Introduction
Tuberculosis of lymphnode or TB lymphnode is also known as Tuberculous lymphadenitis (or tuberculous adenitis) is the most common form of tuberculosis infections that appears outside the lungs(extra pulmonary). Tuberculous lymphadenitis is a chronic, specific granulomatous inflammation of the lymph node with caseation necrosis, caused by infection with Mycobacterium tuberculosis or related species of Mycobacterium.
The lymph node TB usually causes a painful swelling of one or more lymph nodes. Most often, the disease is localized to the anterior or posterior cervical chains (70-90%) or supra clavicular.
The cervical spine (neck region) consists of seven bones (C1-C7 vertebrae), which are separated from one another by intervertebral discs. These discs allow the spine to move freely and act as shock absorbers during activity.
The supraclavicular fossa is an anatomically complex region of the upper neck, the contents of which lend themselves to diverse differential diagnosis for pathology within the region.
The characteristic morphological feature is the tuberculous granuloma (caseating tubercule). This consists of giant multinucleated cells (Langhans cells), surrounded by epithelioid cells aggregates , T cell lymphocytes and fibroblasts. Granulomatous tubercules eventually develop central caseous necrosis and tend to become confluent, replacing the lymphoid tissue.In addition to swollen lymph nodes, called lymphadenitis, the person may experience mild fevers, not feel like eating( loss of appetite for food) or lose weight./, weakness.
Causitive agents of lymph node tuberculosis:
It is usually caused by pathgenic bacterium most common cause of tuberculosis in the lungs, namely Mycobacterium tuberculosis. It has sometimes also been caused by related mycobacterial species including M. bovis, M. kansasii, M. fortuitum, M. marinum, and Mycobacterium ulcerans.
M. tuberculosis is a serious global health problem, with approximately one third of the world's population infected by this bacterium.
There are Five Stages of progression of tuberculous lymphadenitis
(1)Lymphadenitis :enlarged, firm, mobile, discrete nodes showing non-specific reactive hyperplasia.
(2)Periadenitis: large rubbery nodes fixed to surrounding tissue owing to periadenitis.
(3)Cold abscess:central softening due to abscess formation.
(4)'Collar stud' abscess formation
(5)Sinus
Tuberculous lymphadenitis is popularly known as collar stud abscess, due to its proximity to the collar bone and its superficial resemblance to a collar stud, although this is just one of the five stages of the disease. One or more affected lymph nodes can also be in a different body part, although it is most typical to have at least one near the collar bone.The characteristic morphological feature is the tuberculous granuloma (caseating tubercule),giant multinucleated cells (Langhans cells), surrounded by epithelioid cells aggregates, T cell lymphocytes and few fibroblasts. Granulomatous tubercules evolve to central caseous necrosis and tend to become confluent, replacing the lymphoid tissue.
It is not spread by contact (non contagious) because this bacterium only resides and develops in the lymph nodes, not spreading out.It is non contagious.
Tuberculous lymphadenitis is seen in most developing countries, especially in the context of HIV/AIDS.
Lymph node TB may spread to lungs:
Reactivation of latent TB can start in the lymph nodes resulting in dissemination of Mycobacteria to the lungs and other organs. Involvement of the lymph nodes may improve Bacille Calmette-Guerin (BCG) vaccine efficacy.
The causes for lymph nodes to become Tuberculous:
Tuberculous lymphadenitis is the result of lymph nodal infection by tuberculous mycobacteria, such as Mycobacterium tuberculosis or Mycobacterium bovis. M. tuberculosis is a serious global health problem, with approximately one third of the world's population infected by this pathogen.
The complications of lymph node TB:
Possible complications of lymph node tuberculosis are
Enlarged lymph nodes; Persistent purulent leak; Recurrence many times; nodes stick together.
Tuberculosis causes nerve compression;
Tuberculosis has spread to other organs.
The most common lymph node infected in TB:
Lymph nodes, particularly thoracic lymph nodes, are among the most common sites of extrapulmonary tuberculosis .
Lymph TB is called lymphasdenitis.
Tuberculous lymphadenitis is among the most frequent presentations of extrapulmonary tuberculosis (TB). Tuberculous lymphadenitis in the cervical region is known as "scrofula." This syndrome can also be caused by non-tuberculous mycobacteria.
Laboratory diagnosis of lymph nodes TB:
Diagnosis of tuberculous lymphadenitis usually involves fine-needle aspiration (FNAC) or excisional biopsy with histopathologic examination, examination for acid-fast organisms, and culture for mycobacteria.Lymph node biopsy detect TB.
GeneXpert test:
Genexpert is a new test for rapid diagnosis of TB and drug resistance. The test is very fast and fully automated, detecting acid fast bacilli and in less than 2 hours, as compared to standard cultures which detect growth in 3 to 5 weeks and an additional 3 weeks for drug resistance determination.
GeneXpert is a rapid molecular test that allows the detection of M. tuberculosis and simultaneously detects resistance to the antibiotic rifampicin, all in less than two hours.
GeneXpert test of lymph node TB is done from biopsy material .
It is a semiautomated and rapid method based on the detection of DNA of Mycobacterium tuberculosis and mutations responsible for rifampicin resistance.
This method has been endorsed by the World Health Organization (WHO) for rapid diagnosis of TB .
Gene-Xpert, a CBNAAT (Cartridge Based Nucleic Acid Amplification Test) is a widely accepted diagnostic test for Tuberculosis. This test is a rapid diagnostic test for Tuberculosis detection as well as Rifampicin resistance in direct smear negative cases. Gene-Xpert is real-time PCR based rapid molecular assay for diagnosing TB.
A sputum sample is collected from the patient with suspected TB. The sputum/biopsy material is mixed with the reagent that is provided with the assay, and a cartridge containing this mixture is placed in the GeneXpert machine. All processing from this point on is fully automated.
Chemotherapeutic treatment of lymph node tuberculosis:
The chemotherapy is the main treatment for lymph node tuberculosis.
Lymph node TB is a serious condition with a several months treatment plan. Antibiotics like isoniazid, rifampin, and ethambutol are prescribed by physicians.
Treatment with anti-tubercular medications normally lasts up to one year. Symptoms may temporarily get worse during treatment.
A close cooperation between the ENT surgeon, the infectious disease specialist and the pathologist is the key to an optimum approach to lymph node tuberculosis at the head and neck level.
Lymphadenopathy usually disappears in 30–40% of patients after 3 months of antituberculous chemotherapy and in 80% after 6 months of treatment.
TB lymph nodes is treatable. The currently recommended treatment for lymph node tuberculosis is 6 months of rifampicin and isoniazid plus pyrazinamide for the first 2 months, given either daily or thrice weekly.
Treatment of Tuberculous Lymphadenitis.
Rifampicin Isoniazid Ethambutol Pyrizinamide are used in the treatment of tuberculosis. Rifampicin Isoniazid Ethambutol Pyrizinamide is a combination of four medicines namely
Rifampicin, isoniazid and ethambutol,Pyrizinamide which treats tuberculosis.
How Isoniazid Rifampicin Ethambutol Pyrazinamide works?
Isoniazid Rifampicin Ethambutol Pyrazinamide is a combination of four medicines: Isoniazid, rifampicin, ethambutol and pyrazinamide which treat tuberculosis. Isoniazid works by preventing the TB bacteria from forming their own protective covering, while rifampicin inactivates a bacterial enzyme (RNA-polymerase) which is required by TB bacteria to make essential proteins and to reproduce. Together, they kill the bacteria and eradicate the infection. Ethambutol and pyrazinamide on the other hand, work by slowing the growth of these bacteria.
The regimen of standard anti-TB treatment consisted of a combination of isoniazid (5 mg/kg/day or a total daily dose of 300 mg), rifampicin (10 mg/kg/day or a total daily dose of 600 mg), ethambutol (15 mg/kg/day), and pyrazinamide (25 mg/kg/day) once a day for the first 2 months.
It is also recommended to perform the excision of adenopathies ≥3 cm in diameter, abscesses, and fistulas.
Drainage is not necessary if followed by anti-tubercular medication.
Lymph node dissection is also indicated in case of recurrence, resistance to antibacillary drugs, and paradoxical upgrading reaction.
Use of Steroids in treatment of TB lymphnode:
Steroids when given along with anti-tubercular drugs treatment led to faster and earlier resolution of tuberculous lymphadenitis. Complication and sequela in form of residual lymph node are also less in steroid group as compared to non steroid group.
It was concluded that steroids when given along with anti-tubercular treatment led to faster and earlier resolution of tuberculous lymphadenitis.
Oral steroids are also used to reduce the inflammation.
Although steroids (Prednisone) will cause the lymph nodes to decrease in size, regardless of the cause of the enlargement, it is strongly discouraged because it could mask a serious underlying cause of the enlarged nodes, delay the correct diagnosis, and, possibly, complicate the treatment.
Corticosteroids are often used as an adjunct in the treatment of various forms of tuberculosis (TB) and for the prevention of complications, such as constrictive pericarditis, hydrocephalus, focal neurological deficits, pleural adhesions, and intestinal strictures.
Omnacortil-10 Tablet 10's belongs to the class of steroid or corticosteroid medicine.Omnacartil 10 mg is used to treat inflammatory and auto-immune conditions such as allergies, inflammation (affecting lungs, blood vessels & heart, bowel, kidneys, muscles, joints, eye or nervous system), skin conditions, infections and cancers (such as leukemia, lymphoma, and myeloma).
Lymph node TB does not come back. Most cases of lymph node enlargement after completing tuberculosis (TB) treatment are due to paradoxical reaction (PR), not relapse, and therefore, do not require re‐treatment.
Information compiled by:
Dr . Bhairavsinh Raol
