Human Immunodeficiency Virus Lymphadenitis Patterns on Fine-Needle Aspiration Cytology

OBJECTIVE

The aim of this work was to study the microscopic patterns of human immunodeficiency virus (HIV) lymphadenitis on fine-needle aspiration cytology (FNAC) and correlate them with cluster of differentiation 4 (CD4) counts.

STUDY DESIGN

A retrospective study of known HIV-positive patients who underwent lymph node FNAC over a period of 5 years (2009-2013) was undertaken. The cytology slides were retrieved and reviewed. Out of 317 cases, 38 (11.7%) were diagnosed as HIV lymphadenitis. We analysed the cytomorphological patterns of HIV lymphadenitis and correlated them with the CD4 cell counts.

RESULTS

Smears of HIV lymphadenitis were classified akin to histology patterns (A, B, and C) depending on cellularity, number of tingible body macrophages, mitosis, apoptotic bodies, plasma cells, Warthin-Finkeldey giant cells, and proliferating blood vessels. Thirty-one cases showed pattern A, 3 showed pattern B, and 4 were of pattern C. Pattern A had the highest CD4 cell count.

CONCLUSION

Histologic patterns of HIV lymphadenitis are recognisable on FNAC smears. These can offer a clue to the diagnosis and guide further workup, even in the absence of history. The changes can mimic those of the infective lymphadenitis, Castleman disease, and lymphoma. Hence, the clinical history, serological correlation, and awareness of cytomorphology can aid the correct diagnosis.

Cytomorphological Analysis of Lymph Node Lesions in HIV-Positive Patients with CD4 Count Correlation: A Cross-Sectional Study

OBJECTIVES

To study the cytomorphological spectrum of lymph node lesions in HIV-positive patients and correlate the cytological findings with the CD4 count.

STUDY DESIGN

This was a cross-sectional study of 23 months' duration which included 110 HIV-positive cases proved according to the guidelines of the National AIDS Control Organisation. Fine-needle aspiration cytology (FNAC) was done on clinically palpable lymph nodes. Special stains and culture were done wherever necessary. CD4 count was done by flow cytometry and subsequently correlated with the cytological findings.

RESULTS

Our study included 110 cases, ranging in age from 6 to 70 years, peaking in the 3rd to 4th decade (n = 46). The male-to-female ratio was 1.75:1 and the predominant site was the cervical group of lymph nodes (n = 71). Each lesion was correlated with CD4 count, laboratory and clinical findings, and was further segregated based on WHO and CDC staging. Cytological lesions were tubercular (53.6%), reactive (27.1%), suppurative (6.4%) lymphadenitis, lymphoma (4.5%), cystic lymphoid hyperplasia (2.8%), metastases (1.9%), cryptococcal lymphadenitis (0.9%). The mean CD4 count was 217.4, 434.4, 181.4, 149, 580, 225, and 207 cells/µL, respectively. There was a highly significant correlation of cytological findings with CD4 count (χ2 value = 44.57 and p < 0.001).

CONCLUSION

FNAC is a primary, safe, and valuable tool for the identification of opportunistic infections, neoplastic and nonneoplastic lesions, as well as therapeutic modality in certain conditions. Correlation of lesions with CD4 count provides information about immune status, HIV stage and segregating cases, and also aids further evaluation and management.

Removal of nonthyroidal neck masses with improved cosmetic outcomes in skin-lifting surgery

Objective

To evaluate the cosmetic benefit of neck skin-lifting surgery for the removal of nonthyroidal neck masses.

Study Design and Setting

Fifty patients with neck masses were divided into the following 2 surgical groups that were matched in age, sex, and the size, location, and pathology of lesions: skin lifting (n = 25) and conventional (n = 25). The operation time, hospital stay, complications, and subjective satisfaction with the incision scar as assessed on a visual analogue scale (VAS) were compared between the 2 groups.

Results

All but 2 lesions (lymphomas) were benign and were removed completely, drained, or biopsied. The surgery time, hospital stay, and complication rates did not differ significantly between the groups. The mean satisfaction score of the patients was 8.2 ± 1.1 in the skin-lifting surgery group and 4.8 ± 2.5 in the controls ( P < 0.001). The incision scars were commonly hidden by natural hair or collars in the patients who received skin-lifting surgery.

Conclusion

This surgical technique can be safely applied to most benign masses in the entire neck excluding the thyroid region, especially in patients who prefer neck scars to be invisible. EBM rating: B-2b

[The surgical options of cervical tuberculous lymphadenitis]

OBJECTIVE

To analyze the clinical features & variation features of cervical tuberculous lymphadenitis and to discuss its effective surgical treatment.

METHOD

Retrospective analysis of 27 cases of cervical tuberculous lymphadenitis patients admitted to the hospital from January 2008 to December 2013. The cervical tuberculous lymphadenitis is classified based on the enhanced CT scanning conducted before operation and the preoperative evaluation of clinical characters of patients. The lymphaden ncisional biopsy was conducted on the type I patients with cervical tuberculous lymphadenitis. The lesion resection was performed on the type II and mixed type I + II patients. The regional cervical lymph node dissection was carried on the type III, the type IV and other mixed type patients. The negative pressure drainage ball was placed after operation, and the cavity was flushed with 5% povidone iodine solution. The antituberculosis therapy was performed after wound healing.

RESULT

The analysis of the clinical features for 27 patients: the incidence rate on the left side, right side, both sides and middle-line is 63.0%, 25.9%, 7.4% and 3.7% respectively. The majority of patients whose lesion involving more than one region account for 62.1%; the patients whose lesion involving one region account for 37.9%. The most common is level V involved lesion (69.0%), then level IV (62.1%), level III (51.7%), level II (34.5%), level I (10.3%) and level VI (3.4%) in order. The analysis of the CT imageology features for 27 patients: the simple type is the majority (65.5%), and the most common is type III (24.1%), then the type I (17.2%), type II (13.8%) and type IV (10.3%) in order. The mixed type is minority (34.5%), but the two mixed is often (31.0%). The three mixed is only located on one side (3.4%). The recurrence never happened on the patients with resection and standard antituberculosis therapy.

CONCLUSION

For the cervical tuberculous lymphadenitis, the suitable surgical treatments shall be selected according to the lesion characteristics & location and CT imaging manifestations presurgical evaluation. The effective way to treat cervical tuberculous lymphadenitis is to conduct negative pressure drainage after operation, to flush the cavity with 5% povidone iodine solution and to perform antituberculosis therapy.

TUBERCULOUS CERVICAL LYMPHADENOPATHY AND THE ROLE OF SURGICAL TREATMENT

The relationship between the size of a lymph node in tuberculous cervical lymphadenopathy (TCL) cases and the role of surgery is unclear. We examined the outcomes in patients with TCL treated between October 2011 and November 2013 at the ENT Department, Hatyai Hospital. Ninety-seven patients were included in the study. The subjects were divided into five groups based on clinical presentation and anatomical site of the involved lymph nodes: 1) solitary lymph node (n = 36), 2) multiple lymph nodes at one anatomical site (n = 31), 3) lymph nodes at multiple anatomical sites (n = 16), 4) patients with lymph node abscesses (n = 12), and 5) patients with fistulas (n = 2). Of the 36 solitary lymph node cases, 14 had a lymph node ≥ 3 cm in diameter. Eight of the 14 had complete surgical excision of the node before receiving a full course of medication and all did well. Six of the 14 who were treated with drug therapy alone had problems: 2 progressed to abscess formation and 4 had residual enlargement of their lymph nodes that required surgery. The cure rates differed significantly by type of treatment (p < 0.001). Of the 47 cases with multiple cervical lymph nodes ≥ 3 cm in diameter, 13 were treated with medication alone; 9 (69%) did well and 4 developed an abscess and had residual lymphadenopathy. All 34 cases treated with modified neck dissection before a full course of medication were cured. The cure rates differed significantly by type of treatment (p = 0.004). These results suggest surgical treatment for all accessible lymph nodes ≥ 3 cm in diameter in patients with TCL prior to a full course of drug therapy significantly increases the cure rate compared to medication alone.

Tuberculous lymphadenitis as a cause of obstructive jaundice

Obstructive jaundice secondary to abdominal tuberculosis is extremely rare. We present a patient with jaundice secondary to compression of the common bile duct by TB lymphadenitis. A 49-year-old woman was admitted to our department for nausea,epigastric pain and jaundice. Abdominal ultrasonography and computer tomography scan were suggestive of stenosis of the distal common bile duct caused by a retro pancreatic mass. At laparotomy, an enlarged lymph node behind the head of the pancreas was found, causing compression and stenosis of the distal parts of the choledochus. The lymph node frozen section analysis showed epithelioid granuloma with caseous necrosis,strongly suggesting tuberculous origin. Choledochoduodenal anastomosis was performed. Definitive pathohistological examination confirmed TB lymphadenitis. ATB should be considered as a potential cause of jaundice especially in immuno compromised patients and endemic areas. Diagnosing abdominal tuberculosis can be a challenging task. No satisfactory diagnostic gold standard is available so that in most cases the diagnosis cannot be reached before exploratory laparotomy.Early detection enables successful conservative treatment and eliminates the necessity of surgery.

[The symptoms and surgical tactics for complicated forms of the abdominal cavity tuberculosis]

The results of treatment of 12 patients, suffering complicated forms of abdominal tuberculosis and external intestinal fistulas, were presented. Late diagnosis of abdominal tuberculosis in the patients, suffering the complications phase of the disease, is caused by unclear symptoms presence in early stages of the disease. Clinical and laboratory indices in peritonitis of a phthisis origin are nonspeciphic. In 91% of patients, admitted to the hospital for complicated forms of abdominal tuberculosis and external intestinal fistulas, the operative treatment was indicated. Surgical intervention (more frequently right-sided hemicolectomy, enterostomy, the abscesses opening, the caseously-changed lymph nodes excision, formation of anastomosis) was performed in 11 patients for peritonitis and external intestinal fistulas. The method of a secure invagination anastomoses formation was elaborated, permitting to perform primary restoration operations. An early diagnosis, early effective therapy and radical surgical intervention conduction for complicated abdominal tuberculosis promote the patients to survive.

[Surgery for tuberculosis--a ten-year experience]

We reviewed our institutional experience of surgical cases of tuberculosis in the last decade. There were 42 surgical cases, including 26 cases of tuberculoma, 5 cases of tuberculous lymphadenitis, 4 cases of tracheobronchial tuberculosis, and 7 cases of tuberculous empyema. The most aim of the surgery for tuberculoma and lymphadenitis were to make differential diagnosis from malignant neoplasm. Sleeve resection was done in 3 cases of tracheobronchial tuberculosis and Montgomery T-tube placement was underwent for a case of tracheal stenosis. Radical surgery was indicated for 4 cases of empyema and open window thoracostomy for 3 cases. There was no major complication and operation-related death. The surgical indication for tuberculosis is very limited nowadays because of effective chemotherapy, however, surgery is still relevant in selected small groups of tuberculosis patients. Exchanging more information and alliance among physicians and thoracic surgeons will become more important for better tuberculosis treatment.

[A case of possibly life-threatening abscess formation in cervical lymph node tuberculosis]

Abscess formation in the cervical lymph nodes is a well-known clinical manifestation. Special care should be taken in atypical cases. In this article we describe the case of a young foreign male with tuberculosis-induced cervical abscess formation where surgery revealed a large connecting mediastinal abscess.

[Infraorbitally located tuberculous lypmhadenitis: a case report]

Tuberculosis, which is one of the oldest diseases of the human kind, is again becoming an important health issue in recent years. Although mostly seen in lungs, it can also be localized in the lymph nodes, skin, meninges, spleen, surrenal tissues, which is referred to as extrapulmonary forms of tuberculosis. Tuberculous lymphadenitis is the most common clinical form of extrapulmonary tuberculosis and it is generally localized in cervical lymph nodes. A 50-year-old female patient presented with a hard fixed mass originating from medial canthus ending at nasolabial sulcus. In the magnetic resonance imaging examination, a solid contrast enhancing mass 20 x 18 x 15 mm in size, which was isointensely monitored with muscular structures in T1 based visuals and hyperintense in T2 sequences, was seen. The mass was excised under general anesthesia and histopathological examination revealed tuberculous lymphadenitis. Thus, the case is discussed according to literature and shows us that tuberculosis may be the reason for lymphadenitis in the areas out of the cervical region and it should always be kept in mind in the differential diagnosis.

[Cervical tuberculous lymphadenitis: the location of surgery]

INTRODUCTION

In spite of the current effectiveness of antibacillary chemotherapy in most tubercular sites, peripheral lymph node involvement continues to pose a challenge to treatment.

PATIENTS AND METHODS

It is a retrospective study, from 2002 to 2005, of 326 patients treated at the otorhinolaryngology department of Hassan II University Hospital, Fez, Morocco, for cervical lymph node tuberculosis.

RESULTS

The tuberculosis of lymph nodes accounts for more than 23% of all affections managed in our department. The mean age of our patients was 32 years. A slight female predominance was noted. All of our patients benefited from surgery with diagnostic and/or therapeutic purposes. The treatment was supplemented by two rifampicine-isoniazide-pyrazinamide/four rifampicine-isoniazide antibacillary chemotherapy. The course of disease was marked by lymph node recurrence and failure of medical treatment in 54 patients.

DISCUSSION

In the absence of, or in waiting for, bacteriologic confirmation, the surgery keeps a place impossible to circumvent, either as a diagnostic or therapeutic operation, in first-line treatment in the presence of a cold abscess, an inexhaustible fistula, lymphadenitis with atypical mycobacteria, and a large and calcified lymph-node mass for which medical treatment will not be sufficient, or in secondary surgery in the event of failure or progress under medical treatment or in case of residual adenopathy at the end of an appropriate medical treatment.

CONCLUSION

Surgery still has an important place in the management of tuberculosis of lymph nodes.

Severe paradoxical reaction requiring tracheostomy in a human immunodeficiency virus (HIV)-negative patient with cervical lymph node tuberculosis

During drug treatment of tuberculous lymphadenitis, paradoxical response (PR) may occasionally occur. Continued treatment or lymph node aspiration improves PR without severe sequelae. However, we report a case of severe PR in a patient with cervical lymph node tuberculosis causing airway obstruction due to retropharyngeal lymph node swelling during antituberculous treatment. Tracheostomy and drainage of the node were performed to secure the airway. Possible airway obstruction due to PR must be suspected when cervical lymph node tuberculosis involves the retropharyngeal lymph node.

[Intestinal tuberculosis of the terminal ileum causing obstructive ileus and tuberculous peritonitis and presenting numerous peritoneal small red nodules: a case report]

A 38-year-old woman suffering from lower abdominal pain was referred to our hospital. Abdominal computed tomography showed marked thickening of the terminal ileum to the cecum, localized collection of ascites, and multiple mesenteric lymphadenopathy. A barium contrast small bowel series showed solitary severe stenosis of the terminal ileum with marked swelling of the ileocecal valve, where colonoscopy could not pass through, suggesting that ileal stenosis was caused by intestinal tuberculosis. She also showed strongly positive tuberculin skin test. Laparoscopy-assisted ileocecal resection was performed for confirmation of diagnosis and removal of the stenotic intestinal lesion. Laparoscopically, numerous small red nodules scattered on the stenotic ileal serosa, peritoneum, and mesenterium. Histopathological examination revealed ileal tuberculosis causing ulcerative stricture, and mesenteric tuberculous lymphadenitis. The small red nodules were formed of hemorrhagic tuberculous nodules.

[Suboccipital tuberculosis: the clinical and radiation and potentialities of current surgical treatment]

The clinical and radiological manifestations of suboccipital tuberculosis have been analyzed in 7 patients aged 7 to 35 years. A case of this condition accompanied by extensive vertebral destruction, abscesses, and basilar impression is described in a 7.5-year-old child. A radical stabilizing operation was successfully performed using the currently available technologies.

[Tuberculosis of intrathoracic lymph nodes in children and adolescents: diagnosis and surgical treatment]

A hundred and seven children and adolescents with intrathoracic lymph node (LTLN) tuberculosis were operated on. Late diagnosis and long-term ineffective antituberculous therapy lead to the development of complicated forms of ITLN tuberculosis in 44% of children. Computed tomography significantly determines extent, localization, the state of the adjacent tissue, and the phase of a tuberculous process, evaluates the efficiency of antituberculosis therapy, and ascertains the optimum time of a surgical intervention. Surgical removal of the involved ITLN is a highly effective operation causing the minimum number of complications. Bilateral successive one-stage removal of the involved lymph nodes is possible in children with bilateral ITLN tuberculosis.

[Surgical treatment of mycobacteriosis]

The pulmonary resection plays an important role in the management of tuberculosis, especially MDRTB, or non-tuberculous mycobacteriosis. For the satisfactory outcome, pre- and postoperative chemotherapy is mandatory. On the same time, resected specimens should be examined bacteriologically to evaluate preoperative chemotherapy. Acute mycobacterial empyema occurs frequently by the perforation of cavitary lesions, especially with pulmonary NTM. The outcome of such acute and destructive diseases is poor in the case of old age over 70y/o. But without surgical intervention, such difficult condition becomes more miserable. Although mycobacterial mediastinal lymphoadenitis, or osteoarthritis are rare tuberculosis-related disease in Japan, we should keep in mind such rare diseases in ordinary practice.

[Application of mediastinoscopy to diagnosis of mediastinal diseases and staging of lung cancer]

BACKGROUND & OBJECTIVE

It is still very difficult to make a definite diagnosis for some mediastinal diseases through some examinations, such as CT scan and fibrobronchoscopy. To judge the metastasis of mediastinal lymph nodes exactly for lung cancer patients and make proper staging of lung cancer are important for defining therapeutic schedule and estimating prognosis. This study was to explore the application value and summarize the experience of mediastinoscopy in the diagnosis of mediastinal diseases and the staging of lung cancer with enlarged mediastinal lymph nodes.

METHODS

Mediastinoscopy and biopsy were performed in 16 patients with different mediastinal diseases detected by imaging examinations and 14 lung cancer patients with enlarged mediastinal lymph nodes diagnosed by CT scan, PET, or fibrobronchoscopy. The staging of lung cancer was identified according to pathologic diagnosis.

RESULTS

Of the 16 patients with different mediastinal diseases clarified by mediastinoscopy, 5 had nodule diseases, 3 had mediastinal lymph node tuberculosis, 2 had mediastinal lymphnoditis, 2 had lymphoma, 1 had extra-gastrointestinal type gastrointestinal malignant interstitialoma,1 had thymoma, 1 had metastatic small cell carcinoma, and 1 had metastatic adenocarcinoma. Of the 14 lung cancer patients with enlarged mediastinal lymph nodes, 6 had metastatic lymph nodes, and 8 had not; all of the 14 cases were accurately staged and received successful operations without severe postoperative complications.

CONCLUSION

Mediastinoscopy is a safe, accurate and effective procedure for the diagnosis of mediastinal diseases and the staging of lung cancer.

[Abdominal tuberculosis--a surgical reality]

Abdominal tuberculosis is a rare disease, with non-specific findings. Peritoneal tuberculosis is a frequent cause of low gradient ascites. The records of 22 patients (Il males, 11 females, mean age 41,17 years, and range 17-74 years) diagnosed with abdominal tuberculosis (TBC) in First Surgical Clinic, "St. Spiridon" University Hospital Iaşi between 1995 and 2006 were analyzed retrospectively and the literature was reviewed. From these 22 patients diagnosed with abdominal tuberculosis, there were: peritoneal TBC in 16 cases, intestinal TBC in 5 cases, mesenteric lymph nodes TBC in 1 case. The patients with intestinal TBC, were presented with complications, 2 perforations with peritonitis, 1 intestinal obstruction, and 2 as ileo-cecal "tumors" solved by right colectomy, 4 enterectomy (3 entero-enterostomies and 1 ileo-colic anastomosis). The patients with peritoneal TBC were diagnosed by laparoscopy and peritoneal biopsy in 13 cases, and by laparotomy in 3 cases. In peritoneal tuberculosis ascites was present in 15 cases. Other common findings were weight loss (12 cases), weakness (5 cases), abdominal pain (15 cases), anorexia (5 cases) and night sweat (2 cases). Only two patients had chest radiography suggestive of a new TBC lesion. In those patients with peritoneal tuberculosis, subjected to operation, the findings were multiple diffuse involvements of the visceral and parietal peritoneum, white "miliary nodules" or plaques, enlarged lymph nodes, ascites, "violin string" fibrinous strands, and omental thickening. Biopsy specimens showed granulomas, while ascitic fluid showed numerous lymphocytes. Post operatory evolution and management were applied by the TBC Medical System and the patients were treated 6 months by tuberculostatics, with favorable evolution. Abdominal tuberculosis should be considered for diagnosis, in patients with non-specific symptoms of abdominal pain, fever, loss of appetite, abdominal distension and even symptoms of acute abdomen. Laparoscopy is the best approach for peritoneal tuberculosis, and emergency surgery is necessary for acute complication like obstruction and peritonitis. Specific antituberculosis drugs are indicated in postoperative period.

Surgical Excision versus Antibiotic Treatment for Nontuberculous Mycobacterial Cervicofacial Lymphadenitis in Children: A Multicenter, Randomized, Controlled Trial

BACKGROUND

The optimal treatment of nontuberculosis mycobacterial cervical lymphadenitis in children has not been established. Until recently, surgical excision was the standard treatment, but the number of reports of successful antibiotic treatment is increasing, which questions whether surgery is the preferred treatment. In this randomized, multicenter trial, we compared surgical excision with antibiotic treatment.

METHODS

One hundred children with microbiologically proven nontuberculous mycobacterial cervicofacial lymphadenitis were randomly assigned to undergo surgical excision of the involved lymph nodes or to receive antibiotic therapy with clarithromycin and rifabutin for at least 12 weeks. The primary end point was cure, defined as regression of the lymph node enlargement by at least 75%, with cure of the fistula and total skin closure without local recurrence or de novo lesions after 6 months, as assessed by clinical and ultrasound evaluation. Secondary end points included complications of surgery and adverse effects of antibiotic therapy.

RESULTS

Intention-to-treat analysis revealed that surgical excision was more effective than antibiotic therapy (cure rates, 96% and 66%, respectively; 95% confidence interval for the difference, 16%-44%). Treatment failures were explained neither by noncompliance nor by baseline or acquired in vitro resistance to clarithromycin or rifabutin. Surgical complications were seen in 14 (28%) of 50 patients; staphylococcal wound infection occurred in 6 patients, and a permanent grade 2 facial marginal branch dysfunction occurred in 1 patient. The vast majority of patients who were allocated to antibiotic therapy reported adverse effects (39 [78%] of 50 patients), including 4 patients who had to discontinue treatment.

CONCLUSIONS

Surgical excision is more effective than antibiotic treatment for children with nontuberculous mycobacterial cervicofacial lymphadenitis.

Tuberculosis of the thyroid gland: a case report

Thyroid tuberculosis is a very rare condition even if the incidence of extrapulmonary forms of tuberculosis has increased. We report the case of a 56-year old female patient with tuberculosis of the thyroid gland and tubercular lymphadenitis of the neck mimicking thyroid malignancy. The diagnosis was established on histological examination after surgery in August 2002. Total thyroidectomy and central neck dissection were performed for very hard euthyroid multinodular goiter and paratracheal bilateral lymphadenopathy. There were no evidence of tubercular involvement of the other organs. The patient underwent combination treatment with antitubercular drugs for 6 months. During the three years follow-up period there was no evidence of disease recurrence.

Diagnostic dilemma of abdominal tuberculosis in non-HIV patients: An ongoing challenge for physicians

AIM: To assess the clinical features, yield of the diagnostic tests and outcome of abdominal tuberculosis in non-HIV patients.

METHODS: Adult patients with discharge diagnosis of abdominal tuberculosis (based upon; positive microbiology, histo-pathology, imaging or response to trial of anti TB drugs) during the period 1999 to 2004 were analyzed. Patient’s characteristics, laboratory investigations, radiological, endoscopic and surgical findings were evaluated. Abdominal site involved (intestinal, peritoneal, visceral, and nodal) and response to treatment was also noted.

RESULTS: There were 209 patients enrolled. One hundred and twenty-three (59%) were females. Symptoms were abdominal pain 194 (93%), fever 134 (64%), night sweats 99 (48%), weight loss 98 (47%), vomiting 75 (36%), ascites 74 (35%), constipation 64 (31%), and diarrhea 25 (12%). Sub-acute and acute intestinal obstruction was seen in 28 (13%) and 12 (11%) respectively. Radiological evidence of pulmonary tuberculosis was found in 134 (64%) patients. Basis of diagnosis of abdominal tuberculosis were radiology (Chest and barium X-Rays, Ultrasound and CT scan abdomen) in 111 (53%) and histo-pathology (tissue obtained during surgery, colonoscopy, CT or ultrasound guided biopsy, laparoscopy and upper gastro intestinal endoscopy) in 87 (42%) patients. Mycobacterium culture was positive in 6/87 (7%) patients and response to therapeutic trial of anti tubercular drugs was the basis of diagnosis in 5 (2.3%) patients. Predominant site of involvement by abdominal TB was intestinal in 103 (49%) patients, peritoneal in 87 (42%) patients, solid viscera in 10 (5%) and nodal in 9 (4%) patients. Response to medical treatment was found in 158 (76%) patients and additionally 35 (17%) patients also underwent surgery. In a 425 ± 120 d follow-up period 12 patients died (eight post operative) and no case of relapse was noted.

CONCLUSION: Abdominal TB has diverse and non- specific symptomatology. No single test is adequate for diagnosis of abdominal tuberculosis in all patients. Abdominal TB in non-HIV patients remains an ongoing diagnostic dilemma requiring a high index of clinical suspicion.

Cervical atypical mycobacterial lymphadenitis in childhood: findings on sonography

PURPOSE

To describe the sonographic appearance of cervical lymph nodes in twelve children with histopathologically confirmed atypical mycobacterial lymphadenitis.

MATERIALS AND METHODS

Sonography of cervical lymph nodes was performed with a real-time linear scanner using a 13 MHz probe. Sonographic findings were retrospectively reviewed in 9 girls and 3 boys age 1.7 to 10.7 years (median age, 3.7 years), with cervical lymphadenopathy at initial presentation.

RESULTS

Strong echoes within the lymph nodes were found in 4 (33 %) of the children, corresponding to calcifications on histopathological examination. Loss of regular nodal shape with circumscript polypoid spread of nodal masses into the subcutaneous tissue was found in 6 (50 %) patients; at least 1 of these 2 features was noted in 10 (83 %) of our 12 patients. At surgery, abscess formation was found in 8 (67 %) children.

CONCLUSION

When nodal calcifications and spread of nodal masses into the subcutaneous tissue are found in patients with cervical lymphadenopathy, the examiner should maintain a high level of clinical suspicion for atypical mycobacterial lymphadenitis. Contrary to other causes of cervical lymphadenopathy, total surgical excision is the treatment of choice. Identification of these patients prior to surgery is therefore of utmost importance. Our data suggest that sonography could serve as an easy non-invasive method for this purpose.

[Clinical characteristics and management of primary cervical tuberculous lymphadenitis]

OBJECTIVE

To investigate the clinical characteristics and management of primary cervical tuberculous lymphadenitis.

METHOD

Thirty-two patients with primary cervical tuberculous lymphadenitis were reported, of which four patients were diagnosed definitely by fine needle aspiration cytology, twenty-eight patients were diagnosed definitely by incisional or excisional biopsy. Twenty-nine patients have been examined by computer tomography (CT) before biopsy. Twenty-seven patients got anti tuberculosis therapy for six months after the total masses resection or regional cervical lymph node dissection, while the others got general anti tuberculosis chemotherapy for one year.

RESULT

CT showed the iso-density enhancement or heterogeneous enhancement of the masses. All patients were followed up. After anti tuberculosis therapy for three months, one patient was diagnosed as cervical tuberculous lymphadenitis combined with cervical lymph node metastasis of nasopharyngeal carcinoma and treated by radiotherapy in the department of oncology, the other thirty-one patients had no relapse and other manifestations of tuberculosis.

CONCLUSION

The characteristics of primary cervical tuberculous lymphadenitis have been changed, cervical masses localized mostly to the posterior cervical regions were the first and major clinical symptoms. CT examination will be helpful for the diagnosis and differential diagnosis of such disease. Primary cervical tuberculous lymphadenitis can be treated effectively with combination of standard anti tuberculosis chemotherapy and surgical excision of the cervical lymph nodes. Operations play an important role in the therapy of primary cervical tuberculous lymphadenitis, such as shortening the treatment period, reducing the dosage, noxious and side-effect of drugs and avoiding the forming of abscess or sinus.

Clinics in diagnostic imaging (108). Tuberculous dactylitis of the thumb, mediastinal and left hilar lymphadenopathy, and probable left cervical lymphadenopathy

A five-year-old girl presented with a history of left neck swelling for one week and right thumb swelling for three weeks. Imaging studies revealed a "collar-stud" abscess in the left side of the neck, massive mediastinal lymphadenopathy with a left anterior chest wall abscess, and right thumb dactylitis that was typical of tuberculosis (TB). Surgical drainage of the left neck swelling revealed acid-fast bacilli. Young children are more susceptible to tuberculous infection, and at greater risk of extrapulmonary spread. A child infected with TB indicates recent transmission, usually from an adult. Good contact tracing is essential. Individuals with HIV infection are also at greater risk of TB and atypical mycobacterial infection as well extrapulmonary TB. The clinical and radiological features of both pulmonary and extrapulmonary TB are discussed, with additional illustrative cases.

[Surgical treatment for tuberculosis of intrathoracic lymph nodes in children and adolescents]

Ninety-four children and adolescents with tuberculosis of intrathoracic lymph nodes (TITLN) were operated on. Late diagnosis and long-term ineffective antituberculous therapy (chemotherapy lasted 2-3 years in 29.8% and 4-5 years in 19.1%) lead to the occurrence of complicated forms of TITLN in 34% of children. Computed tomography (CT) reliably determines the extent, site, and phase of a tuberculous process, assesses the time course of changes in the efficiency of antituberculous therapy. CT aids in defining the optimal time of surgical interventions. Bilateral consecutive one-stage removal of affected lymph nodes is possible in children with bilateral TITLN.

A forgotten old disease: mediastinal tuberculous lymphadenitis in children

OBJECTIVE

The purpose of the study was two-fold: (1) to highlight the varied presentation of mediastinal tuberculous lymphadenitis (MTL) in children and (2) to identify parameters, that may help in the early diagnosis of this condition.

METHODS

Between January 1995 and December 2002, 13 children with histological diagnosis of MTL were retrospectively assessed for age at presentation, history of exposure to TB, presenting symptoms, investigations, initial diagnosis, surgical treatment and outcome. Stepwise multiple linear regression analysis was used to determine potential risk factors for early diagnosis of MTL.

RESULTS

Thirteen children presented with: (a) fever, night sweats and weight loss (4); (b) acute respiratory distress (2); (c) cough and shortness of breath (SOB) (5); (d) stridor (1); and (e) chest pain (1). TB was suspected only in 6 children (46%) at presentation. In the other 7 cases (54%) the presumed diagnoses were: neuroblastoma (n=1), metastatic malignancy (n=1), bronchial polyp (n=1), bronchogenic cyst (n=2), and presumed foreign body (n=2). Bronchoscopy was diagnostic in identifying cheesy material within the bronchus and organisms on lavage in 4 (30%) and in identifying external compression in 2 (15%). Thoracotomy and excision of the lymph node mass was necessary to treat the mediastinal compression and to ascertain the diagnosis of TB in 3 children (23%). All 13 children had complete resolution of tuberculous lymphadenitis following anti-tuberculous treatment. The diagnostic clues in this cohort of patients were cough and SOB with history of exposure to tuberculosis (P=0.0001) and bronchoscopy and lavage with positive staining for acid-fast bacilli (P=0.0001).

CONCLUSIONS

Tuberculosis was not suspected in 54% of children with MTL, and they posed diagnostic dilemma on admission. Bronchoscopy must be used as a diagnostic tool in children where tuberculosis cannot be excluded by radiology or specific skin tests. Thoracotomy and excision may be necessary to treat the obstructive symptoms.

[Mycobacterial cervical lymphadenitis: role of surgery]

OBJECTIVE

To discuss the place of surgery in the management of mycobacterial cervical lymphadenitis.

PATIENTS AND METHODS

It's a retrospective study (1982-2002) about 246 patients treated in the ENT department of Farhat Hached Sousse for cervical lymph node tuberculosis. Resolution was considered when neither symptoms nor lymphadenopathy in examination were noted.

RESULTS

The mean age of our patients was 28 years. A light female prevalence was noted. In 5 patients diagnosis was established by lymph node punction. A medical treatment of first intention was then managed with a failure in 3 cases, after deadlines from 3 to 4 months. All other patients were operated: cellulolymphadenectomy (47%), adenectomy (47%) or drainage of a cervical abscess (4%). Recurrence and antituberculosis treatment resistance were noted respectively in 6% and 3% of cases.

DISCUSSION

Two questions are still discussed in the management of mycobacterial cervical lymphadenitis: 1- Is surgery necessary for the diagnosis? 2- When is surgery indicated directly? Histological specimen established the diagnosis in all cases and excluded a mestastatic lymph node. In some situations surgery must be indicated at first: cold abscess, lymph node fistulation.

CONCLUSION

Surgery still has an important place in the treatment of tuberculosis lymphadenopathy.

[Tuberculosis abdominal lymphadenitis revealed by a duodenal stenosis]

Tuberculosis abdominal lymphadenitis is rare and exceptionally revealed by digestive complications. We report one case of digestive stenosis due to duodenal external compression by tuberculosis lymph nodes. Surgical resection of periduodenal lymph nodes was performed without gastric resection or gastrointestinal anastomosis. Medical treatment of tuberculosis was successful and the patient remains asymptomatic.

Mycobacterium lentiflavum as an emerging causative agent of cervical lymphadenitis

A lymph node excision was performed on a 45-year-old woman with left cervical swelling. The disorder which developed after the patient had undergone oral surgery for a severe periodontal disease failed to respond to antimicrobial chemotherapy. A mycobacterial strain subsequently identified by high-performance liquid chromatography analysis of cell wall mycolic acids as Mycobacterium lentiflavum grew from the excised specimen. This case and previously published reports highlight the relevance of M. lentiflavum as an emerging causative agent of mycobacterial cervical lymphadenitis.

[Abdominal tuberculosis: clinical and therapeutic evaluation]

In this paper we present our experience concerning abdominal tuberculosis. The aim of this study is to evaluate various methods and to establish therapeutic approach to patients with abdominal tuberculosis. There were six patients (3 males and 3 females), aged between 22 and 67 years old, such as: 2 patients developed peritoneal tuberculosis, 3 patients developed intestinal tuberculosis and one patient developed mesenteric lymph node tuberculosis. We concluded that early diagnosis is often impossible and laboratory report was non-specific. Because surgical treatment in abdominal tuberculosis was made in complicate forms, we concluded that enterostomy "a minima" is the best therapeutic method.

A case of tuberculous granuloma at the supra-sternal notch that was difficult to differentiate from a thyroid tumor

BACKGROUND

Despite a decline after World War II, the rate of tuberculosis remains higher in Japan than in other countries. We report a case of tuberculous granuloma at the supra-sternal notch that was difficult to differentiate from a thyroid tumor.

CASE REPORT

The patient was a 75-year-old Japanese woman who was referred to our hospital for further investigations and treatment of an anterior neck tumor, that was diagnosed as a suspected of thyroid malignancy by another institute. The thyroid function and biological data were normal except for an elevated erythrocyte sedimentation rate. Imaging studies showed a mass at the supra-sternal notch, and the border between the tumor and the thyroid gland was indistinct. The tuberculosis bacillus group was identified by fine needle aspiration cytology. The patient was treated surgically for tuberculous granuloma, and histopathological findings revealed that the lymph node tuberuculosis had invaded the thyroid gland. We started anti-tuberculous therapy after the operation. The post-operative course was uneventful with good wound healing.

CONCLUSIONS

When a markedly elevated erythrocyte sedimentation rate and c-reactive protein value are associated with an anterior neck mass, tuberculosis should be considered in the differential diagnosis of thyroid swelling. Fine needle aspiration cytology is a rapid, simple and effective diagnostic method for extra-pulmonary tuberculous lesions involving the neck. When there is abscess formation or features of compression, or if the mass cannot be differentiated from a thyroid tumor, combined therapy involving anti-tuberculous agents and surgery must be considered.

Management Pathways and the Surgical Diagnosis of Tuberculous Lymphadenitis: Can They Be Improved? The Bradford Experience

OBJECTIVE

To study the diagnostic pathway for tuberculous lymphadenitis from initial referral to the commencement of antituberculous therapy with the object of identifying potentially avoidable delays.

DESIGN

Retrospective case series study.

SETTING

District General Hospital, England, UK.

SUBJECTS

Thirty-four patients with head and neck tuberculous lymphadenitis diagnosed by a positive histological specimen over the 3-year period 1998-2000.

RESULTS

There were no clear pathways for referral and management. There were substantial variations in the management between different specialties and even sometimes within the same specialty. There was evidence of poor communication between various teams.

CONCLUSIONS

The study shows that for the management of head and neck tuberculous lymphadenitis, there is a need for a 'hospital' or 'trust' approach. It also reinforces the arguments for a dedicated 'neck lump clinic' with easy access both from the general practitioners and from other specialties within the hospital and for a protocol for handling biopsy specimens from nodes.

[Cervico-facial actinomycosis--case reports]

In the article the authors made the review of actinomycosis bibliography. They also presented characteristic features infections enter ways, course of the disease, diagnostic tests and treatment methods. Two cases of face and neck actinomycosis were presented. All of them treated in Katowice-Ochojec Hospital ENT ward in last five years. Abnormal clinic symptoms made difficulty to put the diagnosis. Satisfactory results were achieved after set up final diagnosis and proper treatment.

[Surgical therapy of pulmonary tuberculosis]

In individual cases of tuberculosis surgical therapy is part of an interdisciplinary therapeutic concept. Identifying the optimal point of time for surgery has a strong impact on the further course of the healing process and thus on the prognosis. Indications for surgical therapy are: 1. multi-drug-resistant pulmonary tuberculosis (MDR-TB), 2. late-onset complications (apergilloma, tuberculosis of the tracheobronchial tree or of mediastinal or hilar lymph nodes), 3. tuberculosis of the pleura. In MDR-TB an individual concept for therapy based on all chemotherapeutic options as well as thorough planning of the surgical procedure must be provided. Resections in tuberculotic late-onset complications should be performed in patients with persisting cavernous pulmonary tuberculosis as well as in patients with post tuberculosis complex; main goal is the prevention of tuberculotic relapse. Surgical strategies for tuberculosis of the pleura include the debridement of the pleural cavity in video assisted surgical technique, decortication, partial thoracoplasty with musculoplasty or chest fenestration.

Tuberculosis of the Lymph Glands of the Neck: A Limited Role for Surgery

BACKGROUND AND OBJECTIVE: The clinical problem of a neck mass in general and tuberculous lymph nodes in the neck in particular may present a diagnostic dilemma. This retrospective study was conducted to highlight clinical presentation, management, and outcome.

PATIENTS AND METHODS: All patients (n = 59) diagnosed with tuberculosis of the cervical lymph node in Irbid governorate during the period 1996 through 2000 were reviewed for standard criteria, in addition to diagnostic and therapeutic modalities.

RESULTS: Medical records were reviewed and relevant data were included; all age groups were equally involved with a female/male ratio of 2:1. Most of the patients presented with a neck mass to the outpatient surgical clinic. The diagnosis was made mainly based on the clinical picture and results of the Mantoux test, Ziehl-Neelsen staining, and culture of bacilli. Fine needle aspiration cytology and histologic examination of incisional or excisional specimens are the main objective diagnostic tools. All patients were treated with antituberculous drugs under directly observed therapy short-course regimen with 83% cure rate.

CONCLUSION: Tuberculosis of the cervical lymph nodes responds well to antituberculous drugs and the surgical role is limited to guidance in fine needle aspiration, incision and drainage, and incisional and limited excisional biopsy. Major excisional procedures are not without complications and should be avoided.

Tuberculous mediastinal mass presenting with stridor in a 3-month-old child

A 3-month-old boy with a history of intermittent stridor was found to have obstructive emphysema on chest x-ray. Further investigations found a mediastinal mass compressing the carina and left mainstem bronchus. The mass was excised and found to be of tuberculous origin.

Treating tuberculous lymphadenitis--ifs and buts

Treatment of tuberculous (TB) lymphadenitis is virtually a specialist's job due to multiple aetiopathological factors. Diagnosis is difficult often requiring biopsy for several times. Treatment monitoring is more complex due to peculiar behaviour of TB lymph nodes. Situation has become worse due to sharp increase in the incidence of atypical mycobacteria. Due to profound improvement in antibiotic action, life-expectancy of immuno-compromised patients has also increased along with increased incidence of atypical mycobacteria in them. Clarithromycin, ethambutol, rifabutin and amikacin seem to act best on atypical mycobacteria-induced lymphadenitis. Along with rise of multi-drug resistance (MDR), drug-resistant TB lymphadenitis cases are also on the rise.

[Surgery on tuberculosis lymphatic system and abdominal organs]

The paper presents data on surgery for tuberculosis of the lymphatics and abdominal organs. Removal of tuberculosis-affected peripheral lymph nodes during etiotropic therapy yields positive therapeutical results in 84.6% of patients. The efficiency of early operations has been first evidenced by a dynamic study of the systemic immunity. Complicated abdominal tuberculosis is encountered in 44.2% and forced emergency and planned operations on the abdomen to be performed; good late results should be consolidated by combined bactericidal therapy.

Cervical lymphadenitis caused by Mycobacterium lentiflavum

We report a case of human infection caused by Mycobacterium lentiflavum and review the literature for infections caused by this bacterium. The patient was a 19-month-old boy with involvement of a cervical lymph node. Surgical removal of the lymphadenopathy was both diagnostic and curative.