Extra ptb lymphnode tb

Overview of lymph node TB, extra-PTB, INDEX TB GUIDELINE FOR TUBERCULAR LYMPHADENITIS OR LYMPH NODE TUBERCULOSIS

1. Lymph node TB Tubercular Lymphadenitis Dr. S uresh K umar Yogi MBBS & MD RESPIRATORY MEDICINE

2. The burden of EPTB is high, ranging from 15–20 % of all TB cases in HIV-negative patients. W hile in HIV-positive people it accounts for 40–50 % of new TB cases. Tuberculous lymphadenitis is among the most frequent presentations of extrapulmonary tuberculosis (TB). Introduction Text book of tuberculosis-3 rd edition S K SHARMA

3. Lymph node TB ( TB lymphadenitis ) may occur as the sole manifestation of TB infection, or alongside pulmonary or miliary TB. LNTB is the most common form of EPTB in India, accounting for around 35% of EPTB cases . Total estimated incidence of LNTB was 30.8 per 100 000 population in India in 2013 (RNTCP , 2014 ). In rural India, the prevalence of tuberculous lymphadenitis in children up to 14 years of age is approximately 4.4 cases per 1000 .(1) 1.Narang P, , Mendiratta DK, Sharma SM, et al. Prevalence of tuberculous lymphadenitis in children in Wardha district, Maharashtra State, India. Int J Tuberc Lung Dis 2005;9:188‑94.

4. Tuberculous lymphadenitis is considered a local manifestation of the systemic disease, whereas lymphadenitis due to nontuberculous Mycobacteria is truly a localized disease. TB lymphadenitis may occur due to: Reactivation of healed focus involved during primary infection Progressive primary tuberculosis i.e. spread from lung into mediastinal lymph node Spread from tonsil and Hematogenous spread due to miliary TB Pathogenesis Text book of tuberculosis-3 rd edition S K SHARMA

5. Tuberculous lymphadenitis most frequently involves the cervical lymph nodes followed in frequency by mediastinal , axillary , mesenteric, hepatic portal, perihepatic , and inguinal lymph nodes.

6. Tb cervical lymphadenitis tends to occur more often in female and presents in young adults. Slowly enlarging lymph nodes and may otherwise be asymptomatic. Some patients my present with fever ,weight loss, fatigue and night sweats. Cough is prominent symptom in mediastinal lymphadenopathy . Clinical presentaion

7. S tages of TB lymphadenitis. Stage 1 -Enlarged, firm, mobile, discrete nodes. Stage 2 - Large rubbery nodes fixed to surrounding tissue Stage 3 - Central softening abscess. Stage 4 -Collar stud formation. Stage 5 -Sinus tract formation. Typical TB sinus has thin, bluish, undermined edges with scanty watery discharge Jones PG, Campbell PE. Tuberculous lymphadenitis in childhood: The significance of anonymous mycobacteria . Br J Surg 1962;50:302‑14

8. Text book of tuberculosis-3 rd edition S K SHARMA

9. Reactive lymphadenitis, (secondary to viral, bacterial infections) Tuberculosis Lymphomas lymphadenopathy of NTM Generalised lymphadenopathy of HIV Sarcoidosis Secondary carcinomas Uncommon causes like fungal diseases, toxoplasmosis Differential diagnosis

10. Multiplicity, matting and caseation are the three features which helps in the diagnosis of TB lymphadenitis.

11. Presumptive peripheral LNTB Patients with enlarged lymph nodes ( over 1 cm across ) in the neck, armpit or groin. And / or with symptoms of fever, weight loss, night sweats and cough Patients who should be investigated for LNTB

12. Presumptive mediastinal LNTB Patients presented with cough, fever, shortness of breath, weight loss or night sweats. And hilar widening on chest X-ray and/or mediastinal lymphadenopathy on chest CT in the absence of evidence of active pulmonary TB. Presumptive abdominal LNTB Patients with dull or colicky abdominal pain, abdominal distension, weight loss, night sweats or fever, and E vidence of abdominal lymphadenopathy on abdominal ultrasound scan, CT or MR

13. chest X-ray and HIV test should be done in a ll patients presenting with symptoms consistent with LNTB, to seek for active or previous pulmonary TB . EPTB is associated with HIV infection. All patients should be offered integrated counseling and testing . Diagnosis

14. Fine needle aspiration cytology (FNAC) should be done in all patients. Send specimen for: Microscopy and culture for Mtb with drug susceptibility testing; Cytology Xpert MTB/RIF test; Excision biopsy In selected- If FNAC has been inconclusive , or where malignancy is suspected. Send specimen for : 1.In normal saline Xpert MTB/RIF test; Microscopy and culture for Mtb with drug susceptibility testing ; 2 . In formalin histopathology

15. Ultrasound or CT scans of chest and abdomen Selected Indicated when diagnosis is not clear, and In HIV positive people Finding abdominal lymphadenopathy should prompt biopsy to rule out lymphoma as a differential diagnosis . Lymphadenopathy in abdominal tuberculosis usually occurs in mesenteric, peri -pancreatic, periportal , and para -aortic groups of lymph nodes. The distribution reflects the lymphatic drainage of sites in the small bowel and liver that have been seeded haematogenously . The nodes may be seen as conglomerate masses and/or as scattered enlarged nodes with hypoechoic or anechoic centres because of necrosis . The involvement of retroperitoneal nodes and lesions not confined to one anatomic area of drainage are more suggestive of lymphoma. @-Jain R, Sawhney S, Bhargava DK, Berry M. Diagnosis of abdominal tuberculosis: sonographic findings in patients with early disease. AJR 1995; 165: 1391-5.

16. A thickening of the small bowel mesentery of 15 mm or more and an increase in mesenteric echogenicity combined with mesenteric lymphadenopathy has been reported as the characteristic sonographic feature of early abdominal tuberculosis.(@) @-Jain R, Sawhney S, Bhargava DK, Berry M. Diagnosis of abdominal tuberculosis: sonographic findings in patients with early disease. AJR 1995; 165: 1391-5.

17.   Multiple enlarged (≥12 mm) abdominal lymph nodes were significant predictors of tuberculosis with a positive likelihood ratio of 11.4, but the 95% CIs were wide (4.3–30.3) due to the small numbers of patients with tuberculosis . Sculier  D,  Vannarith  C,  Pe  R, et al. Performance of abdominal ultrasound for diagnosis of tuberculosis in HIV-infected persons living in Cambodia.  J Acquir Immune Defic Syndr  2010; 55:500–2. Sonographic image of (a)  enlarged lymph nodes  in the periportal area; (b) focal lesions in the  spleen  of approximately 3 mm in diameter; (c) focal lesions in the spleen of approximately 10 mm in diameter

18. Lymph node TB Xpert MTB/RIF should be used as an additional test to conventional smear microscopy, culture and cytology in fine-needle aspiration cytology (FNAC) specimens. (Strong recommendation, low quality evidence for sensitivity estimate, high quality evidence for specificity estimate .) Pooled sensitivity and specificity against culture are 83.1 % and 93.6% respectively. Recommendations: Diagnosis of EPTB using the Xpert MTB/RIF test

19. Bacteriologically c onfirmed LNTB case A patient with symptoms and signs of LNTB and has at least one of the following: Positive microscopy for AFB on examination of lymph node fluid or tissue P ositive culture of Mtb from lymph node fluid or tissue Positive validated PCR-based test (such as Xpert MTB/RIF) Diagnostic definitions

20. Clinically diagnosed LNTB case A presumptive LNTB patient who undergoes diagnostic testing and has all of: N egative microscopy, negative culture and negative PCR based tests. No other diagnosis made to explain signs and symptoms. S trongly suggestive evidence on other tests, such as radiological findings, histopathological findings, clinical course.

21. First line treatment for adults and children with LNTB- 2RHZE/4RHE Duration - Six months , standard first-line regimen is recommended for peripheral lymph node TB Treatment

22. In patients with drug‑resistant TB , the treatment must rely upon the recent PMDT (WHO )guidelines which are primarily based on drug sensitivity pattern.

23. Assess response to treatment at 4 months. Consider possible treatment failure in patients who have worsened or deteriorated after initial improvement – this requires diagnostic investigation and possibly a change of treatment. Deterioration in the first 3 months may be due to paradoxical reaction – this does not require repeat diagnostic tests or change of treatment. Follow up

24. IRIS –”immune reconstitution inflammatory syndrome”, in PLHA patients on ART Paradoxical reaction is generally used to describe a clinical worsening of TB disease in HIV – seropositive and negative patients after initiation of ATT. Symptomatic management is sufficient in vast majority of cases. In case of ARDS, TUBERCULOMA, and pericardial effusion, glucocorticoid therapy is needed for few weeks. DST should be done in all case of paradoxical reactions. Text book of tuberculosis-3 rd edition S K SHARMA

25. Some patients with LNTB have residual lymphadenopathy at the end of treatment . T he largest node is- < 1 cm in size - usually do not have continued active TB infection. Reassured the patient . > 1 cm in size- classified as partial responders . The expert group suggested, these patients should receive an additional 3 months of RHE , followed by a biopsy sent for histology and TB culture in patients who fail to respond to that.

26. For mediastinal TB, Progress on ATT can be monitored with chest X-ray, but CT scan may be indicated if lymph nodes do not reduce in size after 4 months . In patients who fail to improve on ATT, the alternative diagnoses of lung cancer, lymphoma , sarcoidosis and fungal infection should be considered. Current expert opinion on when to stop ATT in patients with persistently enlarged mediastinal lymph nodes is to stop when there is documentation of absence of interval change in CT/MRI of mediastinal lymph nodes for more than 4 months , with resolution of all other signs and symptoms .

27. The indications for surgical management of TB lymphadenitis are: Treatment failure: Surgical treatment is beneficial to establish the diagnosis and management of drug‑resistant organisms Adjuvant treatment for drug sensitive cases: For patients who have discomfort from tense, fluctuant lymph nodes surgical treatment is beneficial Paradoxical reaction: In a retrospective review, aspiration, incision, and drainage or excision were associated with a trend toward a shorter duration of paradoxical reactions Nontuberculous mycobacteria : In children with NTM lymph node removal has been associated with better outcomes Surgical Management Fontanilla JM, Barnes A, von Reyn CF. Current diagnosis and management of peripheral tuberculous lymphadenitis. Clin Infect Dis 2011;53:555‑62.

28. Appearance of freshly involved nodes Enlargement of the existing nodes Development of fluctuation Appearance of sinus tracts Residual lymphadenopathy after completion of treatment Relapses. D ifficulties In Management Gupta PR. Difficulties in managing lymph node tuberculosis. Lung India 2004;21:50-3.

29. 1.Record all the possible sites of involvement, nature, and size of the involved lymph nodes at the starting of treatment. 2 . Identify any coexisting disease and treat it simultaneously . 3. Performe TB Gene X-pert or line probe assay on initial lymph node sample, so that if lymph nodes enlarge during therapy, it becomes clear whether this is due to a paradoxical reaction or drug resistance. How to overcome difficulties in managing lymph node tuberculosis ? Gupta PR. Difficulties in managing lymph node tuberculosis. Lung India 2004;21:50-3.

30. 4 . Most nodes that enlarge during therapy or appear afresh ultimately respond to treatment. Only a close follow up is required for these patients. 5. Appearance of fluctuation in one or more lymph nodes calls for aspiration under all aseptic precautions. 6. Any secondary bacterial infection should be dealt with appropriately that may include incision and drainage . 7. Any worsening after 8 weeks of therapy calls for en‑bloc resection of the involved lymph node chain to avoid appearance of ugly sinus tracts. 8. Nonhealing sinus tracts need resective surgery. Gupta PR. Difficulties in managing lymph node tuberculosis. Lung India 2004;21:50-3.

31. 9. On completion of treatment, if any residual lymph nodes exist, they should be observed closely. Any increase in the size or appearance of symptoms calls for excisional biopsy for histopathology, culture, and TB Gene Xpert . Most patients respond to retreatment with the same regimen. 10. Relapse: Relapse rates of up to 3.5% have been reported in patients treated for TB lymphadenitis. This should be treated with the same drugs but culture or molecular diagnostic test must be performed to rule out resistance or NTM disease.[$] $-Breen RA, Smith CJ, Bettinson H, Dart S, et al. Paradoxical reactions during tuberculosis treatment in patients with and without HIV co‑infection . Thorax 2004;59:704‑7

32. 11. Drug resistance: [#] Though it is at times difficult to confirm drug‑resistance in LNTB, it is essential to demonstrate drug resistance prior to starting multidrug-resistant regime . Similarly, single agent ( fluoroquinolones or others) should never be introduced even if response to treatment is not appropriate. Each case should be reasonably investigated with culture or molecular diagnostic tools. Further, appropriate measures should be taken to prevent the use of second‑line drugs in unproven cases. #- Deveci HS, Kule M, Kule ZA, Habesoglu TE. Diagnostic Challenges in Cervical Tuberculous Lymphadenitis: A review. North Clin Istanbul 2016;3:150‑5 .

33. 12 . Systemic steroids have been shown to reduce inflammation during the early phase of therapy for lymph node tuberculosis and may be considered if a node is compressing a vital structure, i.e. bronchus or in diseases involving cosmetically sensitive areas. Prednisolone 40 mg per day followed by gradual tapering over the next 6 weeks, along with appropriate chemotherapy is adequate . However, the safety and utility of this approach remains largely unproven except in intrathoracic disease where it was found to relieve the pressure on the compressed bronchus. Gupta PR. Difficulties in managing lymph node tuberculosis. Lung India 2004;21:50-3.

34. Thank you