Superficial glandular tuberculosis; treatment with chemotherapy

The chemotherapy of tuberculous lymphadenopathy in children

The chemotherapy of tuberculous lymphadenopthy, the commonest form of extra-pulmonary tuberculosis, is reviewed and a recommendation made for the treatment of this condition in children. Fifteen papers were identified recording the treatment and follow-up of 1133 adults and children with six-month isoniazid and rifampicin based regimens. In 32 (2.8%) cases treatment was recommenced, but in only one case was relapse microbiologically confirmed and in a further four histology was compatible with tuberculosis. Four studies enrolling 484 adults and children, record the follow-up of patients receiving 6-18 months treatment with INH and RMP based regimens; treatment was recommenced in 24 (5%), but in no case was relapse confirmed microbiologically. Five papers describe the treatment and follow-up of 246 adults and children receiving nine-month INH and RMP based regimens and record the recommencement of treatment in 4 (1.6%) cases, but in no case was relapse confirmed microbiologically. Four controlled studies failed to show any advantage for treatment regimens longer than six months. Paradoxical recurrence and worsening of clinical features was common during and following all regimens being recorded in from 3 to 20% of patients. Very seldom were these events accompanied by evidence of culture of Mycobacterium tuberculosis to confirm microbiological failure to respond or relapse. Tuberculous lymphadenopathy in children can be safely treated with six months of INH and RMP with PZA given for the first two months and accompanied by EMB in areas with a high prevalence of drug resistance. Every effort should be made to confirm the diagnosis and possible relapses microbiologically.

Peripheral tuberculous lymphadenitis: epidemiology, diagnosis, treatment, and outcome

We reviewed 106 patients referred to our institution for treatment of peripheral tuberculous adenitis to establish the epidemiologic, clinical, and pathologic manifestations of this disease. Tuberculous lymphadenitis occurred predominantly in young, foreign-born women a mean of 5 years after arrival in the United States. Tuberculin skin tests were positive in 94% of cases. Lymphadenopathy occurred most frequently in the neck (57%) or supraclavicular area (26%) and involved 1-3 nodes. Forty (38%) patients had an abnormal chest radiograph consistent with granulomatous infection. Culture-positive pulmonary tuberculosis was diagnosed in 41% of those patients with abnormal chest radiographs. Fine needle aspiration was an essential step in the evaluation and diagnosis of tuberculous lymphadenitis. Granulomas were seen in 61% of fine needle aspirates and 88% of surgical biopsies. Positive cultures for Mycobacterium tuberculosis were obtained from 62% of fine needle aspirate samples and 71% of excisional biopsies. The presence of necrosis and/or neutrophilic inflammation in tissue samples correlated with culture positivity. Given the high yield of positive cultures from fine needle aspirates, surgery was rarely indicated as an initial step in immunocompetent adults. In this cohort, 101 patients received a final diagnosis of peripheral tuberculous lymphadenitis. Eighty-two percent received their entire therapy under direct observation, and response to antituberculous therapy was uniformly successful. Paradoxical expansion of adenopathy was seen in 20% of all patients and was more commonly noted in human immunodeficiency virus-seropositive patients. We present a diagnostic algorithm based on our experience.

Diagnosis and treatment of cervical tuberculous lymphadenitis

PURPOSE

This study presents the long-term results of treatment of a series of patients with tuberculous mycobacterial lymphadenitis of the head and neck.

PATIENTS

Twenty-one patients were seen in a 10-year period. The median age at onset was of 41.2 years (range, 4 to 79 years), and the male-to-female ratio was 11:10. Sixteen patients were of Ethiopian origin, 3 from the former USSR, and 2 were Israeli women (1 of Indian and 1 of Morrocan origin). Symptoms started between 2 weeks and 6 months before presentation (mean, 5.8 weeks). Most patients had negative chest radiographs, a variable response to the tuberculin skin test, and a negative culture for mycobacterial organisms.

RESULTS

Fine-needle aspiration (FNA) of the cervical lymph nodes was the most reliable method to confirm the bacteriologic agent causing the lymphadenopathy. Acid-fast bacilli smears of the aspirate were positive in all but 3 patients, whereas histologic examination of the lymph nodes gave diagnostic results in only two thirds of cases examined. All patients were treated with antituberculous chemotherapy. Sixteen patients also underwent surgical excision of their cervical lymph nodes, and all of them showed a complete response to the combined treatment. The remaining patients reacted to chemotherapy alone with complete cure. One patient died of gastric carcinoma, and the only acquired immune deficiency syndrome (AIDS) patient died a year later of cytomegalovirus encephalitis.

CONCLUSION

The most reliable indicator of cervical mycobacterial infection is an acid-fast smear from the FNA specimen. Antituberculous chemotherapy, with or without surgical excision of the involved cervical lymph nodes, is the method of choice for treatment of this disease.

Mycobacterial infections of the head and neck

Despite the decline of pulmonary tuberculosis in the Western world, the incidence of cervical mycobacterial infections has remained relatively unaffected. A retrospective review was conducted of 20 patients treated for head and neck tuberculosis from 1984 to 1991. They were mostly an immigrant group coming from underdeveloped countries close to the equator. All cases were treated with antituberculous chemotherapy; 18 patients also underwent surgical excision of their lymphadenopathy. Sixteen patients showed complete response to combined treatment and one relapse was successfully retreated with antituberculous medication. Three patients died from unrelated causes--two from human immunodeficiency virus infection and one from nasopharyngeal carcinoma. The most reliable indicator of mycobacterial infection was the pathologic specimen, making the need for surgical intervention an important diagnostic consideration. As with other reports, most patients in our series had negative chest x-ray films, variable responses to skin testing, and negative cultures. The epidemiology, pathogenesis, and management of this disease are discussed.

The treatment of superficial tuberculous lymphadenitis

Tuberculosis of the superficial lymph nodes responds well to chemotherapy, with uneventful resolution of the condition in 70% of patients. Nodes can appear afresh or enlarge during treatment but usually resolve. Fluctuation, discharge, sinus formation and scar breakdown occur in the minority. At the end of chemotherapy 10% may be left with residual nodes. After chemotherapy nodes can enlarge or appear afresh, usually transiently. Such events do not imply relapse, nor does the persistence of nodes presage relapse. Initial excision does not seem to affect outcome and surgical procedures should be reserved for the relief of discomfort caused by enlarged nodes or tense, fluctuant nodes. Nine months of rifampicin and isoniazid, supplemented by ethambutol for the first 2 months, is the current treatment of choice for tuberculous lymphadenitis. Shorter regimens are under investigation.

Lymph node tuberculosis: a comparison of various methods of treatment

The treatment of lymph node tuberculosis has been studied in 108 patients. Chemotherapy consisted of 18 months' isoniazid with either rifampicin or ethambutol, plus an initial supplement of streptomycin. These 2 regimens were randomly allocated to 19 patients who had previously undergone excision of the lymph nodes, 56 patients who had undergone biopsy and 33 patients who had not had any surgical procedures. The majority of patients were of Indian or Pakistani origin (80%). Histological evidence of tuberculosis was obtained in 64% of the 108 patients and M. tuberculosis was cultured in 30%. No other mycobacteria were grown. Progress during treatment was uneventful in 65% of patients. Fresh nodes appeared during treatment in 12%, existing nodes enlarged in 13% and fluctuation developed in 11% of patients. Discharge and/or sinus formation was infrequent (7%), as was breakdown of a surgical scar (4%). Excision or aspiration after the start of chemotherapy was performed in 19% of patients. In the period up to the end of chemotherapy no difference emerged between the patients who received rifampicin with isoniazid and those who received ethambutol with isoniazid. Satisfactory results were obtained in 98% of the patients by the end of treatment although 13% still had slight node enlargement. The place of surgery is discussed. Follow-up will continue for 18 months after the end of chemotherapy.

Peripheral tuberculous lymphadenitis in the elderly

Retrospective and current studies of peripheral tuberculous lymphadenitis in the elderly (over the age of 60 years) are described. The efficacy and side-effects of standard antituberculous chemotherapy in this group of patients are analysed. Simple excisional surgery with the local instillation of streptomycin is suggested as a rational and effective method of treatment of localized tuberculous lymphadenitis in the elderly.