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ORIGINAL ARTICLE
Year : 2018  |  Volume : 45  |  Issue : 2  |  Page : 76-79

Clinicopathological profile and outcome of 29 lymph node tuberculosis cases


1 Department of Medicine, Chattagram Maa-O-Shishu Hospital Medical College, Agrabad, Chittagong, Bangladesh
2 Department of Respiratory Medicine, Chattagram Maa-O-Shishu Hospital Medical College, Agrabad, Chittagong, Bangladesh

Date of Web Publication10-Dec-2018

Correspondence Address:
Rajat Sanker Roy Biswas
Department of Medicine, Chattagram Maa-O-Shishu Hospital Medical College, Agrabad, Chittagong
Bangladesh
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.JSS_50_18

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  Abstract 


Introduction: In countries like Bangladesh, tuberculous lymphadenopathy is a common extrapulmonary site. Its diagnosis and management is a challenge for the primary care physicians for its various clinical and pathological presentations. Hence, the objective of the present study is to describe the clinicopathological profile and outcome of lymph node tuberculosis (TB) cases in our setting. Methods: It was a prospective observational study done among 29 lymph node cases attending the outpatient and inpatient department of medicine of a tertiary care hospital in a period of 2 years. After written informed consent, clinical points are noted and fine-needle aspiration cytology (FNAC) or biopsy of lymph node was done and histologically evaluated and the patients were followed up further. After collection of all data, it was compiled and analyzed by SPSS version 20. Results: Among 29 cases, female patients (17, 58.6%) were more than the male (12, 41.4%) patients and most of the patients were at the age group of 21–30 years (48.3%). Most patients presented with fever (62.1%), weight loss (51.7%), night sweating 62.1%), anorexia (55.2%), and cough (27.6%). Among all, 20 (69%) patients presented with multiple enlarged lymph node group and 9 (31.0%) had involvement of single group. Cervical group involvement was the most common (25, 86.2%), and matting of lymph node was present in 20 (69%) cases. Among all, 24 (82.8%) cases were diagnosed by FNAC and 5 (17.2%) was diagnosed by biopsy. In microscopic evaluation, 18 (62.1%) cases had caseous necrosis, 27 (93.1%) had epithelioid cells and 8 (27.6%) had giant cells. Regarding other investigations, 8 (27.6%) patients had positive mantoux test (MT), 4 (13.8%) had concomitant pulmonary TB, and one case was found sputum positive for acid-fast bacilli. Regarding outcome evaluation, 20 (69%) cases were declared cured, 7 (24.1%) were lost to follow-up, one case died, and one cases was declared multi drug resistant tuberculosis (MDR) TB. Conclusion: In the study, bacteriological evaluation of the response to treatment cannot be done due to difficulty in obtaining follow-up specimens from the lymph node. Response was judged on the basis of clinical features and local examination findings.

Keywords: Extrapulmonary tuberculosis, fine-needle aspiration cytology, lymph node tuberculosis


How to cite this article:
Roy Biswas RS, Kibria Chowdhury MF, Hasan Mamun SM. Clinicopathological profile and outcome of 29 lymph node tuberculosis cases. J Sci Soc 2018;45:76-9

How to cite this URL:
Roy Biswas RS, Kibria Chowdhury MF, Hasan Mamun SM. Clinicopathological profile and outcome of 29 lymph node tuberculosis cases. J Sci Soc [serial online] 2018 [cited 2019 Mar 19];45:76-9. Available from: http://www.jscisociety.com/text.asp?2018/45/2/76/247160




  Introduction Top


Tuberculosis (TB) is one of the most ancient diseases of humankind, and it is prevailing in the society perhaps for several million years.[1] Tuberculosis is caused by a group of closely related bacterial species termed Mycobacterium tuberculosis complex. Today, the principal cause of human TB is M. tuberculosis. Other members of the M. tuberculosis complex that can cause TB include Mycobacterium bovis, Mycobacterium microti, and Mycobacterium africanum.[2]

Regarding TB burden, 2 billion people, equal to one-third of the world's total population, are infected with the TB bacilli, among them 1.8 million people die every year due to TB. Surprisingly, 98% of TB deaths are in developing world, affecting mostly young adults in their most productive years.[3]

In Bangladesh, the prevalence rate of TB is 404/100,000 and the incidence rate was 225/100,000. Regarding the development of multidrug-resistant cases, it is 29% in retreatment cases and 1.6% in new cases. TB/HIV is 0.01% and extrapulmonary TB is around 20% in Bangladesh. It is to be noted that missing cases of TB after diagnosis and initiation of therapy are 39%, which is the alarming data of Bangladesh.[4]

Worldwide, between 10% and 25% of TB infections occur in extrapulmonary sites. Those sites are pleura (most common), lymph nodes (LNs), bones and joints, central nervous system (CNS; usually meningitis, but can occur in brain or spine), larynx, pericardium, abdominal sites, kidneys, genitourinary tract, and disseminated (miliary). Data of LNTB in Bangladesh are scarce. It is a good opportunity to do a study in this context.


  Methods Top


It was a prospective observational study done among 29 clinically and histopathologically diagnosed lymph node TB cases attending the outpatient and inpatient department of medicine of a tertiary care hospital during a period of 1½ year. Ethical clearance from the hospital authority was taken before starting the study. After written informed consent, clinical points of suspected LNTB were noted. Candidates fulfilling the clinical criteria of LNTB, a plan for fine-needle aspiration cytology (FNAC) or biopsy, were done. After explanation of the procedure, all cases were undergone either FNAC or biopsy of lymph node. If cytological or histological proof of LNTB was found, then that patient was finally included in the study. Diagnosis of LNTB was done as per the cytology or tissue report, and all reports were done by a single expert pathologist. TB diagnosis was based on the findings of granulomatous inflammation in the specimen. Acid-fast bacilli (AFB) culture was not done on cytological or tissue specimen. According to the national guideline of Bangladesh, all patients were given CAT-1 anti–TB, and all patients were tagged with DOT's corner of the hospital. Patients were followed up for next 6 months. Follow-up was extended to those who were advised to extend their anti-TB course further. Treatment response and drug toxicities were noted. Follow-up reports were collected physically or by phone call. After collection of all data, it was compiled and analyzed by SPSS version 20 (IBM, Armonk, NY, USA).


  Results Top


Among 29 cases of lymph node TB, females (17, 58.6%) were more than the male (12, 41.4%) patients and most of the patients were at the age group of 21–30 years (48.3%) [Table 1]. Most patients presented with fever (62.1%), weight loss (51.7%), night sweating (62.1%), anorexia (55.2%), and cough (27.6%) [Table 2]. Among all, 20 (69%) patients presented with multiple enlarged lymph node group and 9 (31.0%) had involvement of single group. Cervical group involvement was the most common (25, 86.2%), axillary was 3 (10.3%), and mediastinal was 1 (3.4%). Matting of lymph node was present in 20 (69%) cases, 20 (69%) had tenderness, and 3 (10.3%) had discharge [Table 3]. Among all, 24 (82.8%) cases were diagnosed by FNAC and 5 (17.2%) were diagnosed by biopsy. Among 29 cases, 18 (62.1%) had caseous necrosis, 27 (93.1%) had epithelioid cells, and 8 (27.6%) had giant cells [Table 4]. Regarding other test results, 8 (27.6%) cases had positive MT test, 4 (13.8%) had concomitant pulmonary TB, and one case was found sputum positive for AFB [Table 5]. Regarding outcome analysis on 29 cases, 20 (69%) were declared cured, 7 (24.1%) were lost to follow-up, one case died, and one case was declared MDR TB. Extension of treatment >6 months was given in 16 (55.2%) cases, surgical excision of involved LN was done in 3 (10.3%) cases, one case developed drug toxicity, and one case was diagnosed lymphoma later [Table 6].
Table 1: Gender, age, and occupation of the study patients

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Table 2: Clinical parameters

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Table 3: Lymph node study findings

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Table 4: Cellular and tissue diagnosis

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Table 5: Screening test results

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Table 6: Outcome

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  Discussion Top


Extrapulmonary TB affects LNs, gastrointestinal tract, musculoskeletal system, genitourinary system, CNS, pleura, and pericardium, although any organ can be involved. Hippocrates recognized the severity of abdominal TB by pointing out that “diarrhoea attacking a person with emaciation is a mortal symptom.”[4],[5] In Bangladesh, TB case notifications have increased significantly since 2012, mainly driven by increased numbers of extrapulmonary and clinically diagnosed pulmonary cases.[3]

In the present study, among all cases of lymph node TB, females were affected more than the male patients. A study done by Khandkar et al.[6] found that female-to-male ratio for LNTB was 2.8:1. Hence, the present study findings are consistent with previous studies that found that LNTB is more common among women. In Bangladesh, most poor females work in different garment factories, live in a crowded place, and are unaware of health hygiene. These may be reason of female preponderance of LNTB in our study.

We found that most of the patients were at younger age group. Age differs between patient populations with LNTB and PTB. Golden and Vikram [5] documented a skewed unimodal distribution toward younger age (25–34 years) in LNTB populations, while displaying bimodal distribution in their PTB population with peaks at 25–34 years and 65+ years.

Most patients presented with fever (62.1%), weight loss (51.7%), night sweating (62.1%), anorexia (55.2%), and cough (27.6%). These are some common constitutional presentation of extrapulmonary TB. General signs (weight loss, sweats, fever, and asthenia) are found in 20%–50%.[7]

Among all, 20 (69%) patients presented with multiple enlarged lymph node group and 9 (31.0%) had involvement of single group. Cervical group involvement was the most common (25, 86.2%), axillary was 3 (10.3%), and mediastinal was 1 (3.4%). Matting of lymph node was present in 20 (69%) cases, 20 (69%) had tenderness, and 3 (10.3%) had discharge. Involved LNTB usually causes a painful swelling of one or more LNs. Most often, the disease is localized to the anterior or posterior cervical chains (70%–90%) or supraclavicular. It is often bilateral, and noncontiguous LNs can be involved.[8] The jugulo-carotidian location is the most common and relapses occur in about 5% of cases.[9]

Regarding diagnosis, 24 (82.8%) cases were diagnosed by FNAC and 5 (17.2%) were diagnosed by biopsy. They meet the different histopathological and cytopathological criteria. Among all, 8 (27.6%) had positive MT test, 4 (13.8%) had concomitant pulmonary TB, and one case was found sputum positive for AFB. When the bacillus is not found, histology may help by showing an epithelioid and giganto cellular granuloma with caseous necrosis in immunocompetent patients. Surgical biopsy resection of the LN is the best examination for diagnostic confirmation, with a sensitivity of 100% for histological analysis and 60%–90% for the bacilli culture.[10]

Outcome analysis on 29 cases revealed that 20 (69%) were declared cured, 7 (24.1%) were lost to follow-up, one case died, and one case was declared MBR TB. Extension of treatment >6 months was given in 16 (55.2%) cases, surgical excision of involved LN was done in 3 (10.3%) cases, one case developed drug toxicity, and one case was diagnosed as lymphoma later. Six months' regimen showed variable response in the outcome of lymph node TB,[11],[12] and in the present study, treatment regime needed to extend beyond 6 months.

Tuberculous lymphadenitis represents about 10% of cases of TB in Bangladesh and is frequently the sole manifestation of extrapulmonary TB. Disease rates are highest among patients aged 21–30 years, and disease is more common among women. Tuberculous lymphadenitis may respond slowly to standard antibiotic treatment, with persistent discomfort. Frequent patient follow-up during treatment is recommended for reassurance and management of local discomfort, and further study is needed as an adjunct to standard antibiotic therapy to improve the otherwise slow response to treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hirsh AE, Tsolaki AG, DeRiemer K, Feldman MW, Small PM. Stable association between strains of Mycobacterium tuberculosis and their human host populations. Proc Natl Acad Sci U S A 2004;101:4871-6.  Back to cited text no. 1
    
2.
Prasad HK, Singhal A, Mishra A, Shah NP, Katoch VM, Thakral SS, et al. Bovine tuberculosis in India: Potential basis for zoonosis. Tuberculosis (Edinb) 2005;85:421-8.  Back to cited text no. 2
    
3.
Ravigilion MC, O'Brien RJ, Tuberculosis. In: Fauci, Kasper, Hauser, Jameson, Lascolzo, editors. Harrison's Principles of Internal Medicine. 17th ed., Vol. 165. New Delhi: Mac Grow Hill; 2008. p. 1340-58.  Back to cited text no. 3
    
4.
National Tuberculosis Control Programme. Tuberculosis Control in Bangladesh. Annual Report 2015. Dhaka: Director General of Health Services; 2015.  Back to cited text no. 4
    
5.
Golden MP, Vikram HR. Extrapulmonary tuberculosis: An overview. Am Fam Physician 2005;72:1761-8.  Back to cited text no. 5
    
6.
Khandkar C, Harrington Z, Jelfs PJ, Sintchenko V, Dobler CC. Epidemiology of peripheral lymph node tuberculosis and genotyping of M. tuberculosis strains: A case-control study. PLoS One 2015;10:e0132400.  Back to cited text no. 6
    
7.
Hochedez P, Zeller V, Truffot C, Ansart S, Caumes E, Tubiana R, et al. Lymph-node tuberculosis in patients infected or not with HIV: General characteristics, clinical presentation, microbiological diagnosis and treatment. Pathol Biol (Paris) 2003;51:496-502.  Back to cited text no. 7
    
8.
Artenstein AW, Kim JH, Williams WJ, Chung RC. Isolated peripheral tuberculous lymphadenitis in adults: Current clinical and diagnostic issues. Clin Infect Dis 1995;20:876-82.  Back to cited text no. 8
    
9.
Elloumi M, Fakhfakh S, Frikha M. Diagnostic and therapeutic aspects of lymph node TB; study of 41 cases. Tunisia Medical Journal 1999;10:491-6.  Back to cited text no. 9
    
10.
Benjelloun A, Darouassi Y, Zakaria Y, Bouchentouf R, Errami N. Lymph nodes tuberculosis: A retrospective study on clinical and therapeutic features. Pan Afr Med J 2015;20:65.  Back to cited text no. 10
    
11.
Yuen AP, Wong SH, Tam CM, Chan SL, Wei WI, Lau SK, et al. Prospective randomized study of thrice weekly six-month and nine-month chemotherapy for cervical tuberculous lymphadenopathy. Otolaryngol Head Neck Surg 1997;116:189-92.  Back to cited text no. 11
    
12.
van Loenhout-Rooyackers JH, Laheij RJ, Richter C, Verbeek AL. Shortening the duration of treatment for cervical tuberculous lymphadenitis. Eur Respir J 2000;15:192-5.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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