tubercular lymphadenitis - the lung centerthelungcenter.co.in/yahoo_site_admin/assets/docs/... ·...
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TubercularTubercularLymphadenitisLymphadenitis
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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 )
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Clinical PresentationClinical Presentation
Most common presentationMost common presentationPainless enlarging massesPainless enlarging massesSystemic featuresSystemic features
FeverFeverWeight lossWeight lossFatigueFatigueNight sweatsNight sweats
AsymptomaticAsymptomatic
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Clinical PresentationClinical Presentation
Mediastinal lymphadenopathy
CoughDysphagiaOesophageal mediastinal fistulaTracheo oesophageal fistulaThoracic duct obstructionCardiac tamponade
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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
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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
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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 )
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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
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Diagnosis Diagnosis
History History
Clinical examinationClinical examinationEnlarged Enlarged Non tenderNon tenderMultipleMultipleMatted lymph nodesMatted lymph nodes
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DiagnosisDiagnosis
Investigations Investigations
Tuberculin testingTuberculin testingPositive in 75%Positive in 75%
Imaging Imaging Chest X RaysChest X RaysCT scanCT scan
Cytology / HistopathologyCytology / Histopathology
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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
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ImagingImaging
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Chest X Ray Chest X Ray
Healed pulmonary lesionsHealed pulmonary lesions
Paratracheal,hilar,mediastinalParatracheal,hilar,mediastinal lymphnodeslymphnodes
Active pulmonary tuberculosisActive pulmonary tuberculosis
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Chest X RayChest X Ray
Right Right paratrachealparatracheal massmassInfiltrates in Left upper zoneInfiltrates in Left upper zone
• Radiology 1987; 164:115-119
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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
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CECTCECT
CalcificationCalcification
Multiple septa Multiple septa
Obliteration of Obliteration of perinodalperinodal fat fat
• Radiology 1987; 164:115-119
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CECTCECT
Multiple enlarged lymph nodesMultiple enlarged lymph nodesCentral areas of low attenuationCentral areas of low attenuationPeripheral enhancement Peripheral enhancement
• RadioGraphics 2000; 20: 449-470
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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
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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
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Biopsy Biopsy
FNAC FNAC -- Investigation of choiceInvestigation of choice
Relatively PainlessRelatively PainlessNon invasiveNon invasiveOut patient procedureOut patient procedure
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BiopsyBiopsy
Incisional biopsyIncisional biopsyContraindicatedContraindicated
Surgical excisional lymph node biopsySurgical excisional lymph node biopsyGold StandardGold StandardFNAC failsFNAC failsRequired for treatmentRequired for treatment
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Cytology / HistopathologyCytology / Histopathology
Established by visualizing MycobacteriaEstablished by visualizing Mycobacteria
HistopathologyHistopathology
AFB StainingAFB Staining
Mycobacterial culturesMycobacterial cultures
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Histopathogy Histopathogy
Epithelioid cell granuloma with or without Epithelioid cell granuloma with or without multinucleate giant cellsmultinucleate giant cells
Caseation necrosis Caseation necrosis
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AFB StainingAFB Staining
Diagnostic Diagnostic
Yield increases in presence of necrosisYield increases in presence of necrosis
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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
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Treatment Treatment
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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
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Surgical Surgical
Persistent fluctuant lesionsPersistent fluctuant lesions
Not resolving with chemotherapyNot resolving with chemotherapy
FNAC not availableFNAC not available
Symptomatic reliefSymptomatic relief
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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
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ComplicationsComplications
Dysphagia
Oesophageal mediastinal fistula
Tracheo oesophageal fistula
Thoracic duct obstruction (chylothorax, chylous ascites, chyluria)
Cardiac tamponade
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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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All the All the best..best..