Indian Journal of Pathology and Microbiology

LETTER TO EDITOR
Year
: 2013  |  Volume : 56  |  Issue : 4  |  Page : 480--481

Tuberculosis of the parapharyngeal space: A rare case report


Malini Jagannatha Rao1, Ramya Sablur Narayan Gowda2, BL Umapathy1, BV Navaneeth1,  
1 Department of Microbiology, ESIC-MC-PGIMSR, Rajajinagar, Bangalore, Karnataka, India
2 Department of Otolaryngology, ESIC-MC-PGIMSR, Rajajinagar, Bangalore, Karnataka, India

Correspondence Address:
Malini Jagannatha Rao
Department of Microbiology, ESIC-Medical College and PGIMSR Rajajinagar, Bangalore - 560 010, Karnataka
India




How to cite this article:
Rao MJ, Gowda RN, Umapathy B L, Navaneeth B V. Tuberculosis of the parapharyngeal space: A rare case report.Indian J Pathol Microbiol 2013;56:480-481


How to cite this URL:
Rao MJ, Gowda RN, Umapathy B L, Navaneeth B V. Tuberculosis of the parapharyngeal space: A rare case report. Indian J Pathol Microbiol [serial online] 2013 [cited 2020 Aug 10 ];56:480-481
Available from: http://www.ijpmonline.org/text.asp?2013/56/4/480/125400


Full Text

Sir,

Mycobacterium tuberculosis (MTB) infection is known to involve mainly the lungs; however, the invasion of multiple other organs are not uncommon. [1] Extra pulmonary tuberculosis (EPT) can involve any part of the body, common sites are lymph node, pleura, genitourinary tract, bone and joint, central nervous system, abdomen, etc. [2] Tuberculosis of the head and neck comprises approximately 10-15% of cases of EPT. Although antimicrobial therapy has reduced the incidence of parapharyngeal abscess (PPA), these infections remain an important clinical entity. [3]

Tuberculous adenitis presenting as a cold abscess in the parapharyngeal space is unusual. Review of medical literature over the last decade revealed only four cases of parapharyngeal space infection of Tuberculous (TB) etiology. [4] We report this case of TB PPA in a healthy immunocompetent adult male.

 Case Report



A 30-year-old male presented to Otolaryngology department with sore throat since 2 weeks and was diagnosed as acute pharyngitis and was prescribed antibiotics. With no relief the patient presented again to the out-patient department with a painful swelling (3x4 cm in size) in the right upper part of the neck and associated with complaints of painful swallowing and low grade fever since 2 days. The patient had no history of loss of weight, cough or ear discharge, no past history of TB. He had recent contact with open case of TB. The patient was a non-smoker and non-alcoholic.

On physical examination the patient was well built, well nourished, no pallor, cyanosis, clubbing, and lymphadenopathy. Examination of oral cavity revealed a diffuse bulge behind the right posterior pillar of tonsils in the lateral pharyngeal wall with congestion and tonsils being pushed medially. Laboratory findings showed hemoglobin, total count, differential count, platelets, and chest X-ray were under normal limits except erythrocyte sediment rate which was 30 mm in first hour. Human immunodeficiency virus serology was negative and was normal.

A computed tomography (CT) scan of the neck revealed slightly ill-defined collection measuring 4.2 × .0 × 2.3 cm (volume 45 cc) in the neck on the right side, posterolateral to nasopharynx, pharynx and larynx in the right parapharyngeal space suggestive of right PPA [Figure 1]. Few septations were noted in the collection: mass effect/extrinsic compression noted on the adjacent nasopharynx, pharynx, and larynx causing mild narrowing of its lumen. Few mildly enlarged cervical group of lymph nodes measuring 12 8 mm was also noted. Fine-needle aspiration cytology (FNAC) of the PPA showed suppurative lesion. Gram stain revealed inflammatory cells, with no organism; Ziehl Neelsen's (ZN) staining did not reveal acid-fast bacilli (AFB). Aerobic culture of the material for pyogenic bacteria and fungus yielded no growth.{Figure 1}

The Interferon TB Gold Enzyme immune assay (Cellestis, Chadstone, Victoria, Australia) was positive (0.66 IU/ml). Detection of deoxyribose nucleic acid of Mycobacterium tuberculosis complex by real-time polymerase chain reaction (RT-PCR) was positive. Dry, buff-colored colonies were isolated on Lowenstein Jensens medium (after 19 days). Based on these findings the patient was started on short course anti-tuberculous drug therapy (ATT) for 6 months. After 2 months of ATT, the swelling completely regressed and the patient was asymptomatic.

The causes of PPA are attributed to dental infections, tonsillar infections, foreign body in the oropharynx, intravenous drug abuse, tuberculosis, skin infections, peritonsillar abscess, and trauma. [3] Contrast-enhanced CT scan is the gold standard in the evaluation of deep neck infections. CT scans provides valuable information for the site and the extent of infection. Review of the medical literature over the last decade revealed only four cases of parapharyngeal space infection of TB etiology. [5] In India, a case of TB PPA has been reported from an immune compromised patient. [4] In the present case the patient being immunocompetent, ZN smear for AFB and FNAC were negative but MTB grew on culture and was further confirmed by RT-PCR.

In summary tuberculosis should be considered in the differential diagnosis of soft tissue masses of head and neck, particularly when the imaging findings and clinical presentation are atypical. This case illustrates the need of an aggressive diagnostic approach of suspected TB in unusual locations. Early diagnosis of tubercular PPA is essential to prevent any serious complications such as airway obstruction or extend into deep neck spaces.

References

1Swapnali C, Hemant R, Umarji, Kavita A. Tuberculosis of the head and neck: Varied clinical presentations and MRI findings. Oral Radiol 2012;28:146-9.
2Aditya B, Eric SB, Eugene Y. Pharyngeal and retropharyngeal tuberculosis with nodal disease. Radiology 2010;254:629-32.
3Shashindar S, Prepagaran. Apurulant parapharyngeal abscess. Internet J Head Neck Surg 2007;1: 2.
4Anju T, Anand J, Sushil C. Tuberculosis of the Parapharyngeal space. IJO & HNS 1996;48:252-4.
5Fraille RJ, Hernandez MA, Ortiz GA, Augulo GA, Vincente GE, de Miguel HN. Acta Otorrinolaringol-Esp 1998;39:193-5.