Published 10 March 2010, doi:10.1136/bmj.c63
Cite this as: BMJ 2010;340:c63
Practice
Lesson of the Week
Treatment for lymph node tuberculosis
Rob S Sellar, registrar in haematology1, E L Corbett, reader in infectious and tropical diseases2, Shirley D’Sa, consultant haematologist1,3, David C Linch, professor of haematology and head of department1,4, Kirit M Ardeshna, consultant haematologist1,3
1 University College London Hospitals, London NW1 2PG, 2 London School of Hygiene and Tropical Medicine, London WC1E 7HT, 3 Mount Vernon Cancer Centre, Northwood, Middlesex HA6 2RN, 4 University College London, London WC1E 6BT
Correspondence to: K M Ardeshna [Ссылки доступны только зарегистрированным пользователям ]
Treatment for lymph node tuberculosis must be preceded by adequate pathological investigation of the lymphadenopathy
Among the numerous causes of lymphadenopathy, tuberculosis and lymphoma are both relatively common and potentially curable. The clinical features of tuberculous lymphadenitis overlap with those of lymphoma: some patients with each condition are asymptomatic apart from painless swelling, whereas others are unwell and have systemic symptoms such as fevers, weight loss, or night sweats. Accurate diagnosis depends on confirmation with appropriate pathology tests. We present three patients with lymphoma who were initially misdiagnosed as having tuberculosis. In each case this led to a delay in the treatment of the lymphoma, and in one case, chronic side effects from the unnecessary exposure to tuberculosis treatment compromised the treatment of the lymphoma. Lymph node biopsy and adequate histopathological assessment would have prevented these misdiagnoses and should be mandatory in suspected cases of lymph node tuberculosis when microscopy and cytology of fine needle aspirate does not show alcohol and acid fast bacilli, caseating granuloma, or granuloma with Langerhan’s cells.
Case 1
A 24 year old man was referred to a respiratory clinic with a four month history of lethargy, weight loss, and night sweats, together with a mass on the right side of his neck and a prominent right tonsil. More recently he had developed a cough and had had three episodes of green sputum. He was previously well and had no personal or family history of tuberculosis. He was born in the United Kingdom to Pakistani parents and received a BCG vaccination at school. He had visited Pakistan two years previously, and one year before presentation had come into contact with tuberculosis through his work.
Examination found a large neck mass (8 cm by 5 cm) but was otherwise unremarkable. A chest x ray three months before had been normal. Computed tomography of the neck and thorax showed a nodal mass involving the cervical lymph nodes and extending to the supraclavicular region. There was no mediastinal lymphadenopathy. Full blood count and renal and liver function tests were unremarkable. Inflammatory markers were raised. Fine needle aspirate cytology was reported as showing granulomatous lymphadenitis. The patient was diagnosed with lymph node tuberculosis and given Rifater (rifampicin, isoniazid, and pyrazinamide) and ethambutol. Two months later the lump was unchanged; cultures for Mycobacterium tuberculosis were negative. Treatment was modified to isoniazid, ciprofloxacin, ethambutol, and prednisolone because of nausea and abnormal liver function tests. Ethambutol was subsequently discontinued because colour blindness developed as an adverse effect of the drug.
Six months later the lump was unchanged and he was systemically unwell with fever, weight loss, and night sweats. An ultrasound scan revealed a solid lump, from which no pus could be aspirated. Computed tomography showed a necrotic, right sided neck mass together with subcarinal and axillary lymphadenopathy and splenomegaly. An excision lymph node biopsy performed seven months after his presentation confirmed nodular sclerosing Hodgkin’s lymphoma. He arrived at the lymphoma clinic in a wheelchair because of peripheral neuropathy induced by isoniazid. He was given escalated BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisolone) chemotherapy but vincristine, a cornerstone of treatment, was omitted because of its potential to worsen his neuropathy.