Tuberculous lymphadenitis

Background
  • Also known as "scrofula" when involves cervical lymph nodes
  • Most common form of extrapulmonary TB
  • TB causes up to 43% of peripheral lymphadenopathy in the developing world [1]
  • In the US, more common among Asian Pacific Islanders and in females
  • Most cases occur in the setting of reactivation of latent infection

Clinical Features
Tubercular adenitis with sinus.
Matted lymph nodes in the right inguinal region. Discharging sinus and healed scars on the left side.
  • Enlarging, painless, red, firm, mass, most commonly in the anterior or posterior cervical chain
  • Can be complicated by ulceration, fistula, or abscess formation
  • Systemic signs and symptoms are uncommon, except patients with HIV (in whom lymphadenitis is usually generalized)

Differential Diagnosis

Lymphadenitis

Infectious

Non-Infectious

Neck mass

Acute

Subacute (weeks to months)

Chronic
  • Thyroid nodules or cancer
  • Goiters
    • Graves' disease
    • Hashimoto thyroiditis
    • Iodine deficiency
    • Lithium use
    • Toxic multinodular
  • Congenital cysts
    • Branchial cleft cyst
    • Thyroglossal duct cyst- 2nd most common benign neck mass
    • Dermoid cyst
  • Carotid body tumor
  • Glomus jugulare or vagale tumor
  • Laryngocele
  • Lipoma/liposarcoma
  • Parathyroid cysts or cancer

Evaluation
  • Fine needle aspiration: sensitivity and specificity (77 and 93% respectively)[2]
  • Excisional biopsy (if FNA is not diagnostic)
    • highest diagnostic yield
    • Submit specimens for histology, culture, and Nucleic acid amplification testing
    • caseating granulomas on histopathology is highly suggestive of TB
  • CT can be useful to identify involved lymph nodes for biopsy
  • CXR: most do not have evidence of active pulmonary TB in nonendemic countries
  • Sputum smear and culture: positive only in approximately 20% of cases[3]

Management
  • Medical therapy
    • Rifampicin, isoniazid, ethambutol, and pyrazinamide (RIPE therapy) given daily x 2 months
    • Followed by rifampicin and isoniazid (given either daily or three times weekly) x 4 months
  • Surgical excision may be performed if medical therapy fails
  • Do not I&D, can result in permanent sinuses and prolonged drainage

See Also

References
  1. Dandapat MC, Mishra BM, Dash SP, Kar PK. Peripheral lymph node tuberculosis: a review of 80 cases. Br J Surg. 1990;77(8):911-2.
  2. Lau SK. Efficacy of fine needle aspiration cytology in the diagnosis of tuberculous cervical lymphadenopathy. J Laryngol Otol. 1990;104(1):24-7.
  3. Polesky A. Peripheral tuberculous lymphadenitis: epidemiology, diagnosis, treatment, and outcome. Medicine (Baltimore). 2005;84(6):350-62.
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