Tonsillar tuberculosis associated with pulmonary and laryngeal foci

Primary Peritonsillar Tuberculosis in a Rheumatoid Arthritis Patient Treated With Methotrexate

A 48-year-old man diagnosed with rheumatoid arthritis was treated with methotrexate for 10 years. He presented left tonsil ulceration and ipsilateral cervical lymphadenopathy. A tonsillar biopsy revealed tuberculosis. The patient received antituberculous therapy for 8 months with a positive response. However, after resumption of methotrexate due to worsening rheumatoid arthritis, symptoms recurred. The patient initiated antituberculous therapy once more for 6 months, and methotrexate was stopped. At regular follow-up, the patient showed a positive clinical response with resolution of tonsillar ulceration and lymphadenopathy after 14 months of antituberculosis treatment.

Primary tonsillar tuberculosis in a pediatric patient: Case report and literature review

RATIONALE

Tuberculosis is an entity that usually affects the lungs, although extrapulmonary sites can also be involved. Tonsils are rarely affected, especially in the absence of pulmonary disease, primary tonsillar tuberculosis being a diagnostic challenge for the clinician.

PATIENT CONCERNS

We present the case of a 14-year-old female teenager, presented to our Pediatric Service with a 14-day history of dysphagia, odynophagia and left reflex otalgia associated with a 5 kg weight loss. Clinical examination revealed mild pharyngeal erythema, marked enlargement of the left tonsil infiltrating the lateral pharyngeal wall and the uvula and painful, mobile, nonadherent to deep bilateral latero-cervical adenopathy.

DIAGNOSIS

Positive interferon-gamma release assay (QuantiFERON-TB gold). Mantoux test reading was 16 mm.

INTERVENTIONS

During hospitalization, the patient received Clindamycin and Gentamicin for 3 days i.v., with discrete relief of symptoms and inflammatory markers. On the 4th day of hospitalization, treatment with Imipenem/Cilastin is started for 7 days in micro-perfusion, with tonsil hypertrophy decrease in size and favorable clinical evolution.

OUTCOME

Tonsil hypertrophy decreased in size and patient had a favorable clinical evolution. At discharge, the patient was given a 6-month course of anti-tuberculous drug.

LESSONS

The particularity of this case is represented by the rarity of primary tuberculosis of tonsils in children, with unilateral involvement, displaying at the same time a common issue encountered in the current practice: the limitations and the difficult course of setting the diagnosis due to the involvement of relatives in the medical act.

Primary tonsillar tuberculosis

Upper aerodigestive tract involvement with tuberculosis is relatively rare and may be seen in up to 2% of patients with pulmonary tuberculosis. Isolated tonsil involvement with tuberculosis is not commonly seen in clinical practice. We report a case of a 22-year-old postpartum mother who presented with odynophagia, fever, loss of weight and submandibular swelling of 3 months' duration. Clinical examination revealed a submandibular node, and oropharyngeal examination revealed necrotic slough overlying an enlarged left tonsil. Fine-needle aspiration cytology of the node and histopathological examination of the left tonsillectomy specimen revealed necrotising epithelioid cell granulomas, and stain for acid-fast bacilli was positive in the latter. She was diagnosed with tonsillar tuberculosis and was started on antituberculous treatment following which she improved clinically. This case serves to demonstrate an uncommon presentation of primary tuberculosis and reminds us to consider tuberculosis also as a microbiological aetiology for tonsillitis.

Upper Respiratory Tract Tuberculosis

Upper respiratory tract involvement in cases of tuberculosis (TB) of the head and neck continues to be described in the most recent reports from several different regions, including some from developed countries. Laryngeal TB is the most common of all forms of upper respiratory tract TB (URT-TB). Pulmonary lesions in URT-TB are present in about 20% of adults and about 50 to 60% of children. Systemic manifestations are uncommon. URT-TB is especially seen in patients with a variety of risk factors, such as the presence of human immunodeficiency virus (HIV) infection, diabetes, smoking, alcoholism, drug abuse, malignancies, and use of immunosuppressive drugs. Nodules or ulcerative lesions are seen on morphological examination. Endoscopic examination is required for mucosal lesions. Diagnosis of TB is suspected on an epidemiological basis in high-prevalence countries or from the failure of a patient to respond to routine treatment. Smear and/or histopathological examinations help in establishing the final etiological diagnosis. Treatment includes standard anti-TB chemotherapy for at least 6 months with four primary drugs during the initial intensive phase of 2 months and two or three primary drugs during the remaining maintenance phase of 4 months. Treatment is modified on the basis of culture and sensitivity reports in cases of suspected drug resistance. Surgical intervention may be required for some patients with abscess formation and progressive disease unresponsive to medical therapy. Airway obstruction, although rare, even in fulminant cases may require tracheostomy for relief.

Tuberculosis of Waldeyer's Ring with an Atypical Presentation as Chronic Adeno-Tonsilitis

Primary tuberculosis of the oropharynx and nasopharynx is a rare clinical entity.It usually arises secondary to pulmonary tuberculosis. We report a rare case of a 20-year-female, who presented with fever and throat pain. Examination revealed hypertrophied adenoids and tonsils, which was ultimately proved as tuberculosis.Enlargement of the palatine tonsils could be due to a multitude of causes, and a thorough evaluation is necessary to arrive at the right diagnosis.Increased awareness of nasopharyngeal and oropharyngeal tuberculosis is important in tropical countries, as the disease may be overlooked resulting in inappropriate management.

18F-FDG PET/CT findings of pharyngeal tuberculosis

A 58-year-old woman with dysphagia and hoarseness underwent 18F-FDG PET/CT to detect the original lesion and disease spread. Bilateral cervical lymphadenopathy and abnormal FDG uptakes in the right tonsil and pharyngeal wall were demonstrated. CT and MRI confirmed the bilateral cervical lymphadenopathy and mucosal thickening in the pharyngeal wall. On the basis of these findings, biopsy sites were selected. Pharyngeal tuberculosis was diagnosed based on culture of the biopsy specimens. 18F-FDG PET/CT contributed to clinical management in this case by detecting tuberculous lesions and showing the extent of these lesions in one examination.

[Secondary tuberculosis of palatine tonsils--the case report and review of literature]

INTRODUCTION

Tuberculosis, though rarely, is still present in the anatomical area of the laryngological examination.

MATERIAL AND METHODS

A case of 45-year-old woman with secondary tonsillar tuberculosis and poorly symptomatic pulmonary involvement is reported.

RESULTS

She presented with symptoms of chronic tonsillitis and was subjected to tonsillectomy. Because of systemic infection ailments she underwent further internal diagnosis. The histopathological examination of palatine tonsils and result of chest X-ray established the diagnosis of tuberculosis. She was treated with antituberculous drugs for 6 months and achieved improvement.

CONCLUSIONS

The difficulties in diagnosis in this unusual presentation of tuberculosis mimicking chronic non-specific inflammation as well as poorly symptomatic massive pulmonary involvement are outlined.

The pathogenesis and pathology of bovine tuberculosis with insights from studies of tuberculosis in humans and laboratory animal models

This paper reviews key insights the discipline of pathology has contributed to our understanding of bovine tuberculosis in the context of findings of studies of tuberculosis in humans and laboratory animal models. Analysis and extrapolation of data from other species have the potential to expand our understanding of the pathogenesis of the disease in cattle. The distribution of lesions in affected cattle, humans and laboratory animals illustrate the primacy of the respiratory tract as portal of infection and raise questions about the role of the upper respiratory tract surface, tonsil and dorsal lung regions in disease pathogenesis and transmission. The mechanisms behind significant pathological processes such as necrosis, apoptosis and liquefaction, occurring within lesions, are explored and their potential practical significance assessed in the context of herd disease dynamics and vaccine development. It is proposed that effective 'innate' host defences result in many animals and humans remaining disease-free and tuberculin test negative following exposure to infection. Furthermore, the concepts of latency and disease reactivation, considered significant factors in perpetuating tuberculosis in human populations, are explored in the context of the bovine disease.