|Year : 2004 | Volume
| Issue : 4 | Page : 50-53
Difficulties in managing lymph node tuberculosis
Professor of Chest & TB, SMS Medical College, Jaipur., India
P R Gupta
Professor of Chest & TB, SMS Medical College, Jaipur.
|How to cite this article:|
Gupta P R. Difficulties in managing lymph node tuberculosis. Lung India 2004;21:50-3
Lymph node tuberculosis constitutes 20-40% of extrapulmonary tuberculosis. It is more common in children and women than other forms of extrapulmonary tuberculosis and is more common in Asians and Pacific islanders. In developing and under developed countries, it continues to be caused by Mycobacterium tuberculosis and atypical mycobacteria are seldomly isolated. Commonly involved superficial lymph nodes (Scrofula or king's evil) include those in posterior and anterior cervical chains or the suprascapular fossae but others like submandibular, periauricular, inguinal and axillary groups may also be involved. Often, the lymphadenopathy is bilateral and noncontiguous  . Intrathoracic (hilar, paratracheal and mediastinal in decreasing order) and abdominal lymph nodes are also involved in tuberculosis. Frequency of associated pulmonary involvement varies from 5% to 62% ,, Management of lymph node tuberculosis often presents difficulties. However, most cases can be managed medically and surgical intervention is rarely required. This review focuses on the disease caused by M. tuberculosis and the difficulties that may arise during its treatment.
Tuberculous lymphadenitis usually presents as a gradually increasing painless swelling of one or more lymph nodes of weeks to months duration. Some patients, especially those with extensive disease or a co-existing disease, may have systemic symptoms i.e. fever, weight loss, fatigue and night sweats. Distressing cough may be a prominent symptom in mediastinal lymphadenitis.
Initially the nodes are firm, discrete and mobile. The overlying skin is free. Later, the nodes may become matted and the overlying skin inflammed. In more advanced stage, the nodes may soften leading to formation of abscesses and sinus tracts which may be difficult to heal. Unusually large nodes may compress or invade the adjoining structures complicating the course of the disease.
Intrathoracic nodes may compress one of the bronchus leading to atelectasis, lung infection and bronchiectasis or thoracic duct leading to chylous effusion. Other intrathoracic complications include dysphagia, , oesophago-mediastinal fistula, ,, tracheo-oesophageal fistula, , biliary obstruction  and cardiac temponade.  Retroperitoneal nodes may lead to chylous ascitis, chyluria,  and rarely renovascular hypertension.  Sometimes, the cervical nodes may compress the trachea leading to extrathoracic upper airway obstruction.
Impact of Human Immunodeficiency Virus on tuberculous lymphadenitis
HIV co-infection has considerably changed the epidemiology of tuberculosis. Tuberculous lymphadenitis is the more common form of extrapulmonary tuberculosis in these patients. Further, it is more common than lymphoma, Kaposi's sarcoma and generalised lymphadenopathy of HIV.  These patients are often older and males, involvement of multiple sites is more common and the anterior and posterior mediastinal group of lymph nodes are more often involved. A virulent form of disseminated disease may be seen in patients with AIDS. Tender lymphadenopathy, fever, weight loss and co-existing pulmonary tuberculosis are more common in HIV seropositive patients as compared to HIV seronegatives. 
Tuberculous lymphadenitis needs to be differentiated from lymphadenopathy due to other causes. These include reactive hyperplasia, lymphoma, sarcoidosis, secondary carcinoma, generalised lymphadenopathy of HIV, Kaposi sarcoma, lymphadenitis caused by Mycobacteria other than tuberculosis (MOTT), fungi, and toxoplasmosis. In general, multiplicity, matting and caseation are features of tuberculous lymphadenitis but these are neither specific nor sensitive. In lymphoma, the nodes are rubbery in consistency and are seldomly matted. In lymphadenopathy due to secondary carcinoma, the nodes are usually hard and fixed to the underlying structures or the overlying skin.
Diagnosis of tuberculous lymphadenitis
Firm diagnosis of tuberculous lymphadenitis requires demonstration of mycobacteria but the latter may not be found in several specimens that are ultimately proved to be tuberculous in aetiology. Further, obtaining a proper specimen may not always be easy.
History of exposure to a person suffering from pulmonary tuberculosis is highly suggestive of lymphatic tuberculosis in a given clinical setting.
Tuberculin skin test is positive in majority of patients of tuberculous lymphadenitis, the probability of false negative test is less than 10% ,, Thus a positive skin test seems to support the diagnosis and a negative test substantially reduces the likelihood of tuberculous lymphadenitis.
Skiagram chest should be obtained in all the patients suspected to be suffering from tuberculous lymphadenitis. It not only exclude any co-existing intrathorcic disease but the presence of an active or healed pulmonary lesion acts as a supportive evidence for tuberculous lymphadenitis in cases where the diagnosis remains in doubt i.e. a compatible biopsy but a negative culture.
Ultrasound examination of abdomen and CT scan of the chest may be required in some patients. Enlarged lymph nodes may show hypodense areas with rim enhancement or calcification. It may also demonstrate the status of the adjoining structures. It may also help obtaining pathological specimens for cyto-histopathology and culture.
Traditionally, excision biopsy is done to diagnose tuberculous lymphadenitis but fine needle aspiration cytology (FNAC), a relatively less invasive, painless and outdoor procedure, seems to have established itself as a safe, cheap and reliable procedure. , Typically, tuberculous lymph nodes show epithelioid cell granulomas, multinucleated giant cells and caseation necrosis. Caseating granulomas are seen in nearly all the biopsy specimens and 77% of the FNAC's. 
Smears may show acid fast bacilli in 25-50% of specimens and the organisms may be isolated in upto 70% of instances where tuberculous aetiology is considered.  Smears with necrosis had a higher rate of positivity (47%) as compared to smears with no necrosis 
Alternative diagnostic methods such as polymerase chain reaction tests of the tissue to identify tubercle bacilli look promising but serological tests lack sufficient sensitivity or specificity to be of real utility. Invasive procedures like mediastinoscopy, video assisted thoracoscopy or tranbronchial approach may become essential in a few patients with intrathoracic disease.
Tuberculous lymphadenitis is principally a medical disease. Surgical excision as an adjunct to chemotherapy is associated with slightly worse outcome as compared to medical treatment alone or medical treatment with aspiration of the node. 
In general, chemotherapy regimens that are effective in pulmonary tuberculosis should also be effective in tuberculous lymphadenitis also. Both, a 9 month regimen containing isoniazid, riframpicin and ethambutol for first 2 months followed by isoniazid and rifampicin for 7 months,  or a 6 month regimen containing isoniazid, rifampicin and pyrazinamide for 2 months followed by isoniazid, riframpicin for 4 months given on daily basis, ,, or on intermittent basis,  were found to be effective in containing lymph node tuberculosis. As more patients in the ethambutol group required aspiration as compared to the pyrazinamide group, the latter regimens are preferred. In India, RNTCP Category III regimen has been recommended for un-complicated TB lymphadenitis. However, most workers favour a longer duration of treatment.
Difficulties in managing lymph node tuberculosis
Apart from difficulties encountered in the diagnosis of lymph node tuberculosis mentioned earlier, certain problems such as the following, may be encountered during its treatment also:
- Appearance of freshly involved nodes,
- Enlargement of the existing nodes,
- Development of fluctuation,
- Appearance of sinus tracts,
- Residual lymphadenopathy after completion of treatment,
These peculiar problems in the management of lymph node tuberculosis were first highlighted by Byrd et al in 1971.  Although the therapy used by these workers (SHP/HP) was not so potent by modern standards but the refractoriness of lymph node tuberculosis as compared to other involved organs was quite evident. Campbell & Dyson  and Malik et al  had also noted this suboptimal response in lymph node tuberculosis.
Possible explanations this suboptimal response of therapy in lymph node tuberculosis include:
- Disease caused by MOTT (rare in India),
- Unidentified drug resistance,
- Poor drug penetration into the lymph node,
- Unfavourable local milieu,
- Enhanced delayed hypersensitivity reaction in response to mycobacterial antigens released during medical treatment of the disease.
How to overcome difficulties in managing lymph node tuberculosis ?
Proper care in diagnosis, evaluation and close monitoring of the case during treatment are the keys to success in the management of lymph node tuberculosis.
The suggested management plan is as under:
- Record all the possible sites of involvement, nature and size of the involved lymph nodes at the inception of treatment.
- Identify any co-existing disease and treat it simultaneously
- Most nodes that enlarge during therapy or appear afresh will ultimately respond to treatment. Only close follow up is required in these patients.
- Appearance of fluctuation in one or more lymph nodes calls for aspiration under all aseptic precautions.
- Any secondary bacterial infection should be dealt with appropriately that may include incision and drainage.
- Any worsening after 8 weeks of therapy calls for en block resection of the involved lymph node chain to avoid appearance of ugly sinus tracts.
- Non healing sinus tracts need resective surgery.
- Residual lymph nodes after completion of treatment should be observed closely. Any increase in size or appearance of symptoms calls for excisional biopsy for histopathology and culture. Most of these patients will respond to retreatment with the same regimen.
- All efforts should be made to isolate the causative agent and to obtain prompt sensitivity testing particularly in relapsed cases/nonresponders and chemotherapy modified accordingly.
- Since mycobacterium avium-complex is the commonest atypical organism causing lymphadenopathy in HIV positive patients, it should be managed on clarithromycin based drug regimens  .
Systemic steroids have been shown to reduce inflammation during the early phase of therapy for lymph node tuberculosis and may be considered if a node is compressing a vital structure i.e. bronchus or in diseases involving a cosmetically sensitive areas. Prednesolone, 40 mg per day for 6 weeks followed by gradual tapering over the next 4 weeks, alongwith appropriate chemotherapy is adequate. However, the safety and utility of this approach remains largely unproven except in intrathoracic disease where it was found to relieve the pressure on the compressed bronchus. 
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