrapulmonary TB, the lymphatic system is most frequently affected. The presence of necrotic lymph nodes and other organ-specific imaging features increases the diagnostic probability of extrapulmonary TB. Disseminated infection and central nervous system involvement are the most frequent manifestations in immunosuppressed patients. Renal disease can occur in immunocompetent patients with very long latency periods between the primary pulmonary infection and genitourinary involvement. In several cases, gastrointestinal, solid-organ, and peritoneal TB show nonspecific imaging findings. Tuberculous spondylitis is the most frequent musculoskeletal manifestation. It is usually diagnosed late and affects multiple vertebral segments with extensive paraspinal abscess. Articular disease is the second most frequent musculoskeletal manifestation, and synovitis is its predominant imaging finding.©RSNA, 2019.

[Tuberculous lesion of retropharyngeal lymph nodes responsible for labored nasal breathing]. / Tuberkuleznoe porazhenie zaglotochnykh limfaticheskikh uzlov, vyzvavshee zatrudnenie nosovogo dykhaniya.

A 62 year-old patient applied for the medical aid with complaints of labored nasal breathing. She was treated for tuberculosis in the childhood, underwent radical mastectomy in connection with left breast cancer in 2007 and adenotomy at the age of 60 years with the good functional outcome. One year after adenotomy, the enlargement of lymph nodes at the left-hand antero-lateral surface of the neck was detected. The histological changes in the lymph nodes corresponded to the picture of tuberculosis. Pharyngoscopy demonstrated an asymmetric protrusion at the posterior wall of the pharynx more prominent on the left side. Examination by spiral computed tomography revealed the presence of two enlarged lymph nodes with the signs of suppurative melting in the retropharyngeal space. These lymph nodes were opened through the posterior pharyngeal wall which resulted in the restoration of the normal pharynx configuration and the normalization of nasal breathing.

Coexistence of metastatic breast carcinoma and primary tuberculosis in axillary lymph nodes: a report of a rare case.

Concomitant breast cancer metastasis and tubercular lymphadenitis in axillary lymph node is an extremely rare occurrence. Axillary lymph node metastasis is the most important factor in the staging of breast carcinoma and the number of axillary nodes showing metastases alters the stage. As tuberculosis also produces nodal enlargement, this can mimic or complicate the staging of malignant disease. Dual pathology in an organ can lead to difficulties in interpretation and inappropriate treatment of tuberculosis as well as carcinoma breast. Moreover, fine needle aspiration cytology (FNAC) from such cases may be misleading if only one of the diseases is picked up. Therefore, the need for multiple attempts at FNAC should be stressed upon for all palpable lumps. We report a case of infiltrating duct carcinoma breast in a 45-year-old female where tuberculosis was discovered in axillary lymph nodes in addition to metastases. As the present case led to incidental discovery of tuberculosis with tumor metastasis, it reinforces the possibility of a coexistent lesion in the pathologists' mind, especially in regions endemic for tuberculosis.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in mediastinal lymphadenopathy.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA) is accepted as a safe and minimally invasive modality for evaluation of mediastinal pathologies in adults. There is scanty literature on the utilization and performance characteristics of Convex probe EBUS-TBNA in children. The authors herein describe two pediatric patients with mediastinal lymphadenopathy wherein the underlying diagnosis was unclear based on the clinico-radiological profile. A possibility of lymphoma was considered in one of the patients. EBUS-TBNA was performed for obtaining tissue samples from the enlarged mediastinal lymph nodes and diagnosis of tuberculosis was established in both the patients. The authors review the available literature on Pediatric EBUS TBNA. EBUS-TBNA is an exciting and promising approach towards safe and accurate evaluation of mediastinal pathologies in children. Pediatric EBUS-TBNA needs further evaluation in prospective studies.

Tuberculosis lymphadenitis in a well managed case of sarcoidosis.

Differentiation between tuberculosis (TB) and sarcoidoisis is sometimes extremely difficult. Sequential occurrence of sarcoidosis and TB in the same patient is uncommon. We present the case of a young man, with a proven diagnosis of sarcoidosis who later developed TB after completion of treatment for sarcoidosis. A 32-year-old male patient presented with low-grade fever since two months. Physical examination revealed cervical lymphadenopathy. Initial fine needle aspiration cytology (FNAC) of the cervical lymph node was suggestive of granulomatous inflammation; the chest radiograph was normal. Repeat FNAC from the same lymph node was suggestive of reactive lymphoid hyperplasia. The patient was treated with antibiotics and followed-up. He again presented with persistence of fever and lymphadenopathy and blurring of vision. Ophthalmological examination revealed uveitis, possibly due to a granulomatous cause. His repeat Mantoux test again was non-reactive; serum angiotensin converting enzyme (ACE) levels were raised. This time an excision biopsy of the lymph node was done which revealed discrete, non-caseating, reticulin rich granulomatous inflammation suggestive of sarcoidosis. The patient was treated with oral prednisolone and imporved symptomatically. Subsequently, nearly nine months after completion of corticosteroid treatment, he presented with low-grade, intermittent fever and a lymph node enlargement in the right parotid region. FNAC from this lymph node showed caseating granulomatous inflammation and the stain for acid-fast bacilli was positive. He was treated with Category I DOTS under the Revised National Tuberculosis Control Programme and improved significantly. The present case highlights the need for further research into the aetiology of TB and sarcoidosis.

Tuberculosis of superficial lymph nodes, a not so rare event to consider in diagnosis. A case in an elderly male.

Tuberculosis (TB) is still one of the most frequent infectious diseases worldwide. Until the 1990s, Western European countries showed a low frequency of TB infection, but the rise of immigration has led to a rapid increase in its occurrence. In the elderly, TB is emerging as a significant health problem (age-related decline of the cell-mediated immunity, associated illnesses, use of immunosuppressive drugs, malnutrition, poor life conditions), although its detection and diagnosis is not easy also considering its subclinical presentation. Almost 70% of all TB infections in Italy are found in the lungs; 50% of the extrapulmonary infections affect lymph nodes. Due to the low incidence of superficial tuberculous lymphadenitis without pulmonary manifestations, the possibility of a TB aetiology is often not taken into consideration in the differential diagnosis of lymphadenopathy, resulting in significant delay of appropriate treatment. Herein, we describe the case of a 78-year-old male with nocturnal fever, weakness, night sweats, loss of weight and decay in general condition. The patient had a past medical history of prostate adenocarcinoma treated with hormone therapy. The past medical history in association with clinical findings and laboratory data (anaemia, high titers of fibrinogen and reactive C-protein) led to the suspect of metastatic adenocarcinoma. Only histological and molecular biology findings allowed us to make a correct diagnosis of TB.

[Diagnosis of abdominal tuberculosis in general and specialized healthcare facilities].

The aim of this work was to study clinical manifestations of abdominal tuberculosis (AT) and its diagnosis. It included 142 patients examined in Ulyanovsk region in 1990-2006. 88.7% of them first applied to general practitioners who diagnosed AT in 69.7% of the cases (half of them postmortem). AT was found in one third (30.3%) of the patients attending tuberculosis dispensaries (86.1% during urgent laparatomy). AT manifests itself as clinical conditions requiring therapeutic, surgical, anti-infectious, and anti-tumour treatment. The most informative diagnostic tool is histological study of tissue biopsies obtained during endoscopic and videolaparoscopic procedures. Medical histories also provide materials for early diagnosis and treatment of AT by evidence-based methods; they include data on refractory gastrointestinal ulcers and infiltrates, calcinates located in mesenteric lymph nodes, liver and spleen by X-ray, hypersensitivity to tuberculin.

[A CASE OF ESOPHAGOGASTRIC FISTULA CURE IN A PATIENT WITH COMPLICATED TUBERCULOSIS OF INTRATHORACIC LYMPH NODES].

The authors describe a successful case of esophageal fistula being cured in a patient with complicated tuberculosis of intrathoracic lymph nodes. They show it possible to medically cure the fistula via temporary esophageal stenting, which in combination with therapeutic bronchoscopies enables prompt fistula healing, without resorting to surgical treatment.

Tuberculous lymphadenitis.

Lymphadenitis is the most common extrapulmonary manifestation of tuberculosis. It remains both diagnostic and therapeutic challenge because it mimics other pathologic processes and yields inconsistent physical and laboratory findings. Diagnosis is difficult often requiring biopsy. A thorough history and physical examination, staining for acid-fast bacilli, fine-needle aspiration and PCR are helpful in obtaining an early diagnosis. It is also important to differentiate tuberculous from nontuberculous mycobacterial cervical lymphadenitis because their treatment protocols vary. Treatment monitoring is more complex due to peculiar behavior of TB lymph nodes. Situation has become worse due to sharp increase in the incidence of atypical mycobacteria, poorly controlled HIV epidemic and rise of drug-resistant TB lymphadenitis. Tuberculous adenitis is best treated as a systemic disease with antituberculosis medication. Surgical therapy along with antituberculosis medication can be beneficial in selected patients.

Unexpected pulmonary involvement in extrapulmonary tuberculosis patients.

BACKGROUND: This study aimed to assess the utility of sputum examinations and chest radiographs (CXRs) in patients with extrapulmonary tuberculosis (XPTB) to detect pulmonary involvement of tuberculosis (TB). METHODS: We studied 72 XPTB patients who were managed through the TB Program, King County, WA, from January 2003 through November 2004. RESULTS: The two most common sites of XPTB were the lymph nodes (36 [50%]) and pleura (12 [17%]). Thirty-five of 72 XPTB patients (49%) had abnormal CXR findings. Sputum was not obtained from 15 patients despite sputum induction. Of the 57 patients from whom sputum was collected, 30 (53%) had abnormal CXR findings, 5 (9%) had sputum smears that were positive for acid-fast bacilli, and 12 (21%) had sputum cultures that were positive for Mycobacterium tuberculosis. Weight loss was significantly associated with positive sputum culture findings in a multivariate analysis (odds ratio, 4.3; 95% confidence interval, 1.01 to 18.72; p = 0.049). There was no significant difference in the occurrence of positive sputum culture results between patients with abnormal CXR findings and those with normal CXR findings (7 of 30 patients [23%] vs 5 of 27 patients [19%], respectively; p = 0.656). Of 24 HIV-negative XPTB patients with normal CXR findings, 2 patients (8%) had positive sputum culture findings. CONCLUSIONS: CXR results did not reliably differentiate XPTB patients with and without positive sputum culture findings. Some XPTB patients had positive sputum culture results despite normal CXR findings and negative HIV status. Weight loss in XPTB patients was associated with positive sputum culture results. Sputum examinations in XPTB patients, regardless of the CXR results, may identify potentially infectious cases of TB.

Multinucleate giant cells release functionally unopposed matrix metalloproteinase-9 in vitro and in vivo.

Multinucleated giant cells (MGCs) are characteristic of granulomatous inflammation. Matrix metalloproteinase (MMP)-9, the major monocyte-derived matrix metalloproteinase, is key in inflammatory tissue damage. At 72 h, MGCs secrete 153 +/- 2.5 ng/mL MMP-9, compared with 115 +/- 3.8 ng/mL during macrophage differentiation (P<.05). In contrast, the level of MGC secretion-specific tissue inhibitor, tissue inhibitor of metalloproteinase (TIMP)-1, is lower (P<.05). Mature MGCs secrete constitutively greater concentrations of MMP-9 than do monocytes or macrophages (P<.05). MGCs in tuberculous lymph-node biopsy samples express high MMP-9 levels adjacent to areas of necrosis, whereas TIMP-1 is not detected. Thus, MGCs are potentially important sources of MMP-9 secretion and may contribute to inflammatory tissue damage in human tuberculosis.

Necrotizing non-granulomatous lymphadenitis: a clinicopathologic study of 40 Thai patients.

The purpose of this study was to describe the clinicopathological features of 40 cases of necrotizing non-granulomatous lymphadenitis in Thai patients. The clinical features, histomorphology and special stains were evaluated in 40 Thai patients from the pathology records of King Chulalongkorn Memorial Hospital from January 2001 to December 2003 in those diagnosed as having necrotizing non-granulomatous lymphadenitis. Of the 40 patients, 17 cases (42.5%) had Kikuchi-Fujimoto disease (KFD), 8 cases (20%) had tuberculosis (TB) lymphadenitis and 1 case (2.5%) had systemic lupus erythematosus (SLE) with associated lymphadenitis. Fourteen cases (35%) did not have a specific diagnosis due to a lack of follow-up data. KFD most commonly occurs in young women, and is characterized by the presence of coagulative necrosis and karyorrhexis often centered in the paracortex, an absence of neutrophils and plasma cells, proliferation of various cells composed of lymphocytes, histiocytes, immunoblasts and plasmacytoid monocytes and the absence of a granuloma. Tuberculous lymphadenitis usually occurs in women with a mean age of 34.25 years. The lymph nodes reveal extensive coagulative necrosis involving the cortex, paracortex and medulla, proliferation of mixed inflammatory cells, including neutrophils, lymphocytes and plasma cells in the necrotic area and the presence of proliferating histiocytes at the periphery of the necrotic area. The lymph nodes of SLE-associated lymphadenitis reveal large numbers of plasma cells and hematoxylin bodies. We suggest that necrotizing non-granulomatous lymphadenitis is not specific for any disease, but rather a common histologic change found in diseases, such as TB, SLE, and KFD. Further investigation to obtain a definite diagnosis should be done for appropriate treatment.

A clinical scoring system as useful as FNAC in the diagnosis of tuberculous lymphadenitis in HIV positive patients.

Among HIV positive patients, Fine needle aspiration cytology (FNAC) or biopsy for diagnosis of tuberculous lymphadenopathy is often avoided due to an unspoken stigma. Earlier, we had developed a clinical scoring scale for the diagnosis of tuberculous lymphadenitis (TBLN), which had 88% sensitivity and detected no false positives. In the present study, we attempted to develop similar scale that could assist in diagnosing TBLN in AIDS. All 42 HIV positive patients of adenitis attending Ramdeo Hospital and Research Centre, Jodhpur between August 2001 and December 2004 were studied. History of past tuberculosis, age, history of rapid weight loss, site, size, consistency, and the presence of matting and sinus formation of enlarged lymph nodes, result of tuberculin test, sputum smear and findings in chest radiograph were compared between patients diagnosed as TBLN and those showing non-tuberculous lymphadenitis (Non-TBLN) on cytopathological examination of material obtained by fine needle aspiration. Based on the results, clinical scores from zero to two were assigned to different clinical features. The total clinical score was then calculated for each patient. A total clinical score of five or more included all TBLN cases and only 10.5% false positives. This scoring system can be used in remote peripheral areas, which do not have the facility for biopsy or FNAC.

Abdominal tuberculosis: imaging features.

LEARNING OBJECTIVES: Radiological findings of abdominal tuberculosis can mimic those of many different diseases. A high level of suspicion is required, especially in high-risk population. In this article, we will describe barium studies, ultrasound (US) and computed tomography (CT) findings of abdominal tuberculosis (TB), with emphasis in the latest. We will illustrate CT findings that can help in the diagnosis of abdominal tuberculosis and describe imaging features that differentiate it from other inflammatory and neoplastic diseases, particularly lymphoma and Crohn's disease. As tuberculosis can affect any organ in the abdomen, emphasis is placed to ileocecal involvement, lymphadenopathy, peritonitis and solid organ disease (liver, spleen and pancreas). A positive culture or hystologic analysis of biopsy is still required in many patients for definitive diagnosis.

An unusual presentation of extrapulmonary tuberculosis.

A 22 years old female presented with fever, respiratory distress and a rapidly enlarging, soft left postauricular lump for last two months. She was found anaemic, had a right supraclavicular, non-tender lymph node of about 2.5 cm diameter and mild hepatosplenomegaly. She had a positive Mantoux test, and normal chest x-ray. Ultrasonography of abdomen showed multiple pre-and para-aortic enlarged lymph nodes. Mild pericardial effusion was detected on echocardiography. Fine needle aspiration cytology from the right supraclavicular lymph node showed epithelioid cell granuloma. Excision and biopsy of the dermoid were carried out. The content was pus, which was smear-negative but culture-positive for acid-fast bacilli. The patient responded to antituberculous chemotherapy satisfactorily.