ISSN: 2250 - 0359 Volume 5 Issue 1.5 2015 Unusual presentatjon of tubercular unilateral cervical lymphadenitjs: A case report Chethana R AJIMS India Abstract: Case Report: A 19 year old female presented to ENT OPD with swelling in preauricular region on the lefu side A case of tubercular lymphadenitjs in a 19 year since 2 months .The swelling was small in size old is reported here for its unusual presenta- initjally progressed over the 2 months to the tjon and to create awareness regarding uncom- mon manifestatjons of lymph node tuberculo- present size of 2×2cm .The swelling was pain- sis, so as to diagnose the conditjon early for betuer management. less , there was no associated history of fever , toothache , earache , ear discharge, pain while swallowing .There was no history of cough or loss of weight or loss of appetjte. There was no history of tuberculosis in the past. There was no history of tuberculosis in the family. On examinatjon she was found to be afebrile, with pulse rate of 86beats/min, respiratory rate of 19/min. Drtbalu ’ s otolaryngology online
On investjgatjon her haemoglobin was 9.2g%, She had received BCG vaccine and the scar was total leucocyte count 9900/cum, difgerentjal present . leucocyte count neutrophils 69%, lympho- On physical examinatjon multjple lymph nodes cytes 24%, eosinophils 1%, monocytes 6%, were palpated on the lefu side. ESR 90mm/hr. Peripheral smear showed mi- 1.Lefu preauricular region single lymph node of crocytjc hypochromic anemia. Rest of the size 2×2cm blood investjgatjons were normal. Chest x ray was normal. Usg neck showed multjple en- 2.Lefu jugulodigastric region single lymph node of larged level 1, 2, 3 and 4 on lefu side largest 1×0.5cm measuring 8 to 14mm in size with hypoechoic 3.Lefu submandibular region single lymph node of echopatuern. Few of lymph nodes showed 0.5×1cm partjal necrosis . 4.Lefu posterior triangle multjple lymph nodes larg- FNAC of lefu submandibular and preauricular est measuring 1×1.5cm lymph nodes was done which was reported 5.Lefu supraclavicular region multjple lymph nodes as reactjve lymphadenitjs. Mantoux test was largest measuring 0.5×1cm. done which was positjve with 23mm indura- All the lymph nodes were fjrm in consistency , non tjon.With high clinical suspicion of tuberculo- tender with no local rise of temperature, mobile , sis , positjve mantoux, elevated ESR, USG with no scars or sinuses. neck showing partjal necrosis in few lymph nodes FNAC was repeated .FNAC of lefu Surprisingly there were no palpable lymph nodes preauricular and lefu submandibular lymph on the right side. Examinatjon of the ear , nose , oral cavity and throat was normal. Indirect laryn- nodes showed ill formed granulomas of epi- goscopy was within normal limits . General physi- thelial cells, mature lymphocytes, plasma cal examinatjon did not reveal any palpable lymph cells, histjocytes , centrocytes , centroblasts nodes in the body. Facial nerve was intact , the and immunoblasts against a background of movements of cervical spine was normal. caseous necrosis , stromal fragments and lymphogranular bodies suggestjve of tubercu- lar lymphadenitjs. Patjent was started on antj tubercular treatment category 1 under the Directly Observed Treatment Short course (DOTS) strategy as per RNTCP guide- lines .There was marked response with this treatment and swellings subsided afuer 2 months of treatment. Drtbalu ’ s Otolaryngology online
Four drug regimen (rifampicin , isoniazid , ethambutol and pyrazinamide ) in the Patjent is presently in 4th month of treatment and intensive phase followed by two drugs there is disappearance of swelling , and has gained (rifampicin and isoniazid ) in contjnua- 3 kgs during treatment. Patjent is also being treat- tjon phase is recommended treatment ed for anemia her haemoglobin is 10.4g% at pre- regimen. sent. Conclusion: Discussion: EPTB ofuen poses a diagnostjc delay due Extrapulmonary TB is defjned as TB of organs other to the non descriptjve clinical picture than lungs such as lymph nodes , pleura, genitouri- and low burden of organisms. The in- nary tract , skin , joints , bones etc Tuberculosis of creased awareness of uncommon superfjcial lymph nodes called scrofula is very com- manifestatjons of lymph node tuber- mon in India with cervical lymph nodes most com- culosis at atypical sites may help in monly involved .The clinical picture is ofuen non diagnosing the conditjon early. descriptjve in EPTB , symptoms such as fever , loss of weight and failure to thrive are usually associat- ed .In our case , patjent had swelling in preauricu- lar region with no other symptoms. Tuberculosis needs to suspected in every case of asymptomatjc cervical swelling in India due to high prevalence of tuberculosis in India especially in rural settjngs . The reason why only lefu side lymph nodes alone were afgected stjll remains unan- swered. The gold standard for diagnosis of EPTB is the di- rect demonstratjon of acid fast bacilli in the biop- sy. It is diffjcult to see AFB in such cases due to low bacterial load .FNAC showing features of gran- ulomatous lymphadenitjs is stjll valid for diagnosis of tubercular lymphadenitjs Drtbalu ’ s Otolaryngology online
References: 1.Janmeja AK, Das SK, Kochhar S, Handa U. Tu- berculosis of the parotid gland. Indian J Chest Dis Allied Sci. 2003;45:67 – 9 2. Suleiman AM. Tuberculous parotitis: Report of 3 cases. Br J Oral Maxillofac Surg. 2001;39:320 – 3. 3. Sharma SK, Mohan A. Extrapulmonary tuber- culosis. Indian J Med Res. 2004;120:316 – 53 4. Gopal R, Padmavathy BK, Jayashree K. Extrap- ulmonary tuberculosis: A retrospective study. Indian J Tuberc. 2001;49:225 – 6. 5. Roland NJ, McRae RDR, McCombe AW. Key Topics in Otolaryngology and Head and Neck Surgery. 2nd ed. Oxford: BIOS; 2001. p 275 6. Lalvani A. Diagnosing Tuberculosis Infection in the 21st Century: new tools to tackle an old enemy. Chest. 2007; 131:1898?906. 7. Kant R, Sahi RP, Mahendra NN; Primary tuber- culosis of parotid gland. J. Indian Med Assoc 1977; 68: 212 Drtbalu ’ s Otolaryngology online
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