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  Table of Contents    
CASE REPORT  
Year : 2018  |  Volume : 61  |  Issue : 4  |  Page : 570-572
Bilateral submandibular swelling diagnosed as tuberculous lymphadenitis in an asymptomatic patient: A rare case report


1 Department of Oral Pathology and Microbiology, Government Dental College and Hospital, Aurangabad, Maharashtra, India
2 Rural Health Centre, Aurangabad, Maharashtra, India
3 Department of Microbiology, KEM Hospital, Mumbai, Maharashtra, India

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Date of Web Publication10-Oct-2018
 

   Abstract 


In India, tuberculosis (TB) is a prevalent systemic disease and number of people who die with TB is increasing year by year. TB can be life-threatening, and there is a high mortality rate of systemic infection with TB. Although extrapulmonary TB (EPTB) is a rare form of TB, its prevalence is increasing day-by-day. Reported here is a case of a 28-year-old female patient with a painless swelling bilaterally in the submandibular region. She was diagnosed with bilateral submandibular tuberculous lymphadenitis. Tuberculous lymphadenitis, when occurring in the cervical region, continues to be a common cause of EPTB. Thorough knowledge of this condition is important as it can help in early diagnosis leading to prompt treatment of the patient and prevent further complications.

Keywords: Bilaterally, extrapulmonary, lymphadenitis, submandibular tuberculosis

How to cite this article:
Medhe AS, Mandale SS, Deshpande PU, Bhavthankar JD. Bilateral submandibular swelling diagnosed as tuberculous lymphadenitis in an asymptomatic patient: A rare case report. Indian J Pathol Microbiol 2018;61:570-2

How to cite this URL:
Medhe AS, Mandale SS, Deshpande PU, Bhavthankar JD. Bilateral submandibular swelling diagnosed as tuberculous lymphadenitis in an asymptomatic patient: A rare case report. Indian J Pathol Microbiol [serial online] 2018 [cited 2018 Dec 15];61:570-2. Available from: http://www.ijpmonline.org/text.asp?2018/61/4/570/243000





   Introduction Top


Tuberculosis (TB) is a major health problem worldwide, and the prevalence of TB is increasing year-by-year. The most common type of this disease is pulmonary TB. extrapulmonary TB (EPTB) comprises 15%–20% of all TB cases.[1] TB lymphadenitis which is localized to neck is known as Scrofula. Dental professionals dealing with head-and-neck region should have a thorough knowledge of this form of TB. Hence, with this aim reported here is a case of EPTB presenting as a submandibular swelling.


   Case Report Top


A 28-year-old female patient reported with the chief complaint of swelling bilaterally in the submandibular region for 6 months. The patient was apparently all right 6 months back when she noticed small painless swelling of peanut size in the left submandibular region which gradually increased to the present size and concurrently another smaller swelling developed in the right submandibular region.

On general examination, the patient was of average built and did not complain of fever, cough, or any symptoms of weight loss or night sweats. Past medical history and family history were noncontributory.

Extraorally diffuse bilateral swellings in submandibular region were seen. The left submandibular swelling was greater in size as compared to the right side, size approximately 4 cm × 3 cm in the submandibular region below the lower border of mandible [Figure 1]a. The swelling on right side was 2 cm × 1 cm below angle of mandible [Figure 1]b. Both swellings were firm in consistency, nontender, nonfluctuant, noncompressible, mobile, showed signs of matting. Intraoral examination revealed no intraoral focus of infection.
Figure 1: Diffuse bilateral swellings in submandibular region (a) measuring 4 cm × 3 cm on the left side (b) measuring 2 cm × 1 cm on the right side

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Ultrasonography revealed multiple enlarged lymph nodes in bilateral submandibular (Level I) and cervical region (Level II, III, and IV), largest of the size 2.7 cm × 2 cm in the left submandibular region [Figure 2]d. A chest radiograph was normal.
Figure 2: (a) Histopathological examination revealed lymphoid tissue showing multiple areas of caseous necrosis, surrounded by epitheloid cells which in turn were surrounded by dense infiltrate of lymphocytes and fibroblasts (×4) (b) Area of caseous necrosis surrounded by epitheloid cells (×10) (c) Multinucleated giant cells with peripherally arranged nuclei suggestive of Langhans giant cells (×40) (d) Ultrasonography revealed multiple enlarged lymph nodes in bilateral submandibular (Level I) and cervical region (Level II–IV)

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On the basis of above findings, a clinical diagnosis of lymphadenitis in head-and-neck region was given.

Complete hemogram was within the normal range, but erythrocyte sedimentation rate (ESR) was elevated. Fine-needle aspiration cytology (FNAC) showed granulomatous inflammatory reaction. FNAC smear was then subjected to Ziehl–Neelsen (ZN) staining which revealed no evidence of acid-fast bacilli. A lymph node biopsy was advised. Before undergoing biopsy, the patient was sent for serum examination for HIV antibodies to rule out immunocompromised state and was negative for HIV antibodies. Excision of the left submandibular lymph node was performed. The excised lymph node was cut into two parts, cut section of the node showed area of caseous necrosis. One part was subjected to histopathological examination. Other part was sent for cartridge-based nucleic acid amplification test (CBNAAT). It was stored in normal saline in a Falcon tube, sent immediately. Histopathological examination revealed lymphoid tissue showing multiple areas of caseous necrosis, surrounded by epitheloid cells which in turn were surrounded by dense infiltrate of lymphocytes and fibroblasts [Figure 2]a and [Figure 2]b. These foci of granuloma also showed multinucleated giant cells with peripherally arranged nuclei suggestive of Langhans giant cells [Figure 2]c. CBNAAT was positive for mycobacterium tubercle bacilli and sensitive for rifampicin which confirmed the diagnosis.

In the view of clinical presentation of the case and the investigational reports, a final diagnosis of tuberculous lymphadenitis was given. The patient was put on antitubercular regimen. After appropriate treatment the swelling subsided and the patient remained asymptomatic at the 6 months follow up. The patient was on same regime for 3 more months. No further complications were noticed.


   Discussion Top


The percentage of patients with EPTB in tertiary-care centers in India ranges 30%–53%. EPTB constitutes almost 35% of all forms TB, most common of which is scrofula, i.e., the involvement of neck lymph nodes, which constitutes about 5% of all cases of EPTB.[2],[3] This classic term “scrofula” meaning “glandular swelling”(Latin).[4] TB lymphadenitis is more common in young groups and in females according to most of the authors while pulmonary TB is more common in males and in older age groups.[5]

The tubercle bacilli enter the body through inhalation which results in involvement of tonsils and adenoids leading to further entry of bacteria into lymphatics. This could also be caused by the lymphatic or hematogenous dissemination by a focus which originally formed in lungs. According to some authors tuberculous, cervical lymphadenitis results from infected gums, tongue, and buccal mucosa which healed subsequently without being detected, so it is concluded that TB cervical lymphadenitis is the lymph node component of primary complex of oral cavity.[6] The rarity of TB lymphadenitis in relation to oral cavity was due to the protective effect provided by saliva.[7]

In the present case, the patient had a swelling bilaterally in submandibular region. Intraorally examination revealed no obvious dental involvement. OPG did not show any source of dental involvement in relation to the swellings excluded odontogenic origin of the lesion.

Mycobacterium TB has bronchopulmonary apparatus as a primary site of action and head and neck are usually the secondary one.[8],[9] As the ESR was raised, the chest radiograph and sputum test for acid-fast bacilli was done but were noncontributory.

Ultrasonography of the swellings revealed bilateral submandibular and cervical lymphadenopathy. Hence, FNAC was carried out, it is the most useful and quite often used technique for the diagnosis of TB of lymph nodes.[10]

FNAC showed granulomatous inflammatory reaction but no epithelioid cells or Langhans giant cells. FNAC smear was then subjected to ZN staining which revealed no evidence of acid-fast bacilli. A lymph node biopsy was advised. Before undergoing biopsy, the patient was sent serum examination for HIV antibodies to rule out immunocompromised state and was negative for HIV antibodies. The most enlarged lymph node (left submandibular lymph node) was excised. Cut section of this excised node showed areas of caseous necrosis. Therefore, a part of the excised node was subjected to histopathological examination and the other part was sent for CBNAAT.

Histopathology was consistent with that of TB lymphadenitis, and CBNAAT was positive for mycobacterium bacilli. CBNAAT detects pulmonary TB with greater efficacy than sputum microscopy (diagnosis in <2 h). It also detects rifampicin resistance with high specificity and can be used for screening for MDR-TB.

In the differential diagnosis, reactive hyperplasia, lymphoma, sarcoidosis, generalized, and lymphadenopathy of HIV were considered. The presence of Langhans giant cells ruled out the possibility of reactive hyperplasia and lymphoma. Sarcoidosis was ruled out based on CBNAAT report. Lymphadenopathy of HIV was ruled out earlier by enzyme-linked immunosorbent Assay (ELISA).

CBNAAT showed sensitivity for rifampicin, so the patient was treated with antitubercular therapy which leads to resolution of the lesion.


   Conclusion Top


Not many cases of this kind are report to the oral clinician so it is important to be aware of such cases of EPTB. It becomes important as the oral clinician works in close to head-and-neck area and these conditions can be life-threatening if not diagnosed early and treated promptly.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Manolidis S, Frenkiel S, Yoskovitch A, Black M. Mycobacterial infections of the head and neck. Otolaryngol Head Neck Surg 1993;109:427-33.  Back to cited text no. 1
    
2.
Martynaik D. A case of middle age man with a neck mass. UWO Med J 2010;78:66-8.  Back to cited text no. 2
    
3.
Sarwar A, Haque AU, Aftab S, Mustafa M, Moatasim A, Siddique S, et al. Spectrum of morphological changes in tuberculous lymphadenitis. Int J Pathol 2004;2:85-9.  Back to cited text no. 3
    
4.
Mohapatra PR, Janmeja AK. Review, tuberculous lymphadenitis. J Assoc Physicians India 2009;57: 585-90.  Back to cited text no. 4
    
5.
Krishnaswami H, Koshi G, Kulkarni KG, Job CK. Tuberculous lymphadenitis in South India – A histopathological and bacteriological study. Tubercle 1972;53:215-20.  Back to cited text no. 5
    
6.
Tan KK. Tuberculous lymphadenitis in Singapore. Singapore Med J 1988;29:441-4.  Back to cited text no. 6
    
7.
Dixit R, Sharma S, Nuwal P. Tuberculosis of oral cavity. Indian J Tuberc 2008;55:51-3.  Back to cited text no. 7
    
8.
Hashimoto Y, Tanioka H. Primary tuberculosis of the tongue: Report of a case. J Oral Maxillofac Surg 1989;47:744-6.  Back to cited text no. 8
    
9.
Rauch DM, Friedman E. Systemic tuberculosis initially seen as an oral ulceration: Report of case. J Oral Surg 1978;36:387-9.  Back to cited text no. 9
    
10.
Chao SS, Loh KS, Tan KK, Chong SM. Tuberculous and nontuberculous cervical lymphadenitis: A clinical review. Otolaryngol Head Neck Surg 2002;126:176-9.  Back to cited text no. 10
    

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Correspondence Address:
Apurva Sonu Medhe
Room No. 133, Department of Oral Pathology and Microbiology, Government Dental College and Hospital, Ghati Campus, Dhanvantari Nagar, Aurangabad - 431 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_655_17

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