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LETTER TO EDITOR  
Year : 2014  |  Volume : 6  |  Issue : 2  |  Page : 91-92
Primary multi drug resistant extra-pulmonary tuberculosis presenting as cervical lymphadenitis


1 Department of Medicine, North Bengal Medical College, Siliguri, West Bengal, India
2 Department of Community Medicine, North Bengal Medical College, Siliguri, West Bengal, India

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Date of Web Publication7-May-2014
 

How to cite this article:
Datta S, Bhattacherjee S. Primary multi drug resistant extra-pulmonary tuberculosis presenting as cervical lymphadenitis. J Global Infect Dis 2014;6:91-2

How to cite this URL:
Datta S, Bhattacherjee S. Primary multi drug resistant extra-pulmonary tuberculosis presenting as cervical lymphadenitis. J Global Infect Dis [serial online] 2014 [cited 2020 Sep 20];6:91-2. Available from: http://www.jgid.org/text.asp?2014/6/2/91/132066


Dear Editor,

Extra pulmonary presentations with multidrug resistant (MDR) tuberculosis (TB) are uncommon forms of the disease, which warrant high degree of suspicion and strong laboratory back up. We report here a case of primary MDR cervical tubercular lymphadenitis.

A 32-year-old male patient presented with persistent glandular swelling around his neck for the past 2 months. One year back, he had taken antitubercular therapy for similar complaints. On completion of treatment, the swellings had reduced in size, but did not completely subside. After 2 months of completion of therapy, the swellings started to enlarge in size along with low grade evening rise of temperature.

On examination, the patient was found to be hemodynamically stable, with mild anemia and enlarged lymph nodes mainly around the submandibular and anterior triangle of the neck bilaterally. The nodes were non tender, painless, matted and adherent to the underlying structures. A few of the nodes also revealed pus points. He did not have any other groups of palpable lymph nodes and other systemic examinations were within the normal limits.

Laboratory examination revealed hemoglobin: 9.9 g/dl, total lymphocyte count: 4800/mm3, N56 L38M4E1B1 and fasting blood sugar: 96 mg/dl. His liver function tests, renal function tests were all within the normal limits. His Human Immunodeficiency Virus (HIV) status was negative for both HIV-1 and 2. The chest X-ray and ultrasonography abdomen were noncontributory.

The subject underwent repeated fine needle aspiration cytology from the lymph nodes, which revealed reactive hyperplasia. Subsequently, excisional biopsy of one of the lymph nodes was done and a part of the tissue was sent for culture for mycobacterial complex along with drug sensitivity testing (DST).

The excision biopsy of the lymph node was noncontributory, but culture revealed Mycobacterium tuberculosis complex DST revealed it to be resistant to isoniazid, rifampicin, streptomycin, ethambutol and ethionamide. Hence a diagnosis of MDR tubercular lymphadenitis was made and he was put on regimen based on the DST. After initiation of therapy, the subject improved dramatically and all the lymph nodes disappeared after completion of the full course of therapy (after 24 months).

The re-emergence of TB as a global health problem over the past two decades, aggravated by increasing multi drug resistance and extensively drug resistance, represents a serious problem in terms of both TB control and clinical management. [1] Drug resistance is a "man-made" problem and is, thus, amenable to corrective action.

MDR-TB can become a formidable problem among HIV-infected patients but even in HIV positive patients, primary involvement of MDR-TB of extrapulmonary site is not so common. Among immunocompetent persons, extra pulmonary presentation of MDR-TB is rarer, although there are some case reports of extrapulmonary MDR-TB involving lymph node, [2] peritoneum, [3] meninges, [4] spine, [5] etc.

Unfortunately, the scenario does not seem to be reassuring, and the present subject is an example that we have still much to know about this disease. Furthermore, the emergence of 'totally drug resistant TB', i.e., resistant to all tested drugs for TB again highlights the fact that we still have much to learn about this killer disease.

 
   References Top

1.Migliori GB, Centis R, Fattorini L, Besozzi G, Saltini C, Scarparo C, et al. Mycobacterium tuberculosis complex drug resistance in Italy. Emerg Infect Dis 2004;10:752-3.  Back to cited text no. 1
[PUBMED]    
2.Kant S, Saheer S, Hassan G, Parengal J. Extra-pulmonary primary multidrug-resistant tubercular lymphadenitis in an HIV negative patient. BMJ Case Rep 2012;2012:1.  Back to cited text no. 2
    
3.Asgeirsson H, Blöndal K, Blöndal T, Gottfredsson M. Multidrug resistant tuberculosis in Iceland - Case series and review of the literature. Laeknabladid 2009;95:499-507.  Back to cited text no. 3
    
4.Sofia M, Maniscalco M, Honoré N, Molino A, Mormile M, Heym B, et al. Familial outbreak of disseminated multidrug-resistant tuberculosis and meningitis. Int J Tuberc Lung Dis 2001;5:551-8.  Back to cited text no. 4
    
5.Pawar UM, Kundnani V, Agashe V, Nene A, Nene A. Multidrug-resistant tuberculosis of the spine - Is it the beginning of the end? A study of twenty-five culture proven multidrug-resistant tuberculosis spine patients. Spine (Phila Pa 1976) 2009;34:E806-10.  Back to cited text no. 5
    

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Correspondence Address:
Dr. Sharmistha Bhattacherjee
Department of Community Medicine, North Bengal Medical College, Siliguri, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-777X.132066

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2008 Journal of Global Infectious Diseases | Published by Wolters Kluwer - Medknow
Online since 10th December, 2008