Non-caseating submental tuberculous lymphadenopathy: A case report

doi:10.4236/crcm.2013.25078

Paper Menu >>

Journal Menu >>

Vol.2, No.5, 291-293 (2013) Case Reports in Clinical Medicine

http://dx.doi.org/10.4236/crcm.2013.25078

Non-caseating submental tuberculous

lymphadenopathy: A case report

M. E. Asuquo1*, V. I. Nwagbara1, S. Akpan1, G. Ebughe2, T. Ugbem2, I. M. Asuquo3

1Department of Surgery, University of Calabar/University of Calabar Teaching Hospital, Calabar, Nigeria;

*Corresponding Author: [email protected], [email protected]

2Department of Pathology, University of Calabar/University of Calabar Teaching Hosp ital, Calabar, Nigeria

3Department of Curriculum and Teaching, Faculty of Education, University of Calabar, Calabar, Nigeria

Received 10 May 2013; revised 20 June 2013; accepted 10 July 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Chronic peripheral ly mphadenop athy in adult s is

an indication of pathology of which tuberculosis

is the commonest in the developing countries.

Presented is a 36-year-old with a huge chronic

Submental lymphadenopathy in a seronegative

patient of 7 years duration. Histology revealed

non-caseating tuberculosis. Tuberculosis should

be considered in Submental lymphadenopathy.

Despite the long duration, the absence of cold

abscess, and or sinus formation may be an in-

dication of the non-caseating tuberculous lym-

phadenopathy.

Keywords: Tuberculosis; Submental L ymph Node;

Non-Caseating Granuloma

1. INTRODUCTION

Chronic peripheral lymph node enlargement in adults

is an indication of an underlying disease that may pose a

diagnostic dilemma to physicians [1]. The commonest

lymph node group affected is reported to be the cervical,

the clinical manifestation varies with the challenges of

diagnosis not unusual [2,3]. Tuberculosis (TB) has been

reported as a common cause of chronic lymphadenopa-

thy in the develop ing countries and one of the most com-

mon of all extra pulmonary (TB) [4,5]. However, in the

developed countries with the rarity of infections, malign-

nancies are reported as the predominant cause of periph-

eral lymphadenopathy [1]. In developing countries in

Asia and Africa where tuberculous infection is common

and other granulomatous infections rare, the presence of

granulomatous features on histology are suggestive of

TB [3]. We present this case of florid non-caseating Su b-

mental tuberculous lymphadenopathy in a human im-

munodeficiency virus (HIV) seronegative patient to high-

light its unusual presentation; diagnostic challenge due to

ulceration from topical herbal medication, florid lesion in

an unusual group of lymph no de without any identifiab le

primary lesion.

2. CASE REPORT

A 36 years old applicant (engineer) presented to the

surgical out patient department (SOPD) as a referral from

the general out patient department with a 7-year history

of an anterior neck swelling. The swelling began as a

nodule, which he felt but was not visible, however in-

creased gradually to the size at presentation. There was

no associated fever, cough, and night sweats. There was

no history of trauma or dental pain, mass was painless

and not associated with pain or difficulty in swallowing.

There was no swelling in any other part of the body. He

sought treatment in some hospital facilities (private and

government) to no avail. Two months prior to presenta-

tion, he applied topical herbal preparation that resulted in

a wound hence his presentation to the University of

Calabar Teaching Hospital (UCTH), Calabar.

Examination revealed a young man in relative good

health, afebrile, and not pale. There was a firm, painless,

lobulated, ulcerated, and immobile mass in the Submen-

tal region of the neck. It measured 8 cm × 6 cm. The

edge of the ulcer was slopping with the floor that showed

granulation tissue with some spots with sloughs and

fixed to the underlying structure, Figures 1(a) and (b).

Examination of the oral cavity, ear nose, and throat, chest

and abdominal examination were normal. A clinical di-

agnosis of Submental lymphad enopathy was made.

Full blood count (FBC) showed: haemoglobin 12.9

g/dl, white blood cell 6.5 × 199/l (neutrophils 40%, eosi-

nophils 2%, and lymphocytes 58%), human immunode-

ficiency virus (HIV) serology was negative and urinaly-

M. E. Asuquo et al. / Case Reports in Clinical Medicine 2 (2013) 2 91-293

292

(a)

(b)

Figure 1. (a) Clinical photograph of submental lymphadeno-

pathy (Anterior view); (b) Clinical photograph submental lym-

phadenopathy (Lateral view).

sis was normal. Chest X-ray was normal, ultrasonogra-

phy reported, predominantly solid heterogeneous mass,

lobulated in outline. It appeared to arise from the subcu-

taneous tissue encroaching on the muscle plane, possibly

lymphoproliferative disorder, or fibrolipoma. Fine needle

aspiration biopsy (FNAB) reported a haemorrhagic back-

ground with mature lymphocytic infiltrate and occasional

histiocytes. Histopathology report showed numerous non-

caseating granulomas consisting of epitheloid cells, lym-

phocytes, plasma cells, and fibroblasts, interspersed by

occasional multinucleate giant cells. The surrounding stro-

ma was fibrocollagenous—non-caseating granuloma, Fig-

ures 2 (a) and (b).

Follow up in the SOPD while awaiting result of his-

tology revealed healing of the ulcer with the mass per-

sistent. Following the diagnosis of Submental tubercu-

lous (non-caseating) lymphadenopathy, he was referred

to the endemic disease unit for further management.

3. DISCUSSION

Tuberculosis ranks second as the leading infectious

cause of death in the world after HIV [6]. The emergence

of HIV introduced a new component to the ep idemiology

of TB with extra pulmonary TB including lymphade-

nopathy TB being more common [7]. Several reports

from the tropics describe TB and other infectious aetiol-

ogy as major causes of lymph node enlargement [8]. The

(a)

(b)

Figure 2. (a) Non-caseating granuloma H & E ×40; (b) Non-

caseating granuloma H & E ×100.

M. E. Asuquo et al. / Case Reports in Clinical Medicine 2 (2013) 2 91-293

293

commonest site of tuberculous lymphadenopathy re-

ported was cervical. Its involvement of cervical lymph

nodes has been known a long time as Scrofula or the

Kings Evil [9]. Olu-Eddo and Omoti reported lympha-

denopathy as the single commonest cause of cervical

lymphadenopathy constituting 35% of cases [4], and in

Saudi Arabia, Al-Sohaibani reported 28% [10]. This com-

munication describes a huge tuberculous lymphadeno-

pathy in an HIV seronegative patient in an uncommon

location for tuberculous cervical lymphadenopathy.

Tuberculous lymphadenopathy is largely confined to

the cervical lymph nodes mostly because tonsils and ade-

noids provide an easy portal of entry for inhaled myco-

bacteria [5]. It may also result from lymphatic or ha-

ematogenous dissemination from an original focus in the

lungs [5], our patient had no identifiable dental or oral

lesion. However, some lesions may be healed without

being detected and may be the case in our patient whose

evaluation revealed no primary focus despite the huge

Submental lymphadenopathy.

Majority of TB is diagnosed on clinical grounds with

or without histological appearance of the biopsy [5]. Ac-

tive lesions are seen as characteristic granulomatous in-

flammatory reaction that forms caseating and non-caseat-

ing tubercles [6]. Our patient’s histologic features were

consistent with non-caseating TB, Figure 2. It is less

common (20%) and described as hypertrophic. The firm

consistency was in keeping with the clinical evaluation

despite the long duration of the lesion; this variety was

unlikely to form cold ab scess and eventually a sinus seen

in the caseating form. The non-caseating TB is seen in

patients with good immunity [11], consistent with our

patient.

In the authors’ setting tradition al healers, enjo y a lot of

patronage especially with long standing lesions. Topical

herbal medication induced chemical inflammation of the

skin and ulceration and was capable of misdirecting cli-

nical judgement and therapy. Delay in presentation and

diagnosis was due to the inability of previous consulta-

tions to result in a proper diagnosis while the morbidity

associated with topical herbal medication, ulceration,

prompted presentation. Health education is pivotal for

early presentation. Physicians should subject chronic cer-

vical lymphadenopathy to histologic evaluation for di-

agnosis and proper treatment as this is crucial for sat-

isfactory outcome.

Huge Submental chronic lymphadenopathy may be

tuberculous. The effect of topical herbal medication on

clinical evaluation should not be underestimated like-

wise the morbidity. Diagnosis is histologic, long-standing

chronic lymphadenopathy without suppuration in a sero-

negative patient should arouse the diagnosis of non-

caseating TB.

REFERENCES

[1] Olu-Eddo, A.N. and Ohanaka, C.E. (2006) Peripheral ly m-

phadenopathy in Nigerian adults. Journal of Pakistan

Medical Association, 56, 405-408.

[2] Adeniji, K.A. and Anjorin, A.S. (2000) Peripheral lym-

phadenopathy in Nigeria. African Journal of Medicine &

Medical Sciences, 29, 233-237.

[3] Nwagbara, V.I., Asuquo, M.E., Ebughe, G., Agbor, C.,

Akpan, S., Ugbem, T. and Asuquo, I.M. (2013) Tubercu-

lous lymphadenitis of the neck. Case series. International

Journal of Medicine, 1, 4-8.

[4] Olu-Eddo, A.N. and Omoti, C.E. (2011) Diagnostic

evaluation of primary cervical adenopathies in a devel-

oping country. Pan African Medical Journal, 10, 52.

[5] Shubha, A.B., Sapna, H. and Dinesh Rao, B. (2010) Tu-

berculous lymphadenitis presenting a diagnostic dilemma.

A Case Report. International Journal of Dental Clinics, 2,

48-52.

[6] Udoh, M.O. (2009) Pathogenesis and Morphology of

Tuberculosis. Benin Journal of Postgraduate Medicine,

11, 91-96.

[7] Ben, C., Patel, P.S., Bharucha, H., Namaambo, K. and

Luo, N. (1996) Importance of human immunodeficiency

virus associated lymphadenopathy and tuberculous lym-

phadenitis in patients undergoing lymph node biopsy in

Zambia. British Journal of Surgery, 83, 75-78.

doi:10.1002/bjs.1800830124

[8] Thomas, J.O., Ladikpo, J.K. and Yawe, T. (1995) Histo-

pathology of lymphadenopathy in a tropical country. East

African Medical Journal, 72, 703-705.

[9] Tan, K.K. (1988) Tuberculous lymphadenitis in Singa-

pore. Singapore Medical Journal, 29, 441-446.

[10] Al-Shohaibani, M.O. (1996) Chronic lymphadenopathy

in the eastern province of Saudi Arabia. East African

Medical Journal, 73, 533-537.

[11] Sriran Bhat, M. (2009) SRB’s mannual of surgery. 3rd

Edition, Jaypee, New Delhi, 391-393.