Delays in the Diagnosis and Treatment of Tuberculous Lymphadenitis in Low-Incidence Countries: A Systematic Review.

Early detection and treatment of tuberculosis (TB) is essential to achieve the goals appointed in the WHO End TB Strategy. Tuberculous lymphadenitis (TBLA) is the most common manifestation of extrapulmonary TB, but the diagnosis can be challenging in low-incidence countries due to sparse and inconsistent clinical features, resulting in delay. We aimed to summarize and discuss the current literature on patient delay, health care delay, and total delay (i.e., time to first health care contact, diagnosis, and treatment) in patients with TBLA in TB low-incidence countries. A systematic review using PubMed was conducted, searching for studies set in TB low-incidence countries (defined as <20 per 100,000 citizens) that reported on health care seeking behaviour, patient delay, health care delay, and/or total delay. Studies were categorized by type of delay and compared. We identified 11 heterogeneous studies with highly variable observations. Mean patient delay varied from 55 to 154 days (range, 14-1,461), mean health care delay from 44 to 94 days (range, 7-224) and median total delay from 77.5 to 122 days (range, 0-2,820). Evidently, more comprehensive insights into the diagnostic pathway and delay in TBLA patients are warranted.

Comparing tuberculosis in children aged under 5 versus 5 to 14 years old in a rural hospital in southern Ethiopia: an 18-year retrospective cross-sectional study.

BACKGROUND: There are few data available about childhood tuberculosis (TB) in rural hospitals in low-income countries. We assessed differences in epidemiological characteristics and treatment outcomes in children with TB aged 0-4 versus 5-14 years in rural Ethiopia. METHODS: For this retrospective cross-sectional study, we analyzed childhood TB registers from a rural Ethiopian hospital. We collected data on the number of cases, type of TB, and treatment outcomes using standard definitions. By means of binary and logistic regression analyses, data were compared from 1998 to 2015 in children aged under 5 versus those aged 5-14 years. RESULTS: We included 1282 TB patients: 583 (45.5%) were under 5 years old, and 699 (54.5%) were aged 5-14 years. More than half (67.2%, n = 862) had pulmonary TB (PTB), which was more common in younger children (82.5%, 481/583) than in older ones (54.5%, 381/699; p < 0.001). Most cases of PTB (87.5%, 754/862) were smear negative, including virtually all (99.6%, 479/481) younger children and most older ones (72.2%, n = 275/381; p < 0.001). The most common types of extrapulmonary TB (EPTB) were TB adenitis (54.5%, 229/420) and bone TB (20%, 84/420). Children under five showed a lower prevalence of adenitis TB (9.9% [58/583] versus 24.5% [171/699], p < 0.001), bone TB (2.9% [17/583] versus 9.6% [69/699], p < 0.001), and abdominal TB (0.9% [5/583] versus 6.3% [44/699], p < 0.001). Most diagnoses were new cases of TB (98.2%, 1259/1282). Overall, 63.5% (n = 814) of the children successfully completed treatment (< 5 years: 56.6%, 330/583; 5-14 years: 69.2%, 489/699; p < 0.001). In total, 16.3% (n = 209) transferred to another center (< 5 years: 19.4%, 113/583; 5-14 years: 13.7%, 96/699; p = 0.006). Thirteen percent of patients (n = 167) were lost to follow-up (< 5 years: 16.0%, 93/583; 5-14 years: 10.4%, 74/699; p = 0.004). Fifty-two (4.1%) children died (no age differences). Being aged 5-14 years was independently associated with successful treatment outcomes (adjusted odds ratio 1.59; 95% confidence interval: 1.16, 1.94, p = 0.002). CONCLUSIONS: We observed a very low diagnostic yield for spontaneous sputum smear in children with TB. In this rural setting in Ethiopia, very young children tend to present with new cases of smear-negative PTB. They have less EPTB than older children but more TB meningitis and show lower rates of treatment success.

Diagnosis and Management of Children With Mycobacterium abscessus Infections in the Head and Neck.

PURPOSE: Controversy exists regarding the most appropriate treatment strategy for children with nontuberculous mycobacterial (NTM) cervical lymphadenitis. Mycobacterium abscessus (MAB) is an uncommon cause of NTM cervical lymphadenitis. The purpose of the present study was to evaluate diagnosis, management, and treatment outcomes in children with MAB-associated cervical lymphadenitis resulting from a pulpotomy. MATERIALS AND METHODS: This was a retrospective chart review of children with NTM lymphadenitis of the head and neck caused by MAB treated at Children's Healthcare of Atlanta hospitals (Atlanta, GA). The predictor variables were patient demographics, dental history, clinical presentation, imaging characteristics, laboratory findings, histopathologic examination, treatment, and complications. The outcome variable was disease resolution or persistence. RESULTS: Twenty-two patients (mean age, 6.5 yr) met the inclusion criteria. All patients had pulpotomy at 1 dental practice. The mean time from dental procedure to symptom onset was 43.1 days (range, 3 to 180 days). Children presented with cervical or submandibular swelling, facial swelling, gingival erythema, and skin erythema. Radiographic findings were submandibular or cervical lymphadenitis, maxillary or mandibular osteolysis, subcutaneous abscess, and pulmonary nodules. All children had confirmed or probable MAB infection diagnosed on the pathologic specimen. There were 2 distinct patient presentations that guided surgical management: isolated noninflammatory cervical lymphadenitis, which was partly or completely excised (n = 11), and adjacent extension or disseminated infection requiring subtotal lymph node excision, bone debridement, and postoperative antibiotics (n = 11). Most children required multiple surgical interventions to remove infected tissues. All achieved clinical resolution. CONCLUSION: In this cohort, treatment of NTM lymphadenitis caused by MAB depended on extent of disease and virulence of bacteria. When complete surgical excision was possible, disease resolution was achieved. However, in cases with adjacent extension or dissemination infection, postoperative antibiotics were necessary.

Suppurative Cervical Tuberculous Lymphadenitis Mimicking a Metastatic Neck Mass.

Tuberculosis is an important public's health problem in developing countries. Although tuberculosis is commonly found in lungs, it could also be found in lymph nodes, mouth, tonsils, tounge, nose, epiglottis, larynx, and pharynx of head-neck region. The most common form of extrapulmonary tuberculosis placed outside the lungs is tuberculous lymphadenitis. Tuberculosis lymphadenitis is the most commonly seen form of the extrapulmoner tuberculosis and usually invades the lymph nodules of the cervical region. An adult patient with tuberculous lymphadenitis has been presented within the context of the literature reviewed. A 42-year-old woman, who has admitted to our clinic with a fistulized mass in the right side of her neck, has been diagnosed and treatment has been performed. No other problems were found in the systemic examination of the patient. Since there is no specific finding of pulmonary tuberculosis, detailed investigations are required in patients admitted with the sypmtomps of neck mass.

[History of scrofula: from humoral dyscrasia to consumption]. / Historia de la escrófula: de la discrasia humoral a la consunción.

The term “scrofula” was used for a long time to designate a chronic swelling of cervical lymph nodes. This paper outlines the prevalent ideas on the nature, pathogenesis and the treatment of this disorder, from classical Greek medicine up to the 18th century. A Hippocratic treatise regarded scrofula as produced by an accumulation of phlegm, with a consequent imbalance or dyscrasia of the body humors. It was believed that it could heal spontaneously; but it could also soften, open through the skin and have an obstinate course. The treatment consisted mainly on local applications, incision to evacuate the soft content, or extirpation of the abnormal mass. In France and England, crowds of scrofulous patients were touched by the kings who were supposed to have a hereditary miraculous power to cure the disease. A Medieval text mentioned that scrofula could also affect other parts of the body. In the 17th century, scrofula was reputed as a frequent condition and was attributed to blood acrimony which coagulated in spongy organs. It was associated to phthisis or consumption due to the lethal outcome in some patients and to a cheese-like appearance of the pulmonary and the scrofulous lesions.

Breast tuberculosis in northeast Iran: review of 22 cases.

BACKGROUND: Breast tuberculosis (breast TB) is an extremely rare disease, so case reviews are also rare. METHODS: This study is a retrospective review of patients with breast TB who were treated between 2002 and 2012 at the Health Center of Gorgan City. RESULTS: All 22 patients were females, their mean age was 32.4 years, and all were new cases. Patients presented with swelling of the breast (22%), lump (55%) and excretion from the involved breast (27%), and breast pain (55%). The highest rate of breast TB occurred in 2011 (27%). All patients received the DOTS regimen for a mean duration of 7.3 ± 0.7 months; in addition, segmental resection was performed on 11 patients (50%). CONCLUSIONS: The findings confirmed that breast TB in Iran should be considered as a differential diagnosis of breast masses. All patients in our study received the daily and 'Directly Observed Treatment Short-course' (DOTS) regimens. Anti-tubercular therapy for six months with or without minimal surgical intervention currently is the main treatment.

[Management of atypical cervical mycobacteriosis in childhood]. / Management der zervikalen atypischen Mykobakteriose im Kindesalter.

Atypical mycobacteriosis is a rare cause of cervical lymphadenitis that most frequently affects immunoincompetent children between the ages of 12 months and 5 years. The typical clinical manifestation is a painless unilateral cervical mass. The nonspecific clinical symptoms and laboratory parameters complicate diagnosis and, therefore, therapeutic management. Various therapeutic options, including surgery, antimycobacterial drug therapy and wait-and-scan approaches are discussed in the literature. Complete surgical excision has become the established treatment of choice. However, controlled randomized studies that clearly demonstrate the benefits of a particular type of therapy are lacking.

[Case of papillary carcinoma of the thyroid gland with concurrent tuberculous lymphadenitis].

We report a case of papillary carcinoma of the thyroid gland and cervical lymph node metastases with concurrent tuberculous lymphadenitis that was diagnosed preoperatively. A 35-year-old woman presented with multiple lymph node swellings and an anterior neck mass. No findings suggesting the coexistence of pulmonary tuberculosis were present. The patient underwent a total thyroidectomy with bilateral neck dissection together with medication. Measures to prevent tuberculosis were undertaken during the perioperative period. The histopathological diagnosis was papillary carcinoma with both metastatic and tuberculous lymphadenitis of the lymph nodes in the neck. The possible coexistence of tuberculous lymphadenitis must be ruled out when lymph node swellings are observed in patients with head and neck cancer, including thyroid carcinoma.

[Peripheral tuberculous lymphadenitis: diagnosis and management]. / Lymphadénite tuberculeuse cervicale et réaction paradoxale: diagnostic et traitem.

Tuberculous lymphadenitis is a frequent presentation of extrapulmonary tuberculosis. It corresponds to about 10% of tuberculosis cases in adults in developed countries, on the rise because of HIV, migrants and immunosuppressive therapy. The clinical diagnosis is often difficult and differential diagnosis is extensive. The patient presents with a history of painless swelling of one or a group of cervical lymph nodes. The mass may be present for 3 weeks to 8 months before the first consultation. The treatment of choice is an oral antimycobacterial treatment and is not surgical. This article reviews the specific clinical manifestations, diagnositc tools and treatment of tuberculous lymphadenitis through two cases.

[Bronchoscopic cryotherapy combined with drugs infusion in the treatment of transbronchial tuberculous].

OBJECTIVE: To summarize the bronchoscopic features of transbronchial tuberculous mediastinal lymphadenitis and to observe the clinical efficacy of cryotherapy combined with drug infusion through bronchoscope. METHODS: Twenty-three cases of tuberculous mediastinal lymphadenitis diagnosed at Changhai Hospital were retrospectively analyzed. The bronchoscopic manifestations and the times, course, efficacy, complications and recurrence rate after treatment with cryotherapy combined with drug infusion were described. RESULTS: The mean age of the patients was (31 ± 10) years and the male to female ratio was 1:1.9. A total of 41 transmural lymph node lesions were found, usually after (3.4 ± 0.6) months with systemic anti-tuberculosis chemotherapy. The lesions occurred at the right side in 21 cases (60.98%). Endoscopic manifestations included caseous necrosis, granulomatous nodules, or both simultaneously, some lesions containing anthracotic substances. The median treatments of cryotherapy and drug infusion were 3 (1 - 6) times and 8 (6 - 11) times respectively. No significant difference was found between multiple lesions and single lesion group in the treatment of combination therapy. Therapeutic efficacy was 38/41 with improvement of bronchoscopic manifestations to smooth mucosa, lumen patency, mild anthracotic pigmentation or scar tissue. The rate of complications which included local bleeding and mediastinal bronchial fistula was 3.59%. No recurrence occurred in a long-term follow-up period. CONCLUSION: Combination of cryotherapy and drug infusion through bronchoscope is a simple, safe and effective method to treat transbronchial tuberculous mediastinal lymphadenitis.

Rare case of tubercular parotid abscess.

Acute parotitis progressing to parotid abscess is rare in children. Staphylococcus aureus is the usual pathogen in parotid abscess. Granulomatous parotid abscess due to tubercular aetiology is extremely rare. Authors report a case of chronic parotid abscess in a child who received multiple courses of antibiotics without any cure. The ultrasonography and CT scan of the parotid gland confirmed the extent of parotid abscess and the changes in the parotid lymph nodes. The surgical drainage and the biopsy of the lymph nodes lead to the diagnosis of granulomatous abscess. The antitubercular therapy finally cured the disease without further recurrence.

Mediastinal tuberculous lymphadenitis with intractable fistula to the neck.

A 62-year-old female consulted our hospital due to an ulceration on the skin of her neck and a mediastinal tumor. Chest CT scan and MRI revealed a mediastinal tumor-like lesion with direct progression to the neck skin lesion. En bloc resection of the tumor including the neck skin ulcer was performed under a median sternotomy. Mediastinal tuberculous lymphadenitis was diagnosed histologically. This is a case of a very rare type of mediastinal tuberculous lymphadenitis that progressed to the neck with an intractable fistula.

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.

Pancreatic tuberculosis: A systematic review of symptoms, diagnosis and treatment.

INTRODUCTION: Although pancreatic tuberculosis (TB) is traditionally considered to be a rare clinical entity, in recent times, an increase in the number of reports of pancreatic TB has been noted. We conducted a systematic review in order to summarise currently available data on pancreatic TB. METHODS: A comprehensive literature search of Medline, Scopus and ISI Web of Science databases was conducted in order to identify papers reporting cases of pancreatic TB. The eligibility criteria for inclusion in the review required that the studies reported patient(s) affected by pancreatic TB and that individual data on age, sex, clinical presentation and outcome were available. RESULTS: In total, 116 studies reporting data on 166 patients were included in the analysis. The majority of patients were males (62.1%) diagnosed at a mean age of 41.61 ± 13.95 years. Most cases were diagnosed in Asia (50.0%), followed by North America (22.9%), Europe (20.5%), Africa (4.2%) and South America (2.4%). Human immunodeficiency virus (HIV) infection was diagnosed in 25.3% of those affected. Pancreatic TB most frequently presented itself in the form of a pancreatic mass (79.5%) localised mainly in the head (59.0%) and less frequently in the body (18.2%) and tail (13.4%). Extrapancreatic TB involvement most frequently affected the peripancreatic lymph nodes (47.3%). More than half of patients (55.2%) were subjected to laparotomy, while 21.08% underwent endoscopic ultrasound fine-needle aspiration biopsy. The presence of TB was identified most frequently through histological analysis (59.6%), followed by culture (28.9%), staining (27.7%) and, in a smaller number, by polymerase chain reaction (9.6%) and cytology (6.6%). Almost all patients received anti-tubercular pharmacological therapy (98.2%), while 24.1% underwent surgery. Despite treatment, 8.7% of patients died. CONCLUSION: Increased awareness of pancreatic TB is needed, not only in endemic areas but especially in relation to HIV infection and other clinical conditions associated with immunoincompetence.

Tuberculous aneurysm of extracranial carotid artery.

Incidence of extracranial carotid aneurysm is rare and represents a challenge to treatment strategy. Two patients presented to us a couple of years apart with pulsatile neck swellings. We propose that the extracranial carotid artery pseudoaneurysm was as a result of direct extension from tuberculous lymphadenitis and discuss the management of these patients.

Tuberculous lymphadenitis as a cause of obstructive jaundice: a case report and literature review.

Obstructive jaundice secondary to tuberculosis (TB) is extremely rare. It can be caused by TB enlargement of the head of the pancreas, TB lymphadenitis, TB stricture of the biliary tree, or a TB mass of the retroperitoneum. A 29-year-old man with no previous history of TB presented with abdominal pain, obstructive jaundice, malaise and weight loss. Ultrasonography (US), computer tomography (CT) scan and endoscopic retrograde cholangiopancreatography (ERCP) were suggestive of a stenosis of the distal common bile duct (CBD) caused by a mass in the posterior head of the pancreas. Tumor markers, CEA and CA19-9 were within normal limits. At operation, an enlarged, centrally caseous lymph node of the posterior head of the pancreas was found, causing inflammatory stenosis and a fistula with the distal CBD. The lymph node was removed and the bile duct resected and anastomosed with the Roux-en Y jejunal limb. Histology and PCR based-assay confirmed tuberculous lymphadenitis. After an uneventful postoperative recovery, the patient was treated with anti-tuberculous medication and remained well 2.5 years later. Though obstructive jaundice secondary to tuberculous lymphadenitis is rare, abdominal TB should be considered as a differential diagnosis in immunocompromised patients and in TB endemic areas. Any stenosis or fistulation into the CBD should also be taken into consideration, and biliary bypass surgery be performed to both relieve jaundice and prevent further stricture.