Tubercular Lymphadenitis - The Lung Centerthelungcenter.co.in/yahoo_site_admin/assets/docs/... ·...

TubercularTubercularLymphadenitisLymphadenitis

Clinical PresentationClinical Presentation

Tubercular lymphadenitisTubercular lymphadenitisAny age (commonly in 2Any age (commonly in 2ndnd and 3and 3rdrd decade )decade )Sex ( F : M , 2:1 )Sex ( F : M , 2:1 )Immune competenceImmune competenceHIV ( Multifocal lymphadenopathy ) HIV ( Multifocal lymphadenopathy )

Clinical PresentationClinical Presentation

Most common presentationMost common presentationPainless enlarging massesPainless enlarging massesSystemic featuresSystemic features

FeverFeverWeight lossWeight lossFatigueFatigueNight sweatsNight sweats

AsymptomaticAsymptomatic

Clinical PresentationClinical Presentation

Mediastinal lymphadenopathy

CoughDysphagiaOesophageal mediastinal fistulaTracheo oesophageal fistulaThoracic duct obstructionCardiac tamponade

Clinical PresentationClinical Presentation

Clinical stages ( Jones and Campbell )Clinical stages ( Jones and Campbell )

Stage 1Stage 1-- Enlarged, firm mobile discrete nodes Enlarged, firm mobile discrete nodes showing non specific reactive hyperplasia showing non specific reactive hyperplasia

Stage 2Stage 2-- Larger rubbery nodes fixed to surrounding Larger rubbery nodes fixed to surrounding tissue owing to periadenitistissue owing to periadenitis

Stage 3Stage 3-- Central softening due to abscess formationCentral softening due to abscess formation

Stage 4Stage 4-- Collar stud abscessCollar stud abscess

Stage 5Stage 5-- Sinus tract formationSinus tract formation

•• Br J Br J SurgSurg 1962; 50:3021962; 50:302--1414

Differential DiagnosisDifferential Diagnosis

Secondary Carcinoma (hard, fixed)Secondary Carcinoma (hard, fixed)

Lymphoma (rubbery, not matted)Lymphoma (rubbery, not matted)

Sarcoidosis (bilateral)Sarcoidosis (bilateral)

Bacterial adenitisBacterial adenitis

Viral adenitisViral adenitis

Differential DiagnosisDifferential Diagnosis

ToxoplasmaToxoplasma

Fungal diseasesFungal diseases

Collagen vascular diseasesCollagen vascular diseases

SarcomaSarcoma

Cat scratch feverCat scratch fever

Non tubercular Mycobacteria ( NTM )Non tubercular Mycobacteria ( NTM )

Tubercular Tubercular lymphadenitislymphadenitis

NTM NTM lymphadenitis lymphadenitis

Age Age Any ageAny age Children Children Constitutional Constitutional symptomssymptoms

Common Common Rare Rare

Disease Disease Systemic Systemic Localized Localized Lung / Pleural Lung / Pleural diseasedisease

Common Common Rare Rare

Tuberculin skin testTuberculin skin test Reactive Reactive Non reactiveNon reactive

Response to ATTResponse to ATT Good Good Poor Poor

Diagnosis Diagnosis

History History

Clinical examinationClinical examinationEnlarged Enlarged Non tenderNon tenderMultipleMultipleMatted lymph nodesMatted lymph nodes

DiagnosisDiagnosis

Investigations Investigations

Tuberculin testingTuberculin testingPositive in 75%Positive in 75%

Imaging Imaging Chest X RaysChest X RaysCT scanCT scan

Cytology / HistopathologyCytology / Histopathology

Tuberculin testingTuberculin testing

Positive in 75 % patientsPositive in 75 % patients

Negative does not rule out possibility of Negative does not rule out possibility of tuberculosis tuberculosis

ImagingImaging

Chest X Ray Chest X Ray

Healed pulmonary lesionsHealed pulmonary lesions

Paratracheal,hilar,mediastinalParatracheal,hilar,mediastinal lymphnodeslymphnodes

Active pulmonary tuberculosisActive pulmonary tuberculosis

Chest X RayChest X Ray

Right Right paratrachealparatracheal massmassInfiltrates in Left upper zoneInfiltrates in Left upper zone

• Radiology 1987; 164:115-119

CECTCECT

Lymph node enlargement Lymph node enlargement

Central necrosis ( hypodense areas )Central necrosis ( hypodense areas )

Peripheral rim enhancement Peripheral rim enhancement

Uniform,thin,complete enhancing rimUniform,thin,complete enhancing rim

Thick,irregular,complete or incomplete,peripheral rim Thick,irregular,complete or incomplete,peripheral rim

Groups of nodes showing peripheral and central rim Groups of nodes showing peripheral and central rim

enhancementenhancement

Non homogenous enhancementNon homogenous enhancement• Radiology 1987; 164:115-119

CECTCECT

CalcificationCalcification

Multiple septa Multiple septa

Obliteration of Obliteration of perinodalperinodal fat fat

• Radiology 1987; 164:115-119

CECTCECT

Multiple enlarged lymph nodesMultiple enlarged lymph nodesCentral areas of low attenuationCentral areas of low attenuationPeripheral enhancement Peripheral enhancement

• RadioGraphics 2000; 20: 449-470

CECTCECT

Central areas of low attenuationCentral areas of low attenuationPeripheral ring enhancementPeripheral ring enhancementCalcification Calcification Perinodal fat obliteration Perinodal fat obliteration

• Radiology 1987; 164:115-119

Others Others

Ultrasound Ultrasound Retroperitoneal Retroperitoneal

Porta hepatis Porta hepatis

Mesenteric lymph nodesMesenteric lymph nodes

MRIMRI

Lymph node enlargementLymph node enlargement

Multiple hypodense areasMultiple hypodense areas

Biopsy Biopsy

FNAC FNAC -- Investigation of choiceInvestigation of choice

Relatively PainlessRelatively PainlessNon invasiveNon invasiveOut patient procedureOut patient procedure

BiopsyBiopsy

Incisional biopsyIncisional biopsyContraindicatedContraindicated

Surgical excisional lymph node biopsySurgical excisional lymph node biopsyGold StandardGold StandardFNAC failsFNAC failsRequired for treatmentRequired for treatment

Cytology / HistopathologyCytology / Histopathology

Established by visualizing MycobacteriaEstablished by visualizing Mycobacteria

HistopathologyHistopathology

AFB StainingAFB Staining

Mycobacterial culturesMycobacterial cultures

Histopathogy Histopathogy

Epithelioid cell granuloma with or without Epithelioid cell granuloma with or without multinucleate giant cellsmultinucleate giant cells

Caseation necrosis Caseation necrosis

AFB StainingAFB Staining

Diagnostic Diagnostic

Yield increases in presence of necrosisYield increases in presence of necrosis

Mycobacterial culturesMycobacterial cultures

ConfirmatoryConfirmatory

Gives the drug sensitivity patternGives the drug sensitivity pattern

Differentiate between non tubercular and Differentiate between non tubercular and

tubercular Mycobacteriatubercular Mycobacteria

Transport mediaTransport media-- Kirchner liquid mediaKirchner liquid media

Treatment Treatment

Medical Medical

ChemotherapyChemotherapyHRZE for 1HRZE for 1stst 2 months2 monthsHR for next 4 to 7 monthsHR for next 4 to 7 months

DOTS DOTS HRZ for 2 monthsHRZ for 2 monthsHR for next 4 monthsHR for next 4 months

Surgical Surgical

Persistent fluctuant lesionsPersistent fluctuant lesions

Not resolving with chemotherapyNot resolving with chemotherapy

FNAC not availableFNAC not available

Symptomatic reliefSymptomatic relief

ComplicationsComplications

Paradoxical responseParadoxical responseNodes may enlarge or new nodes may Nodes may enlarge or new nodes may emerge emerge –– immunological phenomenon immunological phenomenon (transient) (transient)

FluctuationFluctuationSinus tract formationSinus tract formationSecondary bacterial infection and abscess Secondary bacterial infection and abscess formationformationJaundiceJaundice

ComplicationsComplications

Dysphagia

Oesophageal mediastinal fistula

Tracheo oesophageal fistula

Thoracic duct obstruction (chylothorax, chylous ascites, chyluria)

Cardiac tamponade

Complications Complications

Residual lymph nodesResidual lymph nodesClose follow upClose follow up

Increase in sizeIncrease in size

Reappearance of systemic featuresReappearance of systemic features

Excision biopsy (histology and culture)Excision biopsy (histology and culture)

RetreatmentRetreatment

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