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ORIGINAL ARTICLE
Year : 2003  |  Volume : 57  |  Issue : 1  |  Page : 12-5
 

Mycobacterial cervical lymphadenitis in childhood.


Department of Microbiology, Medical College, Amritsar,

Correspondence Address:
N Jindal
Department of Microbiology, Medical College, Amritsar

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PMID: 14514280

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 ¤ Abstract 

A study of 190 children of chronic cervical lymphadenitis showed tuberculous etiology on histopathological examination in 92 (48.4%) and bacteriological evidence of mycobacterial infection (smear and/or culture) in 42 (22.1%). Of these 42, twelve (28.6%) showed histopathological diagnosis of non-specific lymphadenitis. Positive culture for mycobacteria was obtained in 40, of which 30 (75%) were typical M. tuberculosis and 10 (25%) were atypical mycobacteria. The most predominant species of typical mycobacteria was M. scrofulaceum (60%) followed by M. avium intracellulare (40%). There was no remarkable difference in the histopathological pattern of those in which M. tuberculosis was grown and those in which bacterial growth was that of atypical mycobacteria. The diagnosis of chronic cervical lymphadenitis should therefore be taken a step beyond histopathology, up to complete bacteriological examination, especially to confirm the cases of mycobacterial lymphadenitis caused by atypical mycobacteria.


Keywords: Child, Chronic Disease, Human, Mycobacteria, Atypical, isolation & purification,Prevalence, Tuberculosis, Lymph Node, epidemiology,microbiology,pathology,


How to cite this article:
Jindal N, Devi B, Aggarwal A. Mycobacterial cervical lymphadenitis in childhood. Indian J Med Sci 2003;57:12

How to cite this URL:
Jindal N, Devi B, Aggarwal A. Mycobacterial cervical lymphadenitis in childhood. Indian J Med Sci [serial online] 2003 [cited 2014 Nov 27];57:12. Available from: http://www.indianjmedsci.org/text.asp?2003/57/1/12/11880


Chronic cervical lymphadenitis is a commonly encountered problem in clinical practice. It has multifarious etiology but mycobacteria continues to be one of its commonest causes especially in paediatric age group in India and other developing countries.[1] However, during the recent years there has been a change in the pattern of this infections cased by atypical mycobacteria or MOTT (Mycobacteria other than tubercle bacilli) have been reported.[1],[2],[3] Present study was therefore undertaken to determine the prevalence of mycobacterial Chronic cervical lymphadenitis in the children. Since the usual practice is to depend mainly on histopathology for the diagnosis of tuberculous lymphadenitis, correlation between the bacteriological and histopathological findings was also studied.


 ¤ Material and methods Top


A total of 190 patients of cervical lymphadenitis of more than two weeks duration who had not taken any chemotherapy for more than two weeks were included in the study. The excised lymphnodes were divided into two halves and one half was used for histopathological examination and the other for smear (Z.N. Staining) and culture for mycobacteria. The growth of Mycobacteria obtained on Lowenstein Jensen (U) medium was characterised on the basis of colony characters, sensitivity to paranitrobenzoic acid (PNB) 500 Ngm/ ml, biochemical tests[4],[6] and susceptibility to isoniazid, ethambutol and rifampicin.[6],[7] All PNB resistant cultures were also studied for their: (i) rate of growth (ii) growth at 25°C, 37°C and 44°C and pigment production. Chest x-ray and Mantoux Test (MT) was done in all the patients.


 ¤ Results Top


Out of 190 patients studied, 92 (48.4%) showed appearance of tuberculous lymphadenitis on histopathological examination and 42 (22.1 %) demonstrated mycobacteria bacteriologically ie. on ZN smear and /or culture [Table - 1]. Out of these 42, forty yielded positive growth of mycobacteria on culture, of which 30(75%) were recognised as M.tuberculosis and 10 (25%) as atypical mycobacteria. The study of atypical mycobacteria showed that six of these were M. scrofulaceum and four were M.avium intracellulare.

Drug sensitivity pattern of mycobacteria showed that while M.tuberculosis was uniformly sensitive to all the three drugs tested (isoniazid, ethambutol and rifampicin) atypical mycobacteria showed resistance of high degree and only one, two and one of ten strains of atypical mycobacteria were found to be sensitive to isoniazid, ethambutol and rifampicin respectively.

The bacteriologically positive cases also showed prepondrance of males and unilateral enlargement of lymphnodes.The duration of illness varied from 3 weeks to 4 years, though in no case was the culture positive when the duration was more than one year. MT was positive in majority of 89% tuberculous group children below 5 years of age and chest X-ray revealed parenchymatous lesion in 28.2% tuberculous cases.

An attempt was made to correlate bacteriological with histopathological findings [Table - 1]. Out of 92 cases with tubercular histopathology two showed only Z.N. smear positive while 28 (30.4%) were positive on culture and 6 out of these were MOTT bacilli. Another 12 (12.7%) cultures of mycobacteria were grown from 94 cases with histological picture of non-specific chronic Lymphadenitis and four out of these were MOTT. However, statistically the difference in the histopathological pattern of specimens from which M. tuberculosis was grown and those in which bacterial growth was that of MOTT was insignificant (p<0.1).


 ¤ Discussion Top


On the basis of histopathological findings 92 (48.4%) of 190 patients were found to have mycobacterial lymphadenitis. This incidence is almost similar to that reported by Davesaar et al.[2] However, Rohatgi et a1[3] reported only 27% tuberculous cases in their study conducted on patients attending. All India Institute of Medical Sciences New Delhi. They included large number of partially treated and complicated cases which might explain the difference in the rate of positivity.

The overall bacteriological positivity (smear and/or culture) was 22.10% and it was 32.6% in the tuberculous group [Table - 1]. While this percentage is less than that reported by Pamra et al[8] others have reported even lower rate of positivity.[3] Failure to demonstrate the bacilli in smear and /or culture however does not mean their absence in the lymph nodes. Soltys[9] believes that the low proportion of positive cultures is due to the presence of bacteriostatic substances in tuberculous lymph nodes, which inhibit the growth of bacilli in vitro. The low rate could also be due to the bacilli in the glands being scanty. Twelve cultures of mycobacteria were grown from 94 cases showing histopathology of choronic non-specific lympha-denitis [Table - 1]. These might have been early tuberculous cases which could not be recognised on histopathaology since formation of granuloma and emergence of frank histological tuberculous picture is a late phenomenon.[9] Similar experiences have also been reported by or other workers.[2].[3]

Out of 40 cultures positive for mycobacteria, ten (25%) were MOTT. The reported incidence of typical mycobacteria varies from 1.5% to 80%.[10] This variation might be reflecting the variation in the prevalence of typical mycobacteria in different environmental or geographic regions.

Of the various MOTT bacilli, M. scrofulaceum, which is stated to be the most frequent worldwide cause of cervical lymphadenitis was also isolated most commonly (six of ten cases) in our study. The most prevalent group was scotochromogens (60%). Other authors have reported a greater frequency of M.aviumintracellulare[10] which was isolated in the present study from four (40%) cases only. The reason for this could be a notable geographic variation in the distribution. of different species of MOTT bacilli.

Correlation of histopathological picture with bacteriological findings showed that the specimens from which MOTT bacilli were grown failed to reveal any distinctive histopathological features similar to the findings of others.[2].[3] Therefore, from the histopathological examination alone, it would not be possible to predict the type of mycobacteria responsible for infection. Since the treatment of infections caused by M.tuberculosis and MOTT is different (chemotherapy Vs surgical excision) and histopathology in early cases of tuberculous granuloma, it becomes imperative that the diagnosis of cervical lymphadenitis be taken a step beyond histopathology, upto complete and careful bacteriological identification.


 ¤ Summary Top


A study of 190 children of chronic cervical lymphadenitis showed tuberculous etiology on histopathological examination in 92 (48.4%) and bacteriological evidence of mycobacterial infection (smear and / or culture) in 42 (22.1 %). Of these 42, twelve (28.6%) showed histopathological diagnosis of non-specific lymphadenitis. Positive culture for mycobacteria was obtained in 40, of which 30 (75%) were typical M. tuberculosis and 10 (25%) were atypical mycobacteria. The most predominant species of typical mycobacteria was M.scrofulaceum (60%) followed by M.avium intracellulare (40%). There was no remarkable difference in the histopathological pattern of those in which M.tuberculosis was grown and those in which bacterial growth was that of atypical mycobacteria. The diagnosis of chronic cervical lymphadenitis should therefore be taken a step beyond histopathology, up to complete bacteriological examination, especially to confirm the cases of mycobacterial lymphadenitis caused by atypical mycobacteria.

 
 ¤ References Top

1.Sheikh MM, Ansari Z, Perrin A, Tyagi PS. Tuberculous lymphadenopathy in children. Indian Pediatrics 1981;18:293-7.  Back to cited text no. 1    
2.Davesarr SK, Chitkara NL, Study of tuberculous lymphadenitis Indian J Pathol Microbiol 1971;14:113-8.  Back to cited text no. 2    
3.Rohatgi M, Shriniwas, Dewan M, Etiology of chronic cervical lymphadenopathy in infancy and childhood. Indian J Med Microbiol 1988;6:309-14.  Back to cited text no. 3    
4.Das DK, Pant NJ, Chachra KL, Murthy NS, et al. Tuberculous, Iymphadenitis: Correlation of cellular components and necrosis in lymphnode aspirate with AFB positivity and bacillary count. Indian J Pathol Microbiol 1990;33:1-5.  Back to cited text no. 4    
5.Laidlaw M, Mackie and McCartney's Practical Medical Microbiology, 13th Ed. London, Churchill Livingstone: Vol. 11, 1989. p. 413.  Back to cited text no. 5    
6.Tsukamura M, Identification of mycobacteria. Tubercle 1967;48:311-8.  Back to cited text no. 6    
7.Canetti G, Fox W, khomenko A, Mahler HT, et al. Advances in Techniques of testing Mycobacterial drug sensitivity and the uses of sensitivity tests in tuberculosis control programme. Bull WHO 1969;41:21.  Back to cited text no. 7  [PUBMED]  
8.Pamra SP, Mathur GP, A cooperative study of tuberculous cervical lymphadenitis. Indian J Med Res 1974;62:1631-8.  Back to cited text no. 8    
9.Soltys MA. Anti tuberculous substance in tuberculous organs. J Comp Pathol Therap 1953;63:147-9.  Back to cited text no. 9    
10.Joshi W, Davidson PM, Jones PG, Cambell PE, Robertson DM. Non tuberculous mycobacterial lymphadenitis in children. Eur J Pediatr 1989;148:751-4.  Back to cited text no. 10    


Tables

[Table - 1]

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