Tuberculosis (TB) lymphadenitis is not a frequent cause of cervical adenopathy in American children, and the diagnosis often is delayed because of a low index of suspicion on the part of providers. We present the case of a 15-year-old previously healthy African-American adolescent presented with a 3-month history of progressive left neck swelling. He was born in the United States and had not traveled internationally. His father had been incarcerated and had died of unknown causes while incarcerated. The child had not been previously screened for TB infection. The cervical swelling was not red, warm or tender, and he had not noted swelling elsewhere. He lacked fever, weight loss, cough, night sweats or other symptoms. The node had been biopsied 5 weeks before, and those cultures grew Mycobacterium tuberculosis (MTB). He was referred to the TB clinic after a microbiologic diagnosis had been confirmed.
On presentation, he was an afebrile male whose weight was in the 50th percentile. The examination was notable for 3 discrete enlarged left-sided cervical nodes: a 3 × 3 cm submandibular node, a 4 × 5 cm jugulodigastric node, and a 5 × 6 cm left deep lateral cervical node (Fig. 1A). The 2 latter nodes had central fluctuance; the child had no apparent tenderness when the nodes were palpated, and the nodes were not warm or adherent to the overlying skin; they were not matted. He lacked right-sided cervical adenopathy or adenopathy elsewhere. The tuberculin skin test, read 5 days after placement, was blistered (10 × 15 mm) with an additional 31 × 45 mm of surrounding induration. He was HIV-negative. The chest radiograph was normal. A contrast enhanced computed tomography of the neck (Fig. 1B) demonstrated 2 rim-enhancing fluid collections in the left suprahyoid neck and scared enlarged cervical nodes, some with central necrosis or suppuration; there was no inflammation or edema of the surrounding soft tissues.
Daily treatment with isoniazid 300 mg, rifampin (RIF) 600 mg, pyrazinamide 1500 mg, and ethambutol 1200 mg as directly observed therapy and corticosteroids (1 mg/kg of prednisone daily) administered by the family was begun. In addition, interventional radiology performed a therapeutic fine-needle aspiration (FNA) of the 2 fluctuant collections using a single 20G Angiocath needle with a side hole, from a posterior approach to traverse the septation between both collections and removing 45cc of purulent material under ultrasound guidance (Fig. 1C). The lymphatic tissue aspirated was smear- and acid-fast culture-positive; the isolate was susceptible to all first-line TB medications. The appearance after 1 month is shown (Fig. 1D). After 2 months of therapy, the patient had little residual adenopathy of the 2 more posterior nodes that had been drained. He had developed no fluctuance of the submandibular node (that had not been drained), and this node continued to decrease in size and was not adherent to the overlying skin. He tolerated the corticosteroids and anti-TB medication well. The steroids were weaned after a 4-week course, and the child completed a 6-month course of TB therapy with complete resolution of the adenopathy.
TB lymphadenitis is the most common manifestation of extrapulmonary TB in childhood, estimated to comprise up to 24% of all TB cases in children.1 Unilateral involvement is seen in greater than 90% of cases, with multiple adjacent nodes being involved in over 60% of cases.2 One study in an HIV low-prevalence and TB low-incidence country found that culture yield was similar for specimens obtained via FNA and open biopsy (63% vs. 65%, respectively), and the in 46%–73% of cases Xpert MTB/RIF was positive.3 However, one study evaluating FNA to excisional biopsy in TB high-incidence nations found that polymerase chain reaction sensitivity was greater for excisional biopsy than for FNA (63% vs. 17%, respectively).4 While empiric therapy of TB lymphadenitis does not differ from that of pulmonary TB, clinicians must be cognizant of certain complications that may be seen with TB adenitis. This child’s case raises salient points regarding the roles of adjunctive drainage and systemic corticosteroids to decrease complication rates.
Incision into mycobacterial lymph nodes (both tuberculosis and nontuberculosis) increases the risk for draining sinus tracts to the skin. For children with TB, many of whom have normal chest radiographs, this can result in infection control implications that would not have been present otherwise. Moreover, draining sinus tracts can be cosmetically disfiguring and can take months to heal. However, management of very fluctuant mycobacterial nodes is unclear. A percentage of these nodes will become adherent to the overlying skin and, even on effective antimicrobial therapy, result in spontaneous formation of a fistulous sinus tract.
We were concerned that this child was at high risk for sinus tract formation given the large size of the nodes, their central fluctuance and extension towards the skin. As a consequence, we hoped to debulk the lymph nodes via FNA to decrease mass effect. FNA predominantly has been utilized for the diagnosis of TB lymphadenitis, where it has a sensitivity up to 98% and specificity of up to 100% in some pediatric series.5 Few data exist on whether therapeutic, as opposed to diagnostic, FNA can decrease the risk of draining sinus tracts. While excision of nontuberculosis lymphadenitis is superior to medical therapy,6 excision of TB lymph nodes is not recommended, curative or stand-alone therapy. However, it can increase diagnostic yield if an FNA is inconclusive.4 The risk of fistula is not associated with excisional biopsy. Surgical resection may offer improved treatment outcomes for patients with localized multidrug-resistant pulmonary TB, and we hoped that similar benefits could be sought using FNA to debulk the organism load. In addition, this procedure was relatively low risk in this child who was an ideal candidate for the procedure. He was an older child who did not require sedation for the procedure, he lacked pulmonary involvement (decreasing the risk of nosocomial transmission), and his node was in a very accessible location. His procedure was the last case of the day in the interventional radiology suite; airborne precautions were used by the radiologist and his assistants. The interventional radiology and infection control teams were aware of the procedure so that appropriate personal protective and environmental measures could be taken to decrease risk to healthcare workers.
Another reason that there was concern for draining sinus tracts was that up to 15%–25% of immunocompetent patients with TB lymphadenitis develop paradoxical worsening after initiation of effective antibiotics.7 Paradoxical worsening is defined as new or worsening TB symptoms after an initial response to therapy. For patients with TB lymphadenitis, worsening may entail new or enlarging lymph nodes, cold abscesses, systemic deterioration or focal tissue involvement.8 The risk of paradoxical worsening has been found to be higher in younger adult patients,9 adolescents10 and males.9 While most children with paradoxical reactions respond to nonsteroidal anti-inflammatories, we opted to give him corticosteroids as an adjunct to anti-TB therapy. Corticosteroids has clear benefit for children with TB meningitis,11 but the data are less robust for use in TB lymphadenitis. Most published studies are usually single-center series of patients whose interventions were not randomized. In one large retrospective cohort, 47% of patients received corticosteroids and 31% had needle aspiration of TB nodes, and with most patients having a good clinical response.6 However, other studies have found no association between corticosteroid use and the duration of the paradoxical reaction.12 Given the relatively low risk of corticosteroids in this child who was already receiving anti-TB medication and demographic factors that may have put him at higher risk for paradoxical worsening, after discussion with the family, steroid therapy was initiated.
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