ISSN: 0975-8437

INTERNATIONAL JOURNAL OF DENTAL CLINICS 2010:2 (2): 48-52

CASE REPORT

Tuberculosis Lymphadenitis Presenting a Diagnostic Dilemma- A Case Report Shubha A.B., Sapna Hegde, Dinesh Rao B

Abstract Swellings of the submandibular region are a frequent observation in children with deep carious lesions of primary molars and almost always lead the clinician to suspect cellulitis caused by a dental infection. Presented here is one such case which was initially diagnosed as a swelling arising from dental etiology and treated accordingly. No improvement in the child’s condition led to further extensive investigations and the case was diagnosed as tuberculosis lymphadenitis. Keywords: Diagnostic Dilemma, Dental Infection, TB Lymphadenitis. Received on: 24/02/2010

Accepted on: 26/05/2010

Introduction

However, the same cannot be said of the paediatric

Tuberculosis of the lymphatic system is one of the

dental setting wherein patients with severe oral and

most common of all extra-pulmonary tuberculosis,

dental infections frequently present with enlargement

second only to tuberculous pleurisy. Its involvement

of the cervical lymph nodes. Further, lymphadenitis

of the cervical lymph nodes has been known for

may be the only manifestation of the disease and

centuries as scrofula or the King’s Evil1. The unusual

there may not be associated constitutional symptoms,

features of TB lymphadenitis are its sex and age

such as low-grade fever, loss of weight, cough or

1-3

and in

other respiratory symptoms10. It is not unlikely,

the younger age groups, in contrast to pulmonary

therefore, that tuberculosis may be overlooked as a

tuberculosis which is more common in males and in

possible diagnosis in patients visiting a dental facility

distribution, being more common in females

1

the older age group .

with swellings of the lower face and concomitant

In a typical outpatient paediatric clinic of a hospital

enlargement of the cervical lymph nodes.

in India, children with enlarged cervical lymph nodes

What follows is a report of one such confounding

4

are a common presentation . With prevalence as high 5

case of tuberculous lymphadenitis co-existing with a

as 1.5% , tuberculosis is still rampant in this part of

facial swelling of dental origin, which presented a

the world and is responsible for involvement of

diagnostic dilemma and resulted in much discomfort

6

lymph nodes in almost 30-40% of cases . In rural

and inconvenience to the child and his parents, in

India, the prevalence of tuberculosis lymphadenitis in

addition to causing psychological distress and

children upto 14 years of age is 4.4 per 1000 7.

anxiety.

Therefore, on initial examination tuberculosis is often

Case Report

attributed as the underlying cause in most cases of

A 5 year-old boy was brought to the Department of

cervical lymphadenopathy8,9.

Paediatric Dentistry, Pacific Dental College and Hospital, Udaipur, by his very concerned parents,

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with a complaint of pain and swelling in the child’s lower right jaw since 45 days. The pain was continuous and dull in nature, aggravated during mastication and temporarily relieved by medication. The parents reported that the facial swelling showed a gradual increase in size, and during the last 7 days, was associated with a rise in body temperature. The medical history elicited from the parents was noncontributory. Figure

2: Frontal view of patient

Prior to the visit to our paediatric dental facility, the child

was

examined

by

a

general

medical

No bony expansion of the body of the mandible was

practitioner, then by a general dental practitioner and

evident on palpation, but the right submandibular and

finally by a paediatrician, each of whom prescribed

the submental lymph nodes were observed to be

and subjected the child to a course of antibiotic

enlarged, mobile and tender (Figure 3).

therapy, with little effect. The last of these health care professionals further referred the child to our dental facility (Figure 1).

Figure 3: Left and right profiles of patient Intraoral examination revealed poor oral hygiene and deep carious lesions in all lower primary molars with a sinus tract leading from the first primary molar of the left side (Figure 4). The molars in the area of Figure 1: The patient referral pathway

concern, i.e., the right mandibular region exhibited a

The swelling was diffuse and soft, extending from the

high degree of mobility, such that they mimicked

right corner of the mouth to almost the posterior

‘floating molars’. Obliteration of the vestibule was

border of the mandible, involving the entire

evident in the area of these teeth, together with

submandibular region of the right side and also

marked gingival inflammation around the second

crossing over to the left side (Figure 2).

molar.

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days. In the meantime, the root canals were maintained clean. However, when the swelling did not show any signs of subsiding even after a week, a far more serious condition was suspected than was originally thought of. The possibility of an antibioma was ruled out here because the swelling was soft and diffuse rather than hard and localized. Also, routine blood investigations indicated a normal blood profile. Aspirate was obtained from the submental region Figure 4: Intraoral view showing deeply carious

where the swelling was most prominent and

primary molars

subjected to cytology to determine the existence of

An intraoral periapical radiograph revealed pulpal

any infectious or malignant etiology. CT scan (Figure

involvement of both the right mandibular primary

6) showed the presence of multiple enlarged lymph

molar teeth, with periapical infection resulting in loss

nodes in the submental and submandibular region

of the inter-radicular bone in relation to the second

(Level-I), the high jugular nodes of the deep cervical

molar. An orthopantamograph was made, the

chain (Level-II), the middle internal jugular nodes of

interpretation of which was non-contributory (Figure

the deep cervical chain (Level-III), lower deep

5). Hence, routine endodontic therapy was instituted

cervical chain nodes (Level-IV) and the spinal

in the form of an emergency access opening and

accessory nodes and the transverse cervical chain

cleaning of the pulp canals without any more undue

nodes (Level-V) bilaterally. The results of the FNAC

antibiotic therapy, taking into consideration the fact

revealed the presence of lymphoid tissue with few

that the child had already undergone three courses of

foci of collections of epitheliod cells, caseative

antibiotic therapy very recently.

necrosis and occasional Langhan’s-type of giant cells, findings which are indicative of tubercular granulomatous lesions.

Figure 5: Panoramic view of dentition Surprisingly, no improvement in the child’s condition by way of reduction in the size of the swelling was

Figure 6: CT scan showing multiple, enlarged lymph

observed on the day of the second appointment. A

nodes

wait-and-watch approach was decided upon for a few

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lymphadenitis are diagnosed on clinical grounds After having arrived at a diagnosis of tuberculous

and/or histological appearance of biopsy tissue1.

lymphadenitis, the patient was successfully treated

FNAC is a well-established diagnostic tool in the

with a six-month regimen of anti-tuberculous

assessment of cervical masses. In developing

medication under the supervision of a paediatrician.

countries like India, where tuberculous infection is common and other granulomatous infections are rare,

Discussion

presence of granulomatous features on FNAC are

Tuberculosis of the lymphatic system is largely confined to the cervical lymph nodes, mostly because the tonsils and adenoids provide an easy portal of entry for inhaled mycobacteria11. It could also result from

lymphatic

spread

or

haematogenous

dissemination from an original focus in the lung. It could also comprise the lymph node component of a primary complex of the oral cavity where structures such as gums, tongue and buccal mucosa can be infected and subsequently healed without being detected1.

highly suggestive of tuberculosis14. Treatment for tuberculous lymhadenitis is essentially the same as for pulmonary tuberculosis, and shortcourse chemotherapy for childhood tuberculosis has been well-established15. In the present case, the medical histories of the patient and his family were non-contributory. Additionally, a confounding factor was present, i.e., a likely dental cause for the enlargement of the lymph nodes, which was highly misleading. However, the failure of antibiotic and dental therapy to bring about

The predominance of TB lymphadenitis in younger groups and in females has been well-documented by various authors2,3 The reasons for this are not clearly understood; however, the underprivileged condition of women in rural Indian society may be a factor12. Cervical lymphadenitis remains a diagnostic and

any improvement in the patient’s condition pointed out to a more serious problem. Here, the use of proper and appropriate investigative techniques, chiefly FNAC, paved the way to establishing an accurate

diagnosis

and

successful

treatment

thereafter.

therapeutic challenge because it mimics other pathologic processes and yields inconsistent physical

Conclusion:

and laboratory findings. A high index of suspicion is needed for the diagnosis of mycobacterial cervical lymphadenitis. Atypical mycobacteria have also been incriminated in producing enlarged cervical lymph nodes. It is important to differentiate tuberculosis from

non-tuberculous

mycobacterium

cervical

lymphadenitis because their treatment protocols are

clinical problem in the paediatric population, reactive and granulomatous enlargement being two important causes. A high index of suspicion is required to diagnose this condition especially when associated with a dental infection. Primary diagnostic evaluation of childhood peripheral lymphadenopathy is mainly

different13. Diagnosis of extra-pulmonary tuberculosis is not so clear-cut because material for confirmatory test is not easily obtainable. Invasive procedures are not always acceptable

Cervical lymph node enlargement is a common

to

patients.

Most

cases

©INTERNATIONAL JOURNAL OF DENTAL CLINICS

of

based on group of lymph nodes involved and FNA and when caused by mycobacteria, is best treated as a systemic disease with antituberculosis medication.

TB

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Authors Affiliations: 1. Shubha A.B. Reader, 2.

9.

Talib VH, Pandey J, Khurana SK. Tuberculosis:

Sapna Hegde, Professor & Head, 3. Dinesh Rao B,

An epidemic in the making. Ind J Pathol

Professor, Department of Pediatric Dentistry, Pacific

Microbiol 1993;36:339-40.

Dental College & Hospital, Udaipur, Rajasthan,

10.

Seth V, Kabra SK, Jain Y, Semwal OP, Mukhopadhyaya S, Jensen RL. Tubercular

India.

lymphadenitis: Clinical manifestations. Indian J References: 1.

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Dandapat MC, Mishra BM, Dash SP, Kar PK. Peripheral lymph node tuberculosis: a review of

12. Khan RA, Wahab S, Chana RS, Naseem S,

80 cases. Br J Surg 1990;77: 911-2. 3.

Siddique S. Children with significant cervical

Subrahmanyam M. Role of surgery and chemotherapy for

peripheral

lymphadenopathy: Clinicopathological analysis

lymph node

and role of fine-needle aspiration in Indian

tuberculosis. Br J Surg 1993;80:1547-8. 4.

setup. J Pediatr (Rio J) 2008;84(5):449-54

Bedi RS, Thind GS, Arora VK. A clinicalpathological

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Department of Pediatric Dentistry, Pacific Dental College & Hospital, Debari, Udaipur 313024, Rajasthan, India E-mail: [email protected]

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