Dr.Barin Bose MS
Tuberculosis remains a problem through out the world and is still a common cause of cervical lymphadenopathy. Tuberculous lymphadenitis is due to infection with Mycobacterium tuberculosis. The basic pathology is a granulomatous inflammation with tubercles which undergoes caseation necrosis and destruction of the lymph node. Spread of the infection to the adjuscent nodes by periadenitis result in the nodes getting adherent to each other, which gives the characteristic physical sign of early matting of the node. Where the node lies deep to the deep fascia as in the neck, the caseous node perforates through the deep fascia and the caseous matter escapes into the superficial fascia resulting in the characteristic coller stud abscess.
The condition most commonly affect children and young adults but can occur at any age. The deep upper cervical lymph nodes are most commonly affected followed by mediastinal, mesenteric, axillary and inguinal group of lymph nodes according to the order of frequency.
There may be a widespread cervical lymphadenitis and matting together of a number of lymph nodes may be evident.
I most instances the tubercular bacilli gains entrance through the tonsi of the corresponding side of the lymphadenopathy. Both bovine and human tuberculosis may be responsible. In 80 % of cases the tuberculous process is limited to the clinically affected group of lymph node but primary focus in the lungs must always be suspected and investigated. As renal and pulmonary tuberculosis occasionally coexists so urine must be carefully examined. Rarely the patient may develop a natural resistance to the infection the nodes may be detected at a later date as calcification on an X ray. This can also be seen after eppropriate treatment of tuberculous adenitis.
If treatment is not instituted the caseated node may liquefy and break down with formation of a cold abscess in the neck. The pus is first confined by the deep cervical fascia but after weeks or months this may become eroded at one point and the pus flows through the small opening in the deep fascia into the space beneath the superficial fascia. The process has now reached the well known stage of a coller stud abscess. The superficial abscess enlarges steadily and if suitable treatment is not adopted the skin over the cold abscess breaks down to give rise to a discharging sinus in the neck which refuses to heal.
Clinically three stages are recognized –
In the first stage The nodes become enlarged without matting. This is known as lymphadenoid type and its differentiation from chronic septic lymphadenitis becomes difficult.
In the second stage due to periadenitis the enlarged nodes become adherent to one another (matted) . This is the most characteristic feature of tuberculous lymph nodes. In third stage caseation takes place in the interior of the nodes so that the nodes become softer with formation of cold abscess. Gradually the cold abscess makes its way towards the skin and ultimately bursts out forming a tubercular ulcer or sinus which refuses to heal.
Clinical Features - Cervical lymph nodes are involved in 70% of cases. Any cervical lymph node may be involved , but nodes in the anterior triangle of the neck are the most frequent site of the disease. Enlargement of lymph node is slow and progressive. Pain is mild but fever and other constitutional disturbances are abscent.
Pathologically five stages of lymphadenitis are recognized –
Stage I – The glands are enlarged, mobile, firm and slightly tender. Histologically this stage shows nonspecific relative hyperplasia .
Stage II – The nodes are enlarged, firm and fixed to surrounding tissue and to each other. Histologically they show periadenitis.
Stage III – The caseation occurs within the lymph node which burst out and collects beneath the deep fascia.
Stage IV – The caseous material perforates the deep fascia and escapes into the superficial fascia resulting in coller stud abscess formation.
Stage V – The cold abscess burst out and gives rise to a persistent discharging sinus.
There are four different types of clinical presentation of of Tuberculous Lymphadenitis –
Diagnosis – Is not difficult in a classical case of chronic lymphadenitis in a young individual, it is associated with matting and soft area of caseation.
ESR is raised , Serum albumin falls and Serum globulin increases.
X Ray Chest – For associated Pulmonary Tuberculosis.
FNAC and Biopsy are essential for confirming the diagnosis. Typical tubercular granuloma, with epithelial cells, giant cells and lymphocytes with area of caseation is characteristic.
A negative MT in presence of lymph node enlargement excludes tubercular lymphadenitis but a positive MT has no diagnostic value.
Treatment – it consists of Multi drug therapy with antitubercular drugs which consists of Rifampisin, Isoniazid and Pyrazinamide for six months period. With a full course of tubercular drug therapy, the tubercular glands subside within 3 to 4 months, the response is even quicker in children.
Cold abscess should be aspirated through a nondependent part and Injection Streptomycin may be instilled locally. This local treatment may have to be repeated two to three times.
Surgical Excision is indicated (a) when the gland persist after adequate chemotherapy (b) For persistant sinus or necrotic and calcified material replacing the Lymph Node.