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CASE REPORT

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

BY
:
TANIA WANGUNHARDJO
PATRICIA HILDAGARDIS BULAN

CASE REPORT

PATIENT IDENTITY
Name

: Mr. RI
Age
: 22 years old
Sex
: Male
Religion
: Moslem
Ethnic
: Java
Occupation
: Student
Education
: Senior high school
Address
: Medokan Semampir AWS Surabaya
Medical Record : 520267
Control
: 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
didnt 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 didnt consume any drugs at that time. There wasnt 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 isnt any family member with tuberculosis

or malignancy, no diabetes and no hypertension.

GENERAL STATUS
General conditions: moderate illness
Awareness / GCS: Compos mentis / 4-5-6
Vital sign:

Tension: 110/80mmHg
Pulse: 72 bpm
Weight: 60 kg

RR: 20 tpm
Temp.axilla: 36,80C

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 movement
P
: sonor/sonor
A
: vesicular/vesicular, rhonchi -/-, wheezing -/-

Cor:

I
P
P
A

: ictus cordis not seemed


: ictus cordis not palpable, thrill (-)
: normal cor border
: S1S2 single, murmur (-), gallop (-)

Abdomen:

I
A
P
P

: flat, symmetric
: bowel sound (+), normal
: soepel (+), tenderness (-)
: 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 solid
mobile
flat surface
clear border
fluctuation (-)
warm (+)

NEUROLOGICAL STATUS
GCS : 4-5-6
Meningeal Sign

Stiff neck
: Laseque
: -/ Kernig
: -/ Brudzinski I,II,III,IV
: -/-/-/ N. Cranialis : Pupil round isokhor 3mm/3mm; light reflex
+/+
N VII and XII normal
Motoric : +5 / +5
+5 / +5

Sensory : normal
Physiology reflex

BPR +2/+2
TPR +2/+2
Phatology reflex
Babinski
Chaddok
Hoffmman
Tromner

:
KPR +2/+2
APR +2/+2
:
: -/: -/: -/: -/-

ASSESMENT
Working diagnose: Axillary Nodul
Primary diagnose: Tuberculous lymphadenitis
Secondary diagnose:Complication diagnose:-

PLANNING
Planning diagnose : Planning therapy :

Rifampicin 600 mg 1x1


Isoniazid 300 mg 1x1
Pirazinamide 500 mg 2x1
Ethambutol 400 mg 2x1
Planning monitoring :
Size of nodul
General condition
Planning education :
- Explain to the patient that its 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 1000
The 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. pectoral
2. subscapular
3. humeral
4. central
5. 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 infection


2. Rapidly enlarging nodes
3. Coexisting HIV infection

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

Stage I
enlarged, mobile, firm and slightly tender
Histologically : 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
HISTORY
1.

2.

3.

4.

There are localizing symptoms or signs to suggest


infection or neoplasm in a spesific site?
Are there constitutional symptoms? (fever, weight loss,
fatigue, night sweats, etc)
Are there epidemiologic clues? (occupational exposure,
recent travel, etc)
Is the patient taking a medication that may cause
lymphadenopathy? (phenytoin, cephalosporin, penicillins,
sulfonamide)

PHYSICAL EXAMINATION

If 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 evaluation
AntiTB :

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 indicated
HIV patient : same treatment ; rifampicin rifapentine

TERIMA KASIH