Tuberculous Lymphadenitis

Gede Budhi Setiawan

Surgical Oncology Division, Surgery Department
School of Medicine, Udayana University – Sanglah Hospital Denpasar
 Curriculum Vitae
Nama : dr. I Gede Budhi Setiawan, Sp.B(K)Onk
NIP / NRP Baru : 19710522 200812 1 002
NIP / NRP Lama : -
No. Kartu Pegawai : P. 289922
Tempat/Tgl Lahir : Denpasar, 22 Mei 1971
Jenis Kelamin : Laki-laki
Agama : Hindu
Status Perkawinan : Menikah
Alamat : Jl. Trijata II / 2 Denpasar - Bali
No. Telp : 0361-223030 / 08123923956
NIK : 5171012205710003
NPWP : 25.221.042.2-903.000
Email : dhiwans@hotmail.com
 Curriculum Vitae
TMT CPNS :01-12-2008
TMT PNS :01-12-2010
Status Kepegawaian : PNS
Jenis Kepegawaian : Diknas
Pendidikan Terakhir : Sp.2
Jabatan Saat Ini : Staf Sub. Bagian Bedah Onkologi
FK UNUD/RSUP Sanglah
TMT Jabatan Saat Ini : -
Masa Kerja Golongan : III/b
Eselon : -
 Curriculum Vitae
TEMPAT KERJA SEKARANG
Organisasi : Direktorat Jenderal Bina Upaya Kesehatan
Satuan Kerja : RSUP Sanglah
Satuan Organisasi : Direktorat Medik Keperawatan
Unit Organisasi : Pelayanan Medik
Unit Kerja : SMF Bedah (Divisi Bedah Onkologi)
 Riwayat Pendidikan
No. Pendidikan Nama Sekolah Tahun Ijazah
1 SD SD Katolik Swastiastu 1984
2 SMP SMPN 5 Semarang 1987
3 SMA SMAN 3 Semarang 1990
4 Dokter Umum FK UNDIP Semarang 1997
5 Pendidikan Bedah Umum FK UNUD Denpasar 2006
6 Spesialis Bedah Konsultan Pusat Pendidikan Spesialis II 2009
Onkologi Konsultan Bedah Onkologi FK
UNUD/RSUP Sanglah

Riwayat Pelatihan Jabatan

No. Nama Pelatihan Lembaga Pelaksana Tahun
1. BHD (Bantuan Hidup Dasar) Diklat/RSUP Sanglah Denpasar 2014
2. PPI Diklat/RSUP Sanglah Denpasar 2014
3. Manajemen Pencegahan & Diklat/RSUP Sanglah Denpasar 2014
Pengendalian Kebakaran
4. Patient Safety Diklat/RSUP Sanglah Denpasar 2014
5. Manajemen Pencegahan & Diklat/RSUP Sanglah Denpasar 2017
Pengendalian Kebakaran
 Riwayat Pendidikan

No. Nama Pelatihan Lembaga Negara Tahun

Pelaksana Pelaksana
1 Pelatihan ATLS Komisi Trauma Indonesia 2001
2 TOT ATLS Komisi Trauma Indonesia 2004
3 Pelatihan ATLS Komisi Trauma Indonesia 2015
4 Pelatihan ATLS Komisi Trauma Indonesia 2017
5 Trainer Development Programme PABI Indonesia 2018
Epidemiology
9 million new cases & 2 millions death of TB world wide
Tuberculous lymphadenitis has increase paralell with
incidence of mycobacterial infection
Nearly 35 % of extrapulmonary TB
About 15-20 % of all cases TB
In HIV-positive, extrapulmonary TB 53-62 % of all cases
Cervical Lymphnodes are the most common site of
involvement ( scrofula - scrofuloderma )
60-90 % with or without involvement of other lymphoid
tissue
Pathogenesis
Tuberculous lymphadenitis is a local manifestation of the systemic disease
May occur :
During primary tuberculous infection or
Result of reactivation of dormant foci or
Direct extension from a contiguous focus
Ghon Focus
Lymphatic drainage
Hilar, mediastinal and paratracheal and supraclavicular llnd are the first
site of spread from the lung parenchyma.
Cervical tuberculous lymphadenitis may represent a spread from the
primary focus of infection in the tonsils, adenoids sinonasal
Clinical Finding
Cervical Lymphadenopathy
Disease of the lymphnodes
Enlargement of the lymphnodes
Cause were varied ( infection, inflamation, degenerative or
neoplasma )
Cervical lymphadenopathy is a sign or a symptom, NOT A
DIAGNOSIS

Only 5 % Cervical lymphadenopathy were Tuberculous

Lymphadenitis
Clinical Presentation
Tuberculous lymphadenitis is the most common clinical
presentation of extrapulmonary TB
Cervical, mediastinal, axillary, mesenteric, hepatic,
perihepatic and inguinal lymphnodes
Unilateral single or multiple painless slow growing -mass,
developing over weeks to months
Mostly in posterior cervical, less common in supraclavicular
Systemic symptoms are common ( low grade fever, weight
loss and fatigue ) - night sweats.
Cough is not a prominent feature
Clinical Presentation
Peripheral tuberculous lymph nodes classification
( Jones and Campbell )
Stage 1, enlarged, firm, mobile, discrete nodes showing non-
specific reactive hyperplasia

Stage 2, large rubbery nodes fixed to surrounding tissue owing to

periadenitis

Stage 3, central softening due to abscess formation

Stage 4, collar-stud abscess formation

Stage 5, sinus tract formation

Diagnosis
Anamnesis, physical exam, tuberculin test, acid-fast bacilli
staining, radiologic examination, FNAB, biopsy and culture.
Differential diagnosis :
Infections (viral, bacterial or fungal),
Neoplasms (lymphoma or sarcoma, metastatic
carcinoma),
Non-specific reactive hyperplasia, sarcoidosis,
toxoplasmosis, cats-scratch fever, collagen vascular
diseases
Diagnosis
Differential diagnosis :
Acute bilateral or unilateral cervical lymphadenitis is usually
caused by a viral upper respiratory tract infection,
streptococcal or staphylococcal infection ( 40% to 80% of
cases )
Subacute or chronic lymphadenitis include cat-scratch disease
and mycobacterial infection.
Generalized lymphadenopathy is often caused by a viral
infection, and less frequently by malignancies,
Most cases of cervical lymphadenitis are self-limited and require
no treatment.
Diagnosis
Ultrasound, MRI, CT
FNAB is a sensitive, specific and cost-efective way to
diagnose mycobacterial cervical lymphadenitis
(sensitivity 77-84%, specificity 80-88%)
Combination of FNAB with culture or a Mantoux test further
increases the diagnostic yield
Combination of FNAB with PCR has the highest diagnostic
value, its can reduce the necessity for open biopsy.
PCR should only be reserved for problem cases in resource
limited countries
Diagnosis - Role of Surgery
Open biopsy is only used when FNAB has not been
diagnostic (sensitivity 80%).
Viewing caseous granuloma is highly suggestive of
tuberculosis.
Treatment
Antituberculosis treatment is the mainstay in the
management of Tuberculous lymphadenitis
First-line drugs are isoniazid (INH), rifampin, ethambutol,
pyrazinamide and streptomycin
Six month treatment ( 2-4 )
Treatment duration could be extended.
Tuberculous infection usually responds very well.
Lymph nodes can enlarge with worsening symptoms in the
course of tuberculosis treatment ( paradoxical reactions )
Treatment - Role of Surgery
Lymphnodes excision usually not indicated in most cases,
only for feasible complete lymphnode excision
Aspiration,- anti gravity aspiration, when lymphnode
fluctuant and surgical excision limited.
Curettage, when the lesion is in proximity to the nerve or
there is extensive skin necrosis. 43

Excision of the skin overlying the mass can be performed

when there is a fistula, scar formation, or necrosis.
Simple incision and drainage are associated with prolonged
postoperative wound discharge and hypertrophic scarring. 7
Treatment - Role of Surgery
Surgery increases the cure rate with excellent
cosmetic result and a low complication rate in
nontuberculous lymphadenitis.
Antibiotics are used to augment surgical therapy
Summary
Most common extrapulmonary manifestation of
tuberculosis
Diagnostics and therapeutic challenge
Anamnesis, physical exam, BTA test, FNAB, PCR are
helpful in obtaining early diagnosis, often requiring biopsy.
Differentiated tuberculous from non tuberculous
lymphadenitis
Best treated as systemic disease with anti-TB medication
Surgical therapy along with anti-TB medication might be
beneficial in selected patients
Thank You