Tuberculous Sinuses Re-Visited
S. Theophilus Bushan,* Amer Irhuma,* Einass Elhudeiri,*
Background:
Tuberculous sinuses occur as a
result of long standing T.B. Lymphadenitis, untreated and or its complication.
Patients may neglect and delay in seeking medical help due to ignorance,
poverty and or lack of education, some times non-availability of medical
facility or undiagnosed initially by the primary care physicians who see the
patient.
Aims of the Study:
This study was mainly initiated
to see why the patients with T.B.sinuses were so much delayed in getting the
timely medical treatment even when medical facility is a state sponsored
programme to all its citizens and resident foreigners.
Methods:
All patients with peripheral
sinuses attended our OPD suggestive of tuberculosis and all cases of T.B.
Lymphadenitis / Sinuses attending TB Hospital (Dharan) from Jan 2001 to June
2002 one and half years analysed.
Results:
25 patients had registered with
Dharan hospital during this one and half years study period both referred and
direct visits. There were 15 male, 7 female, 2 female children and one male
child.Age ranged between 3 years to 64 years. Cervical nodes were effected in
16 patients Supra clavicular, submandibular nodes 2 each Tuberculus sinuses were
resent in 3 patients Lymph node biopsy
was done in 15 patients, and FNAC Smear in 2 patients. AFB (Z-N) stain
was done in sinuses.
Diagnosis was established in 20
patients (80%). PPD (Montox) test was done in 19 patients (76%), PPD was
significant diagnostically is 17 patients (68%) Chest X-ray (MMR) was done in
all the cases yeilded Hilar Lymphadenopathy in 5 patients (20%).
All the patients received W.H.O
regime of anti.T.B. treatment. There were only 2 defaulters
Conclusions:
Most patient are compliant of
therapy 92% (23 patients) only 2 had defaulted (8%). There is both neglect,
ignorance, lack of medical knowledge on part of the patients as well as delay
in diagnosis by the primary care doctors initially when seen first (cases
illustrated).
This needs to be remedied by
C.M.E special programme on tuberculosis
in chest TB hospital regularly to the primary care doctors who usually see
these patients first.
Introduction & History:
Scrofula defined as tuberculosis
of lymphglands has afflicted humans for
thousands of years. Hippocrates (460-377BC) mentioned scrofulous tumours in his
writings and Herodotus (484 ;- 425 BC) described the exclusion of those
patients who had leprous lesions from the general populations1
In Europe
in the middleages this illness was known as KNG'S EVIL because of apparent cure
of many cases following KING'S ROYAL TOUCH!.
Historians have recorded vivid
accounts of the crushing mobs gather to see the royal touch.2
Scrofula most frequently
afflicted children between 2-15 years. In 1884 in England out of 133,000 children
examined, 24% showed obvious scars of scrofula or had enlarged cervical lymph
nodes.3
Patients and Methods:
All the patients registered
with TB (Dharan) hospital referred and
direct visits, as tuberculosis have a master card showing medical data,
investigations and treatment schedule.
All the 25 patients of TB
lymphadenitis and TB sinuses were analysed. All patients had undergone complete
general physical examination routine blood investigations, chest X-ray (MMR).
FNAC smear and lymph node biopsy in selected cases and PPD (Mantoux) test in
majority of the patients.
All the patients were on WHO
regime of management with monthly follow up and some patients are admitted
needing special monitoring.
*
Department of Gen. Surgery 2nd
March Hospital, Sebha , Libya
* Faculty University
of Sebha, School of Medicine , Sebha ,
Libya
Case I:
K.M. 31 years old Libyan female
attended our clinic in Jan.2002 with h/o non healing ulcers in the left axilla
and left hand since 6 months. She had seen 3 different doctors and had many
courses of antibiotics and regular dressings.
On examination she was sickly
looking young female, anemic with multiple sinuses discharging thin watery pus
covered with unhealthy granulation tissue
in the axilla she also had 2 small ulcers over the fourth and fifth
fingers of the left hand covered with
unhealthy granulation tissue.
She under went all routine
investigations including HIV, HbsAg test, chest x-ray all were negative. AFB
smear was negative but PPD (montonx) test was highly positive.
She was started on anti TB
treatment from 17.1.2002. She has completed 6 months course and on regular
monthly follow up All the sinuses have healed. Her appetite has improved and
she has gained weight. Her husband is happy and dedicated to his wife who
always accompanies her to the clinic every visit.
In this case delay in starting
the proper management was due to non-diagnosis by the doctors who saw her before.
Case II.
A.M. 27 years chadian female
attended our OPD in March 2002 with Repeated episodes of abscess over the chest
since 12 months.
She is from Hoon about 600 Km
and was taking medical treatment from different clinics from the near by
Village.
Fortunately she was known to
some hospital staff here who brought her to our clinic for management.
On examination she had partially
opened abscess over the left mammary
region which was incised and drained. Pus was sent for AFB stain.
We carried out all routine
investigations including a chest x-ray, ESR was 70 mm/1st hour PPD was highly positive. Chest x-ray
showed bilateral hilar adenitis.
She was registered with TB
hospital and anti TB treatment was given from 24.3.2002.
Within 1 month her appetite
improved, sinuses are getting better. She is well and regularly visiting Dharan
hospital for the treatment (see the photo).
Case III.
25 years Nigerian male and an
inmate of the jail hale and hearty before imprisonment, developed a swelling
over the Lt sterno clavicular joint, slowly increasing in
size with minimal general symptoms. Since April 2002. He was referred to the 2nd
March Hospital by the attending Physician, where he underwent all the routine
tests. The abscess was drained in June 2002. Pus sent for AFB smear, (chest
x-ray was negative PPD was not available he was on IV antibiotics for 1 week
(inj Rocephin 1g daily) and discharged.
The residual abscess did not
respond to routine medications and he started developing neck swelling as well.
The doctor sent him to Dharan hospital and on clinical grounds he was
started anti T.B. treatment as an in
patient with short course of steroids and he dramatically responded. He is
undergoing full anti TB treatment.
The above 3 cases were success
stories sadly there are unsuccessful stories as well. There were 2 young Libyan
male patients with Bilateral cervical lymphadenopathy one a cold abscess and
another with sinus were advised FNAC and cytology after routine investigations
and a chest x-ray. Both the patients did not return inspite of our firm
instructions these two cases show the negligence and ignorance on the part of
the patients.
Discussions:
Tuberculosis (TB) remains one of
the deadliest diseases in the world mycobacterium tuberculosis kills more
people than any other single infectious agent
TB is a social disease with medical implications.
In 1993 world health
organisation took a unique step of declaring TB to be a world emergency.
WHO estimates each year 8
million new cases of TB occur and 3 million people die from the disease. About
95% of TB occur on the developing countries.
Between 2000 to 2020 about
19-43% of world populaiton will be infected tuberculosis nearly 1 Billion
people will newly be infected, 200 million will be sick and 3.5 million will
die from the disease. About 95% of TB occur in the developing countries. Other
factors may contribute to increase TB such as HIV/ AIDS poverty, over crowding
multidrug resistance etc..4
Tuberculosis of the lymphnodes
is one of the most common form of extrapulmonary tuberculosis.5
In developing countries
tuberculosis is the most common cause of cervical lymphadenopathy.6
There is racial difference in
the form of presentation of extra pulmonary TB in whites 37% present with cervical node involvement where
as 52% the patients originating from Indian sub. Continent.7
Scrofula has been historically a
disease most common in children.8
However numerous recent studies
from developed countries peak age is
between 20 to 40 yrs.8,9
Pathology:
Mycobacterum tuberculosis
infection is spread from the primary focus to regional lymphnodes in almost all
cases.10
This often results in greater
volume of the diseased tissue in regional lymphnodes than at the original site
of infection.11
Infection from the regional
lymphnodes may continue to spread via lymphatic system to other nodes or may
pass through the nodes and reach the blood stream in small numbers, from here
virtually it can spread to any organ in the
body. This form of lymph-hematagenous spread is usually self limited and
more than 90% of primary infectious heal with a positive tuberculosis reaction
and perhaps a little pulmonary calcification.12
The primary (childhood) versus
secondary (adult) tuberculosis is distinctly different relative to lymphnode
involvement.13
In untreated tuberculosis of
children (primary TB) almost all patients will have enlargement of hilar and or
paratracheal lymphnodes apparent on chest radiographs (14-15%) and 5% will
develop scrofula within 6 months of tuberculous infection.16
The node involvement occurs
shortly after the onset of primary infection is supported by the fact that more
than 80% of children with cervical lymph node involvement have radiological
evidence of pulmonary tuberculosis.17, 18
In contract, adult tuberculous
lymphadentis is accompanied by abnormal
chest radiographs only in 30% of
the cases and represent old healed lesions suggesting nodal disease is from
reactivation of previous infection.19, 20, 21
Historically lymphnode
tuberculosis was caused by Bovine Mycobacteria but nearly all lymphnode
tuberculosis now a days is due to mycobacterium tuberculosis.22
The major pathological events of
lymphnode tuberculosis include compression of surrounding tissue, caseation and breakdown of nodes and fibrosis
from healing of the eroded nodes.
Mortality is uncommon but
morbidity and chronic illness are the rule.23
Lymphnode enlargement within the
mediastinum may also be accompanied by compression of major blood vessels,
nerves, occlusion of lymphatic drainage erosion into the chest wall and
sternum.24,25
Involvement of the superficial
lymph node usually results in enlarging mass lesions if untreated swelling
progresses and nodes within a group become matted eventually caseation leading
to rupture causing chronic sinuses.26,27
Clinical Picture:
More than 90% of superficial
tuberculous lymph nodes are found in the head and neck regions. In the cervical
region anterior and posterior cervical group, supra-clavicular and sub
mandibular groups are commonly involved and occasionally pre-auricular and
submental nodes get involved.28
Most infected nodes heal but the
organisms may lie dormant and viable for years or decades and can again
multiply and produce active disease.
In severe immuno compromise,
tuberculous lymphadenopathy may be acute
and resemble acute pyogenic lymphadentis.29
Symptoms:
It presents as painless swelling
of one or more lymphnodes clinical presentation of lymphdenitis include mildly
tender slowly progressive swelling of the involved lymphnodes.30
Most patients give a fairly long
history and usually seek medical advise because the lumps have become painful.
In Asia the presentation is
different , 20% have discharging sinuses, 10% have cold abscess , 10% are
adherent to the skin, these patients usually have negative chest X-ray 90% are
unilateral and 90% involve one node group commonest being deep jugular chain
followed by submandibular and posterior triangle group.31
Generalised lymphdenopathy and
hepato splenomegaly, occur in less than 5% of most series. In cases of
childhood miliary tuberculosis generalised lymphadenopathy may be found in 10%
to 15% of cases.32
In less than 20% of patients
there are associated symptoms such as weight loss, raised temperature,
anorexia, fatigue, malaise and or pain.33
Other uncommon presenting
symptoms of tuberculous lymphadenitis include chronic right sided chest pain
caused by intercostal lymph node involvement.34
A neck mass with dysphagia
caused by a traction diverticulum of the oesophagus35 and
generalised lymph node enlargement suggesting reticulo histocytic tumours.35
On examination peripheral
tuberculous nodes are initially firm or rubbery, discrete and non tender. The
painless quality usually persists despite caseation and erosion through the skin. Occasionally in
young children the nodes may be swollen
and tender owing to secondary bacterial infection.36
The physical appearance of
superficial tuberculous lymphadenitis has been classified into five stages by
Jones and Campbell.37
Stage I. Enlarged, firm, mobile discrete nodes
showing non-reactive hyperplasia.
Stage II. Larger rubbery nodes fixed to surrounding
tissues due to periadenitis.
Stage III. Central softening due
to abscess formation.
Stage IV. Collar stud abscess.
Stage V. Rupture and sinus formation
Majority of cases fall into
stage 2 & 3 at the time of presentation.38
Diagnosis:
1. The differential diagnosis of tuberculous lymphadenitis
is extensive.
Consideration
must be given to infections, sarcoidosis, non tuberculous mycobacteria,
viruses, chlamydia, fungi, toxoplasma and agent of cat scratch ferver.39,
40, 41
2. Neo plastic diseases such as lymphoma, kaposi's sarcoma,
Hodgkin's disease and metastatic carcinoma42 .
3. Drug reactions e.g.
hydantion sodium.43
4. Non-lymphoid neck swellings
-
partotid gland.
-
sub-mandibular gland.
-
branchial arch cyst.
-
cystic hygroma.
-
carotid body tumour.
Medical and social history and
chest x-ray is very important particularly in children. More than 80% of
children have a history of exposure to active tuberculosis and chest x-ray
shows active tuberculosis and this is uncommon in adults.
Diagnostic sensitivity by lymph node aspirate and AFB smear is 70%
In ymphnode excision, examination of the cut surface and smear for AFB yields
about 80% positivity.
Lymphnode biopsy and routine
histological examination and finally Culture of the tissue are confirmatory.
Newer methods:
Fluro-chrome staining advanced
laboratories use auramine-rhodomine stain for the lymphnode aspirate and
mycobacteria fluresee with bright orange colour under low power microscopy.45
Tuberculin skin test:
Mantoux test is preferred
and a standard skin test for detecting
T.B. is Performed by using 5TU (purified protein derivative) usually 0.1 ml is
injected intra dermally and the induration is measured at 48-72 hours Mantoux
test is positive in more than 90% of cases in tuberculous lymphadenitis.46
Culture Technique:
Lowenstein-Jensen culture medium
is most commonly used for myo-bacteria, but the growth takes upto 6-8 weeks.
Now-a-days modern laboratories
simultaneously culture specimen in broth based medium that takes only 2-3 weeks
for mycobacterial growth.Mycobacteria grown in liquid medium are usually
spaciated and sub cultured in the presence of different anti mycobacterial
agents to assess drug sensitivity.
Firefly Luciferase:
This ingenious assay uses the
fluorescent capabilities of fireflies genetically implanted in mycobacteria
tuberculosis. The procedure offers the possibility of testing mycobaterial
drug sensitivity in hours.47
Treatment:
Management of tuberculous
lymphadenitis involves appropriate use of antituberculous drugs and judicious
use of surgical excision in minority of cases.
Chemotherapy is nearly always
curative in cases of superficial lymphadenitis before caseation and sinus
formation.48
Surgery should be limited to
those patients who fail to show improvement Even after an adequate course of
chemotherapy or who have discomfort from enlarged tense & fluctuant nodes.49
Surgery of choice is always
complete excision of the involved nodes and surrounding tissue with a healthy
margin. Surgical excision does not affect the outcome of the disease process.50
Catogory
3 of WHO guidelines
Sputum smear-negative, PTB with
limited parenchymal involvement, extrapulmonary T.B. ( a new, less severe forms
like lymph, plearal effusion, bone (exduding spine) peripheral joint, adrenal
gland.
Initial phase Continuous phase
2 HR2 …………………………….. 6 HE
2 HR2 …………………………….. 4 HR
2 HR2…………………………….. 4 H3 R3
2 H3 R3 23*
…….………………….. 4 H3 R3*
* Applied in the revised
national tuberculosis programme in India Initial phase includes 2 months of H
-isonazid
R-rifampicin and Z pyrizinamide
and Continuos phase of 6 months with H. isonazed, E. ethambutol or 4 months of
H. isoniazid, R, Rifampicin, or 4 months H.isoninzed, R. Rifampicin ( x 3 times
per week ).
Dosage
of 1st line ant tubercular agents
|
Anti
TB drugs
|
Mode
of action
|
Recommended
dose mg / Kg /day
|
Reduce
dose is
|
|
|
Renal
failure
|
Liver
failure
|
|||
|
Isoniazid
(H)
|
Bactericidal
|
5
(4-6)
|
No
|
Only
in severe liver impairment
|
|
Rifampicin (R)
|
Bactericidal
|
10
(8-12)
|
Yes
|
No
|
|
Pyrizinamole (Z)
|
Bactericidal
|
25
(20-30)
|
Yes
|
No
|
|
Streptomycin (S)
|
Bactericidal
|
15
(12-18)
|
Yes
|
No
|
|
Ethambutol (E)
|
Bacteriostatic
|
15
(12-20 )
|
Yes
|
No
|
|
Thiactazone (T)
|
Bacteriostatic
|
2-5
|
yes
|
-
|
Results:
There were total of 243 patients
registered in the study period of 1½
years including pulmonary, extrapulmonary and suspected cases.
Year 2001 year 2002 (6 minths)
Pulmonary - 65 -
49
Extrapulmonary - 34
- 22
Suspect - 39 - 34
138 105
Peripheral lymphadenitis with
sinuses were 25 patients (10.28%) there is high number 73 patients (30.04%)
forming the suspects group whose diagnosis not confirmed but clinically
strongly suspected. Biopsy or FNAC cytology was not done or patients came from
far distances and could not come again for full investigations. But in cases of
tuberculous lymph nodes diagnosis was established in 20 patients (80%).
We used all available modalities
such as FNAC for AFB smear, lymphnode biopsy and montoux test. There were only
2 defaulters and they could not be traced as we do not have a social worker who
can go to their houses.
Conclusions:
There is definite delay of
patients with TB lymphadenitis and sinuses seeking medical help partly due to
ignorance, neglect, lack of education of the patients and also we have noticed
that the primary care physicians who could not make the proper diagnosis for
timely referral to the TB hospital. We propose that there should be C.M.E.
programme about tuberculosis every 6 month to the primary care physician in the
TB (Dharan) hospital so that the attending doctors are updated about
tuberculosis as per W.H.O guidelines.
Acknowledgement:
We wish to thank Dr. Mohammed AA. Abusaifi MPH director Dharan
hospital, Zahid Al Hamid DTCD and their staff for co-operation and fruitful
discussion in data collection and suggestions in the over all management.
CLINICAL PHOTOGRAPHS
 |
 |
A.M. 27 years Female
Nigerian male 25 years
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