LECTURER : DR. DR. BAMBANG ARIANTO, SP.B

 

BY : TANIA WANGUNHARDJO

PATRICIA HILDAGARDIS BULAN

CASE REPORTTUBERCULOUS LYMPHADENITIS

CASE REPORT

PATIENT IDENTITY

Name : Mr. RIAge : 22 years oldSex : MaleReligion : MoslemEthnic : JavaOccupation : StudentEducation : Senior high schoolAddress : Medokan Semampir AWS

SurabayaMedical Record : 520267Control : November, 25th 2015

HISTORY TAKING

Chief Complaint: Armpit nodule History of Disease:

Patient came to outpatient surgery clinique with the chief complaint there was a nodule in his left armpit. He knew that nodul since 1,5 months ago and the size about 3cm in diameter. He felt pain and went to the doctor in primary health care at that time. He got Amoxicilline and Mefenamic acid for his treatment for 4 days, then he felt better (less pain). About 3 weeks ago, he felt pain again in his armpit nodule and he said it was slightly bigger than before. He didn’t know what the trigger for the pain was.

Then, he came to the outpatient surgery clinique in Haji Hospital. There was no fever, no prologed cough, no reduced apetite, no night sweat, and no reduced weight. He didn’t consume any drugs at that time. There wasn’t any other nodules in his body. He was diagnosed with left axillary soft tissue tumor, and was asked to do the FNAB. The FNAB result of left axillary nodul (November 19th, 2015) : Tuberculous lymphadenitis with secondary infection.

Last history disease : There is no history of tuberculosis, no hypertension, and no diabetes melitus, no alergy.

Family history disease : There isn’t any family member with tuberculosis or malignancy, no diabetes and no hypertension.

GENERAL STATUS

General conditions: moderate illnessAwareness / GCS: Compos mentis / 4-5-6Vital sign:

Tension: 110/80mmHg RR: 20 tpmPulse: 72 bpm Temp.axilla: 36,80C

Weight: 60 kg

GENERAL STATUS

Head / face:Anemia / jaundice / cyanosis / dyspnea: - / - / - / -

Neck : enlarged lymph nodes (-) / (-) , thyroid gland (-)

Axilla : enlarged lymph nodes (-) / (+)Thorax:

Pulmo:I : normochest, retraction (-)P : symmetric breathing movementP : sonor/sonorA : vesicular/vesicular, rhonchi -/-, wheezing -/-

Cor:I : ictus cordis not seemedP : ictus cordis not palpable, thrill (-)P : normal cor borderA : S1S2 single, murmur (-), gallop (-)

Abdomen: I : flat, symmetricA : bowel sound (+), normalP : soepel (+), tenderness (-)P : tympani (+)

Extremity : warm acral (+), edema (-)

LOCAL STATUS

Regio: Axilla sinistra I : nodul (+) diameter 4,5 x 3,5 x 0,5 cm blood (-)pus (-)hyperemia (-)

P : tenderness (+)consistency soft solidmobile flat surface clear borderfluctuation (-)warm (+)

NEUROLOGICAL STATUS

GCS : 4-5-6Meningeal Sign

Stiff neck : - Laseque : -/- Kernig : -/- Brudzinski I,II,III,IV : -/-/-/-

N. Cranialis : Pupil round isokhor 3mm/3mm; light reflex +/+

N VII and XII normalMotoric : +5 / +5

+5 / +5

Sensory : normal Physiology reflex :

BPR +2/+2 KPR +2/+2TPR +2/+2 APR +2/+2

Phatology reflex :Babinski : -/-Chaddok : -/-Hoffmman : -/-Tromner : -/-

ASSESMENT

Working diagnose: Axillary NodulPrimary diagnose: Tuberculous lymphadenitisSecondary diagnose:-Complication diagnose:-

PLANNING

Planning diagnose : - Planning therapy :

Rifampicin 600 mg 1x1 Isoniazid 300 mg 1x1Pirazinamide 500 mg 2x1Ethambutol 400 mg 2x1

Planning monitoring : Size of nodulGeneral condition

Planning education : - Explain to the patient that it’s not a malignancy- Explain to the patient that his treatment will be

around 6 months and he must consume it continuously, or it will be MDR-TB.

LITERARY

INTRODUCTION

Tuberculosis (TB) : 1/3 world population >> developing countries

Extra pulmonary TB : 7-30% of TB cases 17 – 43% tuberculous lymphadenitis

TB is responsible for up to 43% of peripheral lymphadenopathy

In India : prevalence of tuberculous lymphadenitis in children > 14 y.o : 4.4 cases per 1000The most common site : cervical lymphnodes

Axillary nodes affected in 3.8-20.3% of tuberculous lymphadenitis;described in patients without previous or active pulmonary TB and no evidence of the origin of TB detected elsewhere.

ANATOMY OF AXILLARY LYMPHNODES

5 principal groups: 1. pectoral2. subscapular3. humeral4. central5. apical

Subclavian lymphatic trunk

Right lymphatic duct

Left : thoracic duct

DEFINITION

Lymphadenopathy : ABNORMAL nodes (size, consistency or number)- Generalized : enlarged in 2 / > noncontiguous areas- Localized : only one area is involved

Lymphadenitis : Inflamation of the lymphnodes

Tuberculous lymphadenitis : Inflamation of the lymphnodes ; cause : Mycobacterium tuberculosa

EPIDEMIOLOGY

The incidence of mycobacterial lymphadenitis has increased ~ mycobacterial infection

9 million new cases & 2 million deaths from tuberculosis worldwide every year

Extra pulmonary TB : 7-30% of TB cases 17 – 43% tuberculous lymphadenitis. In HIV (+) extrapulmonary TB 53 – 62% cases of TB

Common site : cervical lymphnodes (60-90%), mediastinal, axillary, mesenteric, hepatic portal, perihepatic, & inguinal

At any age >> 2nd decade Female > Male (2:1) Black & Asians >>

PATHOGENESIS

Local / systemic manifestation

Primary or Reactivation

Primary infection : Inhaled droplet nuclei bronchi terminal alveoli multiply (GHON FOCUS) Lymphatic drain Hilar lymph nodes (PRIMARY COMPLEX) Regional lymph nodes lymphatic system other nodes blood stream another organ

Superficial lymph nodes :Multiplication M. tuberculosis hyperemia, swelling, necrosis and caseation of the centre of the nodes inflammation, progressive swelling and matting adhesion to the skin (induration & purplish discoloration)

The centre of the enlarging gland becomes soft rupture of caseous material into surrounding tissue or through skin with sinus formation

CLINICAL PRESENTATION

Duration of symptoms : few weeks – several months

Unilateral single / multiple painless slow growing mass / masses; developing over weeks to months

Systemic symptoms : low grade fever, weight loss, fatigue, night sweats, cough (+) 43% cases

History of tuberculous contact (+) in 21,8% cases, and tuberculous infection (+) in 16,1% cases

Tenderness (+) if :1. Secondary bacterial infection2. Rapidly enlarging nodes3. Coexisting HIV infection

5 stage of peripheral tuberculous lymphnodes (Jones & Campbell):

Stage I enlarged, mobile, firm and slightly tenderHistologically : nonspecific relative hyperplasia Stage II enlarged, firm and fixed to surrounding tissue and to each other. Histologically : periadenitis.Stage III The caseation occurs within the lymph node which burst out and collects beneath the deep fascia.Stage IV  The caseous material perforates the deep fascia and escapes into the superficial fascia resulting in coller stud abscess formation.Stage V  The cold abscess burst out and gives rise to a persistent discharging sinus.

DIAGNOSIS

HISTORY1. There are localizing symptoms or signs to suggest

infection or neoplasm in a spesific site?2. Are there constitutional symptoms? (fever, weight

loss, fatigue, night sweats, etc)3. Are there epidemiologic clues? (occupational

exposure, recent travel, etc)4. Is the patient taking a medication that may cause

lymphadenopathy? (phenytoin, cephalosporin, penicillins, sulfonamide)

PHYSICAL EXAMINATIONIf lymph node are detected, the following 5 characteristic should be noted & described: Size Pain/tenderness Consistency Matting Location

SMEARS

CULTURE The precence of 10-100 bacilli/mm3 of the specimen is

enough for (+) culture result. Cultures are (+) in 10-69% of the cases. Several weeks prolong initiation of treatment.

TUBERCULIN TEST Is used to show delayed type hypersensitivity

reactions againts mycobacterial antigen. The test becomes (+) 2-10 weeks after the

mycobacterial infection.

MOLECULAR TESTING PCR fast & useful technique for demonstration of

mycobacterial DNA fragments. Sensitivity 43-84%, specificity 75-100%. The presence of few dead or live microorganisms is

enough for PCR (+). PCR can be applied when smears and cultures are (-).

HISTOPATHOLOGY Langerhans giant cells Caseating necrosis Granulomatous inflammation Calcification

RADIOLOGY & IMAGING Chest radiograph Ultrasound CT MRI

MANAGEMENT

DOTS : Category I (2HRZE/4H3R3)6 months evaluationAntiTB :

1st line drug : isoniazid (INH), rifampin, ethambutol, pyrazinamide & streptomycin

2nd line drug :capreomycin, kanamycin, ethionamide,

thiacetazone, para aminosalicylic acid and cycloserine

Surgery : Lymph node excision usually is not indicatedHIV patient : same treatment ; rifampicin rifapentine

TERIMA KASIH