Approach to lymphadenopathy: how to diagnose tuberculosis lymphadenitis

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Introduction
It is well-known that usual local increase in cervical lymphatic nodes (LN) is a consequence of infections of the upper respiratory tract, nasopharynx, infectious mononucleosis, tuber-culosis as well as also necessary to exclude both lymphoproliferative tumors (lymphomas) and metastases in the LN of tumors of different localization (head and neck, lungs, mammary and thyroid glands) (Freeman, & Matto, 2020).

Aim
To show peculiarities of tuberculosis lymphadenitis diagnosis, to analyze the cause of misdiagnosis and to point out the details of immunocompromised state of the patient.

Case report
The 42-years old patient from India asked for general physician's appointment in private clinic in Kyiv.He complained of multiply enlarged painful LN on left anterior neck for almost two weeks and was also concerned about sore throat persistent for a year.He stopped smoking two years ago, consumes alcohol socially, his living condition and job were satisfactory.He didn't have any drug allergy, without surgeries or injuries, his family history was unremarkable.He had malaria in childhood and spine spondylosis previously which was well controlled by exercise.
After confirming lymphadenopathy (LAP) in a cervical area, we examined all the LN accessible for palpation:1) location: anterior neck LN involved in the process 2) texture and tenderness: soft painful LN, even fluctuant that suggested progressive enlargement, typical for acute inflammation 3) mobility of the LN relative to the skin and surrounding tissues: fixed LN and conglomerates of the LN are found in patients with chronic inflammation or with malignancy, that have to be determinate.
Other objective examination was without evident inflammatory signs as cough, fever, chills, night sweats, weight loss and fatigue.While reviewing the latest tests results it was excluded the preliminary diagnosis of lymphoma against TB infection, therefore the further diagnostic work up consistent of: TB cito testing, HIV elisa test, TB quantiferon test, Genetic test for TB, Gene Xpert MTB/RIF test, anterior neck LN biopsy, TB microscopy of the resected LN, culture and sensitivity of the resected LN.We provided the main objective patient's results concerning of obvious diagnosis in that case report: The new onset extrapulmonary tuberculosis of lymphatic nodes (Table 1).

Discussion
TB is one of the most widespread systemic bacterial infectious diseases worldwide.The frequency of TB in underdeveloped nations is believed to coexist with poor hygiene environment.
TB chiefly affects the pulmonary system besides involving extrapulmonary locations comprising head and neck region, occurring in 0.05-5% of the patients with acquired immunodeficiency syndrome (Brown, & Skarin, 2004).The disease can begin acutely, with fever and severe intoxication, and the inflammatory process can spread from the LN to the subcutaneous tissue and skin.Chronic TB of the external LN is manifested by soft dense nodules, sometimes a chain of small nodules.One group of LN is affected more often: the cervical and submandibular LN diagnosed in children and adolescents, less often -in adults and the elderly, the axillary ones extremely rare as well as other localization.Tuberculous lymphadenitis is popularly known as collar stud abscess due to its proximity to the collar bone and its superficial resemblance to a collar stud, although this is just one of the five stages (Weinstock et al. 2018).The diagnosis consists of anamnesis (contact with patients with TB, pulmonary involvement and other organs, scars on the neck, eye diseases), objective data, tuberculin testing (sharply positive), detection of Mycobacterium tuberculosis in pus, punctate, cytological examination of punctures and histological analysis a biopsy for the diagnosis confirmation.The outcome of the disease depends on the timeliness of diagnosis, the form of LAP and the effectiveness of treatment.At a favorable course there are reduction and consolidation of the LN (sometimes with the subsequent petrification's formation in them), fistulas are closed.Drainage do not provide according to the effect from antituberculosis medications: isoniazid, rifampicin, pyrazinamide, ethambutol.In our case due to appropriate treatment for almost 12 months the patient completely recovered, at regular follow-up visit one year later LN were not detected.
It is known, that seventy-five percent of all LAPs are localized, with more than 50% being seen in the head and neck area (Brown, & Skarin, 2004) achieved through biopsy or excisional removal.Tissue diagnosis by fine needle aspiration biopsy or excisional biopsy is the gold standard evaluation (Brown, & Skarin, 2004;Freeman, & Matto, 2020).
The preliminary diagnosis of lymphoma in our case was excluded due to the confirmation of typical TB LAP with specific testing and morphological changes of the resected LN.Since lymphoma is cell-mediated immunodeficiency, it may result in infections with several pathogens, such as Mycobacterium species and the presence of these pathogens can precede lymphoma or even can contribute to its development (Centkowski et al. 2005).In lymphoma affected LN have a dense-elastic consistency, not fused with the skin, painless: supraclavicular and mediastinal LN are the most often affected.Thus, the main differences between suspicious LAP are (Table 2):

Conclusion
Tuberculosis is still wide-spread in endemic areas, undeveloped countries, its extrapulmonary occurrence is often missed.Misdiagnosis or delay in diagnosis of TB and immunodeficiency patterns may occur because of similar signs and symptoms, such as fever, cough, loss of appetite, loss of weight, night sweats, hepatosplenomegaly and mediastinal lymphadenopathy.History of prior TB infection, residence in a country where TB is endemic, close contact with a TB patient, or positive tuberculin skin test should raise suspicion of extrapulmonary TB.Fine needle aspiration with polymerase chain reaction or culture may accurately identify cervical TB lymphadenitis as well as excisional biopsy.This case report highlights the risk of misdiagnosis of generalized lymphadenopathy and determinate the details of immunocompromised state of predisposed patient from endemic area.
Financing Without external funding.

Conflict of interest
There is no potential conflict of interests.

Table 1 .
. Cervical LN are involved more often than the other lymphatic regions.Based on different geographical areas, the etiology is various, and TB is the main benign cause of LAP in adults and children in tropical areas.For the adequate diagnosis, the affected enlarged LN ≥1 cm in adults should be examined completely.Previous ultrasound, pulmonary & abdominal CT-scan Objective patient's results and their assessment Ukrainian scientific medical youth journal, 2023, Issue 4 (142) http://mmj.nmuofficial.comUkrainian scientific medical youth journal, 2023, Issue 4 (142) http://mmj.nmuofficial.com

Table 2 .
Differential diagnosis between lymphoma and lymphadenitis