Clinical Profile of Patients with Tubercular Lymphadenitis

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1 ORIGINAL ARTICLE Clinical Profile of Patients with Tubercular Lymphadenitis Desai HV 1, Daxini AB 2*, Pandey AS 3, Raval VK 4, Modh DA 5 1 Resident, Pulmonary Medicine Department, SMIMER, Surat, 2 Assistant Professor, Pulmonary Medicine Department, SMIMER, Surat, 3 Professor & HOD, Pulmonary Medicine Department, SMIMER, Surat, 4 Resident, Pulmonary Medicine Department, SMIMER, Surat, 5 Resident, Pulmonary Medicine Department, SMIMER, Surat ABSTRACT BACKGROUND & OBJECTIVES:Tuberculosis is a granulomatous inflammatory process consequent to infection by Mycobacterium Tuberculosis.It is now seen that extra-pulmonary manifestations form a major proportion of new cases, especially since the advent of the Human Immuno-Deficiency Virus (HIV)& Acquired Immuno-Deficiency Syndrome (AIDS) epidemic.tubercular lymphadenitis is the most common extra pulmonary form of tuberculosis, and cervical lymph nodes are the most commonly affected group of nodes. The objective of this study is to assess the clinical profile of Tubercular Lymphadenitis cases attending OPD and indoor facility of Pulmonary Medicine Department at SMIMER,to assess treatment outcome of Directly Observed Treatment Short Course under Revised National Tuberculosis Control Program (RNTCP), and to observe the clinical outcome of the same on Tubercular lymphadenitis. METHODS & MATERIALS :This study included patients of Tuberculous lymaphadentis attending the OPD as well as indoor facilities of the Pulmonary Medicine Department. The study pattern was Descriptive Longitudinal Study. The observational data was collected using formal proforma, which elicited demographic and clinical information. RESULT : Out of the total 75 patients, 61% of patients were from age group of 18 to 30. Nearly all the patients (100%) presented with neck swelling. Out of the total 75 cases, 62 cases (82.6%) had nodes < 3cm, and 13 cases (17.3%) had nodes > 3 cm.tubercular lymphadenitis is more common in females. For the 51 cases(68%) on category I anti TB treatment, treatment completion rate was 88.2% with favorable response seen in 82.2% (45) of those cases. Out of 24 cases on category II anti TB treatment, treatment completion rate was 79.16% with favorable response seen in 79% (19) of those cases. FNAC remains the most accurate and diagnostic tool. CONCLUSION : Early diagnosis and treatment of Tubercular lymphadentis helps getting better cure rates. FNAC stays frontline investigation with rest based on it. It is curable with anti-tubercular drugs if administered according to WHO guidelines under RNTCP. KEYWORDS: Tubercular Lymphadenitis, RNTCP,FNAC, AIDS. INTRODUCTION Tuberculosis is a granulomatous inflammatory process consequent to infection by Mycobacterium tuberculosis 1. It is now seen that extra-pulmonary manifestations form a major proportion of new cases, especially since the advent of the Human Immuno-Deficiency Virus (HIV) & Acquired Immuno-Deficiency Syndrome (AIDS) epidemic. 2 Tubercular lymphadenitis is the most common extra pulmonary form of tuberculosis and *Corresponding Author: Dr. Arvind Daxini Flat No. 203, Building No. 12, Green City, Bhatha-Pal, Surat, Gujarat Cell: docarvind4u@yahoo.co.in cervical lymph nodes are the most commonly affected group of nodes 3.TB lymphadenitis is seen in nearly35 percent of extra pulmonary TB cases, which constituted about 15 to 20 per cent of all cases of TB. In HIV-positive patients, extra pulmonary TB account for up to 53 to 62 percent cases of TB. 4,5 Cervical lymph nodes are the most common site of involvement and reported in 60% to 90% patients with or without involvement of other lymphoid tissue. Mycobacterium Tuberculosis is the most common causative agent in India. 6 Tubercular lymphadenitis most frequently affects patients in their second decade of their life. There is a female predominance (approximately 2:1) in most of the studies. There is increased frequency of tubercular lymphadenitis in Asian 22 Int J Res Med. 2015; 4(4);22-27e ISSN: p ISSN:

2 population. 7.Infection with HIV is associated with an increased frequency of both pulmonary and extra pulmonary tuberculosis, particularly lymphadenitis. 8 Presently, it is generally agreed that anti tuberculosis treatment alone is sufficient in majority of the cases and surgical intervention is required only in selected cases, for specific scenarios.surgery alone as the treatment for tubercular lymphadenitis reveals that there is a high failure and recurrence rate 7. In India, majority of the patients with lymph node TB receive DOTS under the RNTCP. Under RNTCP these patients are treated with Cat - I (one) regimen which involves Isoniazid, Rifampicin, Pyrazinamide and Ethambutol in initial two months of intensive phase as thrice weekly regimen under supervision, while Isoniazid, Rifampicin in later four months of continuation phase. Still some patients do not respond to Cat - I (one) regimen. These patients require Cat - II (two) regimen, which involves Isoniazid, Rifampicin, Pyrazinamide, Ethambutol, and Streptomycin. MATERIAL & METHODS Study type: Descriptive Longitudinal Study Study setting: OPD and indoor facility of Department of Pulmonary Medicine, Surat Municipal Institute of Medical Education and Research (SMIMER), Surat city Study period: Study was conducted for period of one year and 2 months which included one year for data collection and two months for data entry and data analysis. Sample size: Total 75 cases of Tubercular Lymphadenitis attending OPD and indoor facility of Department of Pulmonary medicine, SMIMER and registered for DOTS under RNTCP in SMIMER DOTS center within one-year period included in study. DEFINITION Diagnostic Criteria to define tubercular lymphadenitis case: 1. Clinical (Swelling/weight loss/loss of appetite/fever) and 2. Bacteriological confirmation and/or 3. Histological findings suggestive of TB (chronic granulomatous inflammation with or without caseous necrosis in tissue sample) Selection of Subjects: Study included the patients of tubercular lymphadenitis in out patient setting as well as indoor setting of Pulmonary Medicine Department in SMIMER (including patients of tubercular lymphadenitis from other departments referred to Pulmonary Medicine Department, SMIMER). They were informed about the study and those who agreed to participate and agreed to give valid written informed consent were included in the study. Data collection: Data collected using pretested questionnaire. Study variables like size, site, Number (single/multiple), consistency, matted/ discrete, complicated like sinus or abscess formation and fixity to underlying structure of lymph node were noted in pretested questionnaire. Inclusion criteria: 1. Patients (Age 18 years or more than 18 years) of confirmed Tubercular Lymphadenitis attending OPD and indoor facility of Department of Pulmonary Medicine, SMIMER. (Including patients of tubercular lymphadenitis from other departments referred to Department of Pulmonary Medicine, SMIMER) 2. Cases of Pulmonary Tuberculosis with confirmed Tubercular Lymphadenitis cases. (Age 18 years or more than 18 years) 3. Confirmed Tubercular Lymphadenitis cases with other forms of confirmed extra pulmonary Tuberculosis. (Age 18 years or more than 18 years) Exclusion criteria: Age < 18 years Patients who did not given written informed consent were excluded. Method: Informed written consent for allowing clinical data to be used for study purpose was obtained from all the patients. Detailed History was taken & clinical evaluation was done as per the annexed proforma. All the patients underwent thorough physical (Local and Systemic) examination. For suspected Tubercular Lymphadenitis, FNAC of lymphnode or Lymphnode 23 Int J Res Med. 2015; 4(4);22-27e ISSN: p ISSN:

3 Biopsy confirmed the diagnosis.patients with enlarged lymph node persistent for more than two weeks were selected for fine needle aspiration cytology (FNAC). Aspiration cytology was done by the expert pathologist with 18 gauze wide bore needle. Cytological findings like presence of granuloma, caseous necrosis or presence of Acid Fast Bacilli (AFB) were considered as positive findings for the diagnosis of tubercular lymphadenitis. Acid-fast bacilli smear of the aspirate was done only in suspicious cases.multiplicity,matting and caseation were considered as important findings of tubercular lymphadenitis. Routine or Excision Biopsy of the nodes was carried out in patients with persistent enlarged nodes after one month (after two week antibiotic therapy and inconclusive FNAC) for histopathological confirmation. Surgical opinion was taken whenever required for the diagnosis or management.patients with cytological findings of tuberculosis underwent chest X-ray and two samples of sputum for AFB to detect coexistent pulmonary tuberculosis.mantoux s test and ESR were carried out in all the patients.ultrasonography of swelling(local part)/thorax/abdomen was done as and when required. CBC and Serum HIV were done in all cases to assess serological status.those patients with cytological or histopathological confirmed tubercular lymphadenitis were initiated on DOTS under RNTCP.Adverse drug reaction to ATT was noticed and reported appropriately.complicated form of Lymphadenopathy was noted in the form of abscess, sinus, cervical with mediastinal involvement, cervical with abdominal involvement etc. All patients were followed on monthly basis for six to eight months, and response to treatment was measured by improvement in clinical parameters and average percent reduction in size of the gland, which was measured vertically and horizontally by measuring scale at baseline and every month for six months. OBSERVATION AND RESULTS All 75 cases had cervical lymph node involvement. 4 cases had associated axillary, 1 case had associated inguinal, 1 case had associated mediastinal, and 1 case had associated abdominal lymph node involvement. No other form of associated extra pulmonary tuberculosis was observed. Pulmonary Tuberculosis was associated in ten cases. It was observed that, the disease commonly affectedsecond (18-20) and third decade (21-30) with 24%, and 37.3% respectively. Female preponderance was noted with ratio 57.3% of cases were females and males being 42.6%.Study cases were divided into socioeconomic strata based on Kuppuswamy Classification.Lower socioeconomic group had major share of cases of tuberculosis. It was observed that 15 cases (20%) presented withinone month, 38 cases (50.6%) presented during 1-3 months, 12 cases (16%) during 3-5 months, and remaining 10 cases (13.3%) Presented after 5 months. All the 75 cases (100%) presented with neck swelling. 9 presented with associated fever (12%), 6 with pain over swelling (8%), 10 with weight loss (13.3%), 14 with malaise (18.6%) and 4 with sinus (5.3%). Cough (7 cases-9.3%) and hemoptysis (1 case-1.3%) were seen in associated pulmonary tuberculosis cases. Table No 1: Showing Various Clinical Presentations Symptoms No. of cases Percentage Swelling Fever 9 12 Pain 6 8 Weight loss Cough(associated pulm TB) Hemoptysis(associated pulm TB) Malaise Sinus In present study the commonest site involved was Lymph node group Level-V accounting for 28 cases (37.3%).Level IV and Level III group of lymph nodes were involved in 24% and 14.6% cases respectively. 6 cases (8%) had Level-II 24 Int J Res Med. 2015; 4(4);22-27e ISSN: p ISSN:

4 and 3 cases (4%) had Level I group lymph node enlargement.more than one level of lymph nodes were involved in 12% cases. It was observed that in the present study out of 75 cases of cervical tubercular lymphadenitis, 62 cases (82.6%) had nodes 3cm,13 cases (17.3%) with nodes > 3 cm.out of 75 cases of cervical tubercular lymphadenitis, unilateral involvement was seen in 65 (86.6%) cases and bilateral involvement was seen in 10(13.3%) cases with right predominance as 52% of cases involved in right side, 34.6% involved in left side and 13.3% cases involved bilaterally.it was observed that multiple lymph nodes involvement was more common when compared to single node involvement. Only 26 (34.6%) cases had single lymph node involvement as compared to multiple node involvement in 49(65.3%) cases.in the present study, out of 75 cases, 58 cases (77.3%) had lymphadenitis with firm consistency. Remaining 17 Cases (22.7%) had soft consistency in which 12 cases (16%) had cold abscess, 4 cases (5.3%) had Sinus. In the present study, matting of lymph nodes was observed in 27 (36%)cases and 48 cases (64%) had discrete nodes. Table No 2: Consistenc Y Of Lymphnodes Involved FNAC findings Number of % patients Granulomatous Caseated Cold abscess Total It is observed that in the present study, 17 (22.6%) patients were anemic in which they have Hemoglobin % of less than 10. Majority of patients 37 (49.3%) had Hemoglobin % ranging from and 21(28%) patients had Hemoglobin % of more than 12. In the present study it was observed that majority of the patients 63(84%) had normal WBC counts ranging from /HPF and only 12 patients (16%) had WBC counts of more than 0800/HPF. In the study series of 75 cases, sputum examination for AFB was done for 57 cases, Out of 57 cases; Acid Fast Bacilli were found in 7 cases (12.3%). In the present study, 10 (13.3%) cases had Chest X-ray suggestive of Pulmonary Tuberculosis. Out of it, 4 cases had pulmonary Infiltrative lesion, 3 cases had segmental dense and homogenous lesion and 3 cases had cavitation. Mantoux test was done for all cases, in which 53 cases (70.6%) showed positive Results. In the present study, serum HIV was positive in 6 out of 75 cases (8%).It was observed that, 66 cases (88%) were diagnosed by FNAC alone and 9 Cases (12%) by Biopsy, in which findings were inconclusive with FNAC study. Amongst the cases,58.6% of cases showed granulomatous lesion, 25.3% of cases showed caseation and 16% of cases showed cold abscess. 8 out of 75 cases (10.6%) cases demonstrated AFB in smears from FNAC/biopsy specimens. Ziehl neelsen stain positivity for AFB in FNAC/biopsy specimen is more common in HIV positive patients in present study. Table No 3: Distribution Of Fnac Findings Of Patients Studied Lymph Consistency Firm consistency node In present study, out of 75 cases, 51 new cases were offered Category I anti TB treatment. 49 cases completed 6 months category I anti TB treatment. 2 cases defaulted category I anti TB treatment. In 49 cases that completed treatment, 4 cases had associated sputum smear positive pulmonary tuberculosis with tubercular lymphadenitis. Their sputum smear samples for AFB were negative on treatment completion with regression of lymph node swelling and they were declared as cured. In remaining 45 cases that completed category I anti TB treatment, 37 cases had significant reduction in lymph node swelling size (more than 90% reduction in pretreatment size/reduction in size to less than 10 mm and no palpable welling/disappearance of lymph node swelling). 4 cases showed significant reduction in lymph node swelling size after extension of category I 25 Int J Res Med. 2015; 4(4);22-27e ISSN: p ISSN: No cases of Soft consistency (Total) 1.Cold abscess Sinus Percentage

5 anti TB treatment for two months. 1 case had palpable swelling at the end of extended category I anti TB treatment In 1 case, fresh nodes appeared at the end of extended category I treatment. 2 cases had persistent discharging sinus at the end of extended Category I anti TB treatment. These 4 cases were shifted to category II anti TB treatment with favorable response to category II anti TB treatment. Table No 4: Treatment Outcome of Cases on Category Ii Anti Tb Treatment Number Treatment Outcome of % patients Treatment completed % Cured % Treatment default 2 8.3% Died 0 0 Total In present study, Out of 75 cases, 24 retreatment cases were offered Category II anti TB treatment. 22 cases completed 8 months category II anti TB treatment.2 cases defaulted category II anti TB treatment. In 22 cases that completed treatment, 3 cases had associated sputum smear positive pulmonary tuberculosis with tubercular lymphadenitis. Their sputum smear samples for AFB were negative with regression of lymph node swelling on treatment completion and they were declared as cured In remaining 19 cases that completed category II anti TB treatment, 15 cases had significant reduction in lymph node swelling size (more than 90% reduction in pretreatment size/reduction in size to less than 10 mm and no palpable swelling/disappearance of lymph node swelling).4 cases showed significant reduction in lymph node swelling size (along with healing of sinus in 2 cases) after extension of category II anti TB treatment for two months. Gastrointestinal symptoms such as nausea and vomiting were the commonest reported events. One patient treated with Category II anti TB regimen developed jaundice in the second month of treatment. Isoniazid, Rifampicin and yrazinamide were withheld for 7 days and the jaundice subsided. All the other adverse reactions recorded ranged from mild to moderate in severity and were managed with symptomatic measures. In the present study, adverse drug reaction to anti TB drugs was seen in 6 out of 75 patients (8%). Gastrointestinal adverse effects (nausea, vomiting) were seen in 3 patients (4%). Arthralgia, skin reaction (Pruritus) and Jaundice (Hepatitis) were seen in 1 patient each(1.3% each). Discussion & Conclusion : In the present study, majority of the cases were in the age group between years (28 cases-37.3%). Second common age group was years (18 cases-24%). The same table is compared with other series. Research committee of the tuberculosis association of India 9 series shows that the majority of cases in their study were also between years (37.7% cases). Second common age group was years (25.3%). In study by Ruchi Khajuria, KC et al 10, majority of cases in their study were also between years (34%). In the present study, female preponderance was seen. It was observed that 57.3% of cases were females and males being 42.6%. The male: female ratio was 1:1.34. A female predilection was also observed in the studies by Ruchi Khajura K C 10,Mehmet F Oktay et al 11, Bedi R S, et al 12 with male: female incidence ratio being 146:197 (1:1.3), 24:49(1:2) and 29:48(1:1.7) respectively. In present study, Cervical Lymphadenitis was seen in 75 cases (100%), axillary in 4 cases (5.3%), inguinal in 1 case (1.3%), mediastinal in 1 case (1.3%) and abdominal Lymph node (mesenteric) involvement in one case (1.3%).These observations are comparable with findings of study by Nilaz Mohammad Sulaiman Khail et al 13 observed cervical lymphadenitis in 82.18% cases, axillary lymphadenitis in 6.93% cases, inguinal lymphadenitis in 1.98% cases, mediastinal in 1.98% cases and abdominal lymph node involvement in 0.99% cases.in the present study, it was observed that 66 cases (88%) were diagnosed by FNAC alone and 9 Cases (12%) by Biopsy in which findings were inconclusive with FNAC study. Nearly similar observation were made by Kishore C Prasad et al 14, who observed 92% of 26 Int J Res Med. 2015; 4(4);22-27e ISSN: p ISSN:

6 cases were diagnosed by FNAC and 8% of cases were inconclusive on FNAC. Out of 51 cases (68%) on category I anti TB treatment, treatment completion rate was 88.2%, cure rate was 7.8% (in associated sputum AFB positive pulmonary tuberculosis cases), default rate was 3.9% and death rate was nil. In patients on category I anti TB treatment who completed treatment (45 cases), favorable response on treatment completion was seen in 82.2% cases, favorable response with extension of treatment was seen in 8.8% cases, and in remaining 4 cases (8.8%) response was not favorable even after extension of category I anti TB treatment. Out of 24 cases on category II anti TB treatment, treatment completion rate was 79.16%, cure rate was 12.5% (in associated sputum AFB positive pulmonary tuberculosis cases), default rate was 8.3% and death rate was nil.28. In patients on category II anti TB treatment who completed treatment (19 cases), favorable response on treatment completion was seen in 79% cases, and favorable response with extension of treatment was seen in 21% cases. REFERENCES 1. Harries A, Maher D, Uplekar M, Raviglione M. Tuberculosis manual for Nepal, National Tuberculosis Programme. Ministry of Health, Government of Nepal, Sarda AK, Bal S, Singh MK, Kapur MM. Fine needle aspiration cytology as a preliminary diagnostic procedure for asymptomatic cervical lymphadenopathy. J Assoc Physicians India 1990 Mar; 38(3): Dandapat MC, Mishra BM, Dash SP, Kar PK. Peripheral lymph node tuberculosis: a review of80 cases. Br J Surg Aug; 77(8): Corbett EL, Watt CJ, Walker N, et al. The growing burden of tuberculosis: global trends and interactions with the HIV epidemic. Arch Intern Med. 2003;163: Aaron L, Saadoun D, Calatroni I, et al. Tuberculosis in HIV-infected patients: a comprehensive review. Clin Microbiol Infect. 2004; 10: Indian Council of Medical Research, Tuberculosis in India A sample survey, Special Report Series No. 34, New Delhi. 7. Bailey and Love:short practice of surgery:23 rd edition. 8. Enarson DA, Ashley MJ, Grzybowski S, Ostapkowicz E, Dorken E. Nonrespiratory tuberculosis in Canada. Epidemiologic and bacteriologic features. Am J Epidemiol. 1980; 112: Research committee on TB Association of India (RCT AI). Cervical lymphadenitis, Ind J TB, 1987; 34: Khajuria R, KC et al. Pattern of lymphadenopathy on FNAC in Jammu. Vol-8, no-3; July-Sept Mehmet F Oktay et al. The Journal of Laryngology & Otology Follow up results in tuberculous cervical lymphadenitis February 2006; 120(02), Bedi RS et al. Clinicopathological study of superficial lymphadenopathy in northern India. Ind J TB1987; 34: Nilaz Mohammad Sulaiman Khail et al, A morphological study of tubercular lymphadenopathy, JPMI, 14(1): Prasad KC et al. The Journal of Laryngology & Otology. October (10), Int J Res Med. 2015; 4(4);22-27e ISSN: p ISSN: