TUBERCULARTUBERCULARLYMPHADENITISLYMPHADENITIS

INTRODUCTIONINTRODUCTION

Also known as Also known as

Scrofula Scrofula

Full neck sowFull neck sow

KingKing’’s evils evil

INTRODUCTIONINTRODUCTION

Most common form of extra pulmonary TBMost common form of extra pulmonary TBMost common siteMost common site-- cervical lymph nodescervical lymph nodesCausative organismsCausative organisms

Mycobacterium tuberculosisMycobacterium tuberculosisM.bovisM.bovisM.africanum M.africanum NTM LymphadenitisNTM Lymphadenitis: Non tubercular : Non tubercular MycobacteriaMycobacteria (M.kansasii, M.scrofulaceum, (M.kansasii, M.scrofulaceum, M.aviumM.avium--intracellulare) intracellulare)

ANATOMYANATOMY

Lymph nodeLymph nodeOval/bean shapedOval/bean shapedVarying size: Varying size: pinheadpinhead–– lima beanlima beanBefore lymph is Before lymph is returned to the blood returned to the blood stream, it passes stream, it passes through atleast one through atleast one lymph nodelymph node

Distributed throughout Distributed throughout the body along the the body along the lymphatic vesselslymphatic vesselsTwo types of lymph Two types of lymph vessels:vessels:

-- AfferentAfferent-- EfferentEfferent

Snell S. Richard; Clinical anatomy for medical students, 1999;6:22

FunctionsFunctions

1.1. Filtering the lymphFiltering the lymph2.2. PhagocytosisPhagocytosis3.3. Formation of Antibodies & Immunological Formation of Antibodies & Immunological

defensedefense

Lymphatic vessels: Lymphatic vessels: -- Return lymph to blood Return lymph to blood

stream via:stream via:1. Right lymphatic duct1. Right lymphatic duct2. Thoracic duct2. Thoracic duct

Snell S. Richard; Clinical anatomy for medical students, 1999;6:22

Lymph Nodes InvolvedLymph Nodes Involved

1.1. CervicalCervical2.2. AxillaryAxillary3.3. MediasternalMediasternal4.4. InguinalInguinal

Axillary, mediasternal, Axillary, mediasternal, inguinal node inguinal node involvement in 14 involvement in 14 -- 30%30%

Anatomy of Cervical Lymph NodesAnatomy of Cervical Lymph Nodes

Three main groups:Three main groups:

1.1. Upper horizontal chain of nodesUpper horizontal chain of nodes2.2. Lateral cervical nodesLateral cervical nodes3.3. Anterior cervical nodesAnterior cervical nodes

Anatomy of Cervical Lymph NodesAnatomy of Cervical Lymph Nodes

ClassificationClassificationUpper horizontal Upper horizontal chain of nodes:chain of nodes:

1.1. SubmentalSubmental2.2. SubmandibularSubmandibular3.3. ParotidParotid4.4. PostauricularPostauricular5.5. Occipital Occipital

Dhingra P.L.; Diseases of EAR, NOSE and THROAT, 2004;3:447,448

Lateral cervical nodesLateral cervical nodesThey include nodes, They include nodes,

superficial and deep to superficial and deep to sternocleidomastoid sternocleidomastoid muscle and in the muscle and in the posterior triangleposterior triangle

a.a. Superficial external Superficial external jugular groupjugular group

b.b. Deep group:Deep group:--Internal jugular chain (upper Internal jugular chain (upper

middle and lower groups)middle and lower groups)--Spinal accessory chainSpinal accessory chain--Transverse cervical chainTransverse cervical chain

Dhingra P.L.; Diseases of EAR, NOSE and THROAT, 2004;3:447,448

Anterior cervical Anterior cervical nodesnodes

a.a. Anterior jugular Anterior jugular chainchain

b.b. Juxtavisceral chainJuxtavisceral chain1.1. PrelaryngealPrelaryngeal2.2. PretrachealPretracheal3.3. ParatrachealParatracheal

Dhingra P.L.; Diseases of EAR, NOSE and THROAT, 2004;3:447,448

Classification of Neck Nodes According to LevelsClassification of Neck Nodes According to LevelsLevel ILevel I Submental (IA)Submental (IA)

Submandibular (IB)Submandibular (IB)Level IILevel II Upper jugularUpper jugularLevel IIILevel III Middle jugularMiddle jugularLevel IVLevel IV Lower jugularLower jugularLevel VLevel V Post. Triangle Post. Triangle grpgrpLevel VILevel VI PrelaryngealPrelaryngeal

PretrachealPretrachealParatrachealParatracheal

Level VIILevel VII Nodes of upperNodes of uppermediasternummediasternum

Dhingra P.L.; Diseases of EAR, NOSE and THROAT, 2004;3:450

Axillary Lymph nodesAxillary Lymph nodes

1.1. Apical groupApical group2.2. Anterior axillaryAnterior axillary3.3. Central axillaryCentral axillary4.4. Lateral axillaryLateral axillary5.5. Posterior axillaryPosterior axillary

Chaurasia B.HUMAN ANATOMY.1995;1:34

Inguinal Lymph nodesInguinal Lymph nodes

1.1. Superficial inguinal Superficial inguinal groupgroup

2.2. Deep inguinal Deep inguinal groupgroup

Inguinal Lymph nodesInguinal Lymph nodes

--Primary inguinal node Primary inguinal node involvement very involvement very rarerare

--Usually associated with Usually associated with cutaneous TB, cutaneous TB, scrofuloderma or scrofuloderma or lupus vulgarislupus vulgaris

--Common in Igbos Common in Igbos ethnic group in ethnic group in NigeriaNigeria

--Male preponderanceMale preponderance

Among the cervical group most commonly Among the cervical group most commonly involved are in:involved are in:

--Posterior triangle (spinal accessory group, Posterior triangle (spinal accessory group, transverse cervical chains)transverse cervical chains)

--f/b Upper deep cervicalf/b Upper deep cervical--f/b Submandibular nodesf/b Submandibular nodes--least affected least affected –– parotid, submental, lower deep parotid, submental, lower deep

cervicalcervical

Dhama K. et al. Acta Oto-Laryngologica.2004;124:1095-1098

EPIDEMIOLOGYEPIDEMIOLOGYTUBERCULAR LYMPHADENITISTUBERCULAR LYMPHADENITIS

Age Age -- common in 2common in 2ndnd to 3to 3rdrd decade of lifedecade of lifeSex Sex -- more common in femalesmore common in femalesRace Race –– Asians ,African Americans, HispanicsAsians ,African Americans, HispanicsGeographical variationGeographical variation-- developing and developing and underdeveloped countriesunderdeveloped countriesChanging trends Changing trends –– south east England decline south east England decline in TB lymphadenitis in TB lymphadenitis High frequency of disease in population from High frequency of disease in population from endemic areas of TB endemic areas of TB

EPIDEMIOLOGYEPIDEMIOLOGY

NON TUBERCULAR LYMPHADENITISNON TUBERCULAR LYMPHADENITIS

AgeAge-- more in childrenmore in childrenSexSex-- M = FM = FGeographical variationGeographical variation--more in developed more in developed countriescountries

EPIDEMIOLOGYEPIDEMIOLOGY

Tubercular lymphadenitis and HIVTubercular lymphadenitis and HIV--Infection with HIV a/w increase frequency of Infection with HIV a/w increase frequency of

mycobacterial infectionmycobacterial infection--LN involvement particularly common in HIV ptsLN involvement particularly common in HIV pts--Due to:Due to:

1. Primary HIV induced pathology1. Primary HIV induced pathology2. Associated diseases2. Associated diseases–– TB LN, LAP d/t TB LN, LAP d/t

NTM, kaposi sarcoma, lymphomaNTM, kaposi sarcoma, lymphoma

Tubercular lymphadenitis and HIVTubercular lymphadenitis and HIV

--Cervical nodes most affected followed by axillary Cervical nodes most affected followed by axillary and inguinal nodesand inguinal nodes

-- Multifocal lymphadenopathy very commonMultifocal lymphadenopathy very common--Systemic symptoms very commonSystemic symptoms very common

60 pts with TB LN60 pts with TB LN30% (n=18) 30% (n=18) nativesnatives70% (n=42) 70% (n=42) immigrantsimmigrants

--Afghanistan (n=13)Afghanistan (n=13)--India (n=9)India (n=9)--Pakistan (n=5)

Study of TB LN in Northern Study of TB LN in Northern GermanyGermany

Pakistan (n=5)Chest 2002;121:1179

Result:Result:--cervical (63.3%)cervical (63.3%)--Mediasternal (26.7%)Mediasternal (26.7%)--Axillary (8.3%)Axillary (8.3%)--Inguinal (1.7%)Inguinal (1.7%)

Chest 2002;121:1179

PATHOGENESISPATHOGENESISLocal manifestation of a systemic diseaseLocal manifestation of a systemic disease

M. tuberculosisM. tuberculosis enters via respiratory tractenters via respiratory tract

Lymphohematogenous disseminationLymphohematogenous dissemination

Hilar and mediastinal nodesHilar and mediastinal nodes

Via lymphatics to cervical lymph nodesVia lymphatics to cervical lymph nodes

PATHOGENESISPATHOGENESIS

Peripheral adenitis may occur at time ofPeripheral adenitis may occur at time ofInitial infection Initial infection

ReinfectionReinfection

ReactivationReactivation

TonsilsTonsils--important portal of entry to important portal of entry to the nearest cervical nodethe nearest cervical node

PATHOGENESISPATHOGENESIS

Host factors affecting clinical Host factors affecting clinical presentation: presentation:

1.1. AgeAge2.2. SexSex3.3. RaceRace4.4. ImmunocompetenceImmunocompetence

PATHOGENESISPATHOGENESISInitially node is Initially node is discrete and firmdiscrete and firm

Periadenitis resulting Periadenitis resulting in matting & fixationin matting & fixation

LN coalesce & LN coalesce & softening d/t softening d/t

abscess formationabscess formation

Perforate deep fascia forms Perforate deep fascia forms collar stud abscesscollar stud abscess

Skin become induratedSkin become indurated

SinusSinus

Healing (calcification & Healing (calcification & scarring)scarring)

PATHOGENESISPATHOGENESIS

Non tubercular lymphadenitisNon tubercular lymphadenitisLocalized infectionLocalized infectionRoute of entry Route of entry

Oropharyngeal mucosaOropharyngeal mucosaConjunctivaConjunctivaTonsils Tonsils Gingiva Gingiva Salivary glands Salivary glands

PATHOGENESISPATHOGENESIS

Non tubercular lymphadenitisNon tubercular lymphadenitis

Most common site Most common site –– upper cervical nodes, upper cervical nodes, salivary glands, surrounding nodessalivary glands, surrounding nodesLymph node enlargement may appear rapidlyLymph node enlargement may appear rapidly

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