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Case Report | DOI: https://doi.org/10.31579/2690-4861/475
1 CHR Guelmim; ENT department. Morocco.
2 ENT Department CHU ibn sina Rabat. Morrocco.
*Corresponding Author: N. Belhaj, CHR Guelmim; ENT department. Morocco.
Citation: Belhaj N, Bencheikh R, M.A. Benbouzid, L. Houassaini.Essakalli, (2024), Cervical lymph node tuberculosis in the Moroccan Saharan environment (experience of the Guelmim oued Noune region): diagnostic and therapeutic approach, International Journal of Clinical Case Reports and Reviews, 20(1); DOI:10.31579/2690-4861/475.
Copyright: © 2024, N. Belhaj. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 15 May 2024 | Accepted: 20 November 2024 | Published: 28 November 2024
Keywords: cercvical lymphnodetuberculosis; mycobacterium tuberculosis; surgery; antibacillary
Tuberculosis is a contagious infectious disease caused by a mycobacterium of the tuberculosis complex, mainly mycobacterium tuberculosis or Koch's bacillus.
It remains a public health problem in the world responsible for a high mortality and morbidity. Lymph node tuberculosis is the most common extranodal form; p is a real diagnostic, therapeutic and aesthetic problem despite the current effectiveness of anti-bacillary chemotherapy.
The objective of our study was to analyze the epidemiological, clinical, therapeutic and evolutionary aspects of cervical lymph node tuberculosis in the Guelmim Oued Noun region in order to improve its management; to a retrospective study on a series of 30 patients collected over a period of 2 years.
Tuberculosis remains a major public health problem worldwide, causing high mortality and morbidity.[1] About one-third of the world's population is infected with the tuberculosis bacillus, and more than nine million new cases of tuberculosis occur worldwide each year. In Morocco, 26,000 to 27,000 new cases of tuberculosis of all forms are detected annually. [2]
Tuberculosis presents itself in different clinical forms, most often pulmonary, but in 25% of cases it is extra-pulmonary, dominated by lymphonodal or lymph node tuberculosis, particularly cervical tuberculosis formerly known as scrofula: a term derived from Latin for "glandular augmentation". This represents 43% of lymphadenopathy in developing countries and 5 to 10% in developed countries. [3]
The infectious origin of 'scrofula' was put forward by Bollinger, May and Demme towards the end of the 19th century; indeed, they noted that Mycobacterium bovis affecting cows was the cause of this disease. Lymph node tuberculosis (TG) is the most common extrapulmonary location in Morocco. It continues to pose diagnostic, therapeutic and aesthetic problems. [5.6]
It is a pauci-bacillary form, the diagnosis is essentially based on cytohistology; Standard microbiology remains the key test for determining the causative agent of lymph node tuberculosis and testing its susceptibility to anti-bacillary therapy. However, molecular biology has undergone technological progress, making new means of diagnosing tuberculosis available to the clinician. [5] Clinically, it appears as a bulky mass, polylobed with a pseudotumoral appearance, these are most often unilateral polyadenopathies of unequal consistency under the mandibular or spinal systems; of fluctuating appearance or in prefistulization, which is strongly suggestive of BK.
The treatment is essentially medical, the duration of which is still a matter of controversy; while surgery retains a preponderant place for diagnostic as well as therapeutic purposes, sometimes indicated from the outset in certain specific situations. [7]
The main objectives of our study are:
- To study the epidemiological, diagnostic and therapeutic profile of lymph node tuberculosis in the Saharan region, more specifically the region of Guelmim Oued Nour being described as the largest region in the Sahara.
-To discuss the interest of surgery as a diagnostic and therapeutic means in the treatment of management of BK lymph node
-- Evaluate the effectiveness of current management to derive new strategies to fight this disease
Il s’agit d’une étude retrospective réalisée sur une période de 2 ans du 1er Mai 2022 au Mai 2024.
Including 30 patients with the following inclusion criteria:
Selected patients are those with cervical lymph node tuberculosis confirmed by the demonstration of gigantocellular epitheloid granuloma with caseous necrosis and a positive expert gene.
Excluded patients are those with no histological confirmation, those who are lost to follow-up and whose records are incomplete. Data entry was done in Word and Excel.
The statistical study was done using the Jamovi
Regarding the epidemiological results:
Gender was found to be predominant: 14 (46.7%) male via 16 female (53.33%)
The average age of our patients was 28 years old, with the extreme age of 10-59 years.
Geographical origin: rural origin in 33% while urban origin in 70%.
For: Personnal history of lymph node or extranodal tuberculosis (no cases had been identified); The notion of tuberculosis contagion found in 66% of cases; Smoking was a toxic history found in 12 patients in our series and alcoholism in 3 cases All of our patients consumed unpasteurized milk, mostly good milk. All patients in our series are vaccinated (i.e. 100% of cases).
The frequent reason for consultation in all our patients was cervical swelling with fistulization in only 8 cases (26.7%). (Figure 1.2) For the signs of tuberculous impregnation, we noted at least one sign in 42% of our patients while they were abscent in the rest.
Figure 1.2: Clinical aspects of cervical masses in prefitulization and fistilusium
In addition, only one patient in our series presented other signs suggestive of a malignant pathology, but cytology had reconfirmed the diagnosis to the type of reflex otalgia; of odynophagia see dyspahgia.
On clinical examination, a single lymphadenopathy was found in 12 of the patients, while the remaining 18 polyadenopathy were highlighted.
The size of the ADPs varied between 11 mm and 80 mm;the most affected cervical sector was the upper jugulocarotid; the consistency of the ADPs varied from hard in 2 patients (6.7%); closed 13 patients (43.33%); soft in 8 cases (26.7%) and phlyctenular in 23.3%.
The skin was normal in 78.57% of cases, inflammatory in 10% of patients and fistulized in 11.42% who remain.No other ENT or extra ENT locations found
As far as the paraclinical examinations are concerned, all our patients benefited from a chest X-ray which was noramle in the majority except for two patients who presented hialair but non-secific opacities.
Cervical ultrasound was performed in all our patients in order to study lymph node involvement with different aspects noted (homogeneous hypoechoic aspects; necrosis images found in 88% of patients a hyperechoic appearance in 11% of cases).
CT scan is requested in 3 cases to explore the lymph node areas and their relationship with the vascular axes, in these cases a case of SCM infiltration. All our patients had received an objective blood count: anemia in 10 cases; hyperleukocytosis at the expense of lymphocytes in 4 patients. The CRP requested in all patients was elevated in 5 patients.
Intradermoreaction was performed in 20 patients due to the unavailability of the reagent at the respiratory disease diagnostic center and dispensaries for the duration of the study.
Quantiferon assay not performed in all patients, examination not available in the regional hospital. HIV serology: all our patients benefited from a rapid HIV test, it was positive in 2 patients, the confirmation carried out by serology. Bacteriological and histological confirmation carried out after exploratory cervicotomy objectifying an epitheliogigant granuloma in all our patients; None of our patients have benefited from a needle aspiration. The expert gene study carried out in all patients looking for resistance did not objectify any case of resistance.(figure 3)
Figure 3: histoligical blade showing the epitheliogigant granuloma
All our patients had benefited from an exploratory cervicotomy with an incision that depended on the site of the lymphadenopathy. For the evolution under antibacillary medical treatment was marked by a paradoxical reaction in two patients and a prodigious scar in 5 patients.
In our series, cervical lymph node tuberculosis was the prerogative of young adults; the average age in our series is 29 years old, which is in line with the literature; the data from the R. Bouchentouf series where the average was 26 years [8] and with the T. Habiba series the average was 29 years [9]; while the average age reached 36 years in a study carried out at Fkih ben Saleh. [10]
For sex in our series, a slight predominance of women as described in the literature [2.14.11.12]
According to the literature, active and passive smoking increases the risk of latent tuberculosis infection and tuberculosis disease in their pulmonary and extrapulmonary forms by:
(Alteration of mucociliary clearance; Decreased performance of alveolar macrophages. Decreased cytotoxic activity of 'Natural killer' cells; Decreased cytotoxic activity of Natural killer cells) [13]
Smoking cessation should be an integral part of the management of patients with tuberculosis. [14.15.16].
In our study, the notion of consumption of unpasteurized milk concerned 100% of cases, which was higher than the data in the literature. Indeed, in R. Abdelmalek's study, it was present in 16.96% of cases [17] and was reported in 13.46% of cases by N. Jihane in his study. [14] The danger of consuming milk from tubercular cows has been demonstrated for a very long time. Although the bovine tuberculosis bacillus and the human bacillus are not identical, It has been definitively established, following numerous and important studies, that the bovine bacillus could cause in man the same tuberculous lesions as the human bacillus. This was the conclusion reached in 1942 by the work of the Medical Research Council (Report of the Tuberculosis Committee, No. 246).
In Canada (in 1934), PRlCE, studying the case of 300 tuberculous children under fourteen years of age, established that 15% of cases of extra-pulmonary tuberculosis were due to the bovine bacillus. (The infected children came from areas where milk was not pasteurized. No cases of bovine infection were detected in children fed pasteurized milk) [18]
Even if the diagnosis of extra-pulmonary tuberculosis is made, it is always necessary to look for an associated pulmonary location given the endemic state in our country. In our series, the notion of tuberculosis contagion was reported in 66%. As for the series by N. Jihane, R. Abdelmalek and G. Hamzaoui, it was reported in 5.76% and 3.9% and 9% respectively [14, 17, 2].
The tuberculosis vaccine is a live attenuated vaccine that does not prevent infection but protects against severe forms of the disease (meningitis, miliaria) in young children (70% to 80%). [53] The degree of protection conferred by BCG (Bacillus of Calmette and Guérin) with regard to pulmonary tuberculosis in adults is limited. The average duration of protection is 10 to 15 years. In our series, all patients are vaccinated and this shows the efforts made by the staff of the The tuberculosis vaccine is a live attenuated vaccine that does not prevent infection but protects against severe forms of the disease (meningitis, miliaria) in young children (70% to 80%). [17] The degree of protection conferred by BCG (Bacillus of Calmette and Guérin) with regard to pulmonary tuberculosis in adults is limited. The average duration of protection is 10 to 15 years. In our series, all patients are vaccinated and this shows the efforts made by the staff of the health care system to implement the immunization protocol
For clinical data and time to care; Tuberculosis is a subacute pathology with an insidious onset; It evolves over several weeks or even months, which explains the delay in patient consultations. The interval between the 1st day of symptomatology and the start of treatment is 10 days to 12 months with an average of 4 months. This delay is reported by several authors. We cite as an example the series of W. Kermani where the delay was 7 months [17] and 3 months in the series of R. Bouchentouf as well as in the series of T. Habiba. [13.19].
The most common reason in our patients was cervical swelling (100%). This result is consistent with the data in the literature: the percentages ranged from 80.31% to 100%. [13.16.17.18.19]
These signs are made up of alteration of the general condition, which includes asthenia, anorexia and weight loss that can exceed 10kg, a fever of variable appearance, ranging from a vesper fever (the most frequent case) to a high, oscillating fever, accompanied by chills and night sweats. These symptoms may persist for several weeks before the patient consults. They were present in 42% of cases in our study; as well as in the Kermani series [11].
The paraclinic includes several examinations including:
The chest X-ray, which must be performed on all patients, even those suffering from extrapulmonary tuberculosis, must undergo a chest X-ray, which is still insufficient to rule out associated pulmonary tuberculosis. It may detect parenchymal or mediastinal lymph node involvement or even pleural involvement in the form of an effusion.
As for cervical ultrasound, it remains the 1st line examination in the exploration of cervical masses and the characterization of lymphadenopathy [8]. It makes it possible to confirm the diagnosis of lymphadenopathy, specify its linden, its appearance and guide the punctures. An exploration of the thyroid, parotid and submandibular glands can also be carried out at the same time. Cervical ultrasound is more sensitive than clinical examination for the study of lymph node involvement. [20]
Cervical CT scan is requested in the presence of a clinically suspicious aspect of the cavum and/or lymphadenopathy larger than three centimetres and/or fixed to the superficial and deep planes and allows the relationship with neighbouring organs as well as with the vascular axis to be studied before surgery. CT scans reflect the progression of lymph node tuberculosis from moderate lymph node hyperplasia to the onset of caseous necrosis. [6]
The cutaneous reaction to tuberculin is the expression of a phenomenon of delayed hypersensitivity to certain antigens of M. tuberculosis.A positive reaction in an individual indicates that he or she has been infected but does not make it possible to determine whether the infection is latent or progressive. In addition, it is not possible to determine whether the reaction is due to M. tuberculosis or another mycobacterium. IDR is performed by injecting 5 international units of tuberculin intradermally; on the palmar (internal) side of the forearm. The reading is taken 48 to 72 hours after the injection. It must be carried out by trained health personnel. The reaction is the area of induration (perception of edema on palpation) around the injection site. The diameter of the induration is measured transversely using a ruler (do not measure the erythematous area around the induration, as this is not the reaction but only the indurated area).
The advent of HIV (Acquired Immunodeficiency Virus) infection has complicated the already existing tuberculosis endemic, making tuberculosis the 1st most opportunistic infection related to HIV. In Morocco, a country endemic to tuberculosis, this is particularly observed [21]. In our series, the association was weak in 2 patients, unlike the Assiya E. study where the association was reported in 39.3% of cases. [22]
For confirmation of tuberculosis recourse is had to bacteriology; The MO makes it possible to highlight BK after special preparation of the samples by Ziehl-Neelsen staining with fuschine. The BK appears in the form of a red rod. SLE remains a low contributor in PET scans, in children (difficulty in collecting samples), and in HIV patients. The sensitivity is 70% but its specificity is very low. The Fluorescence Microscope and Especially the LED Microscope; allows BK to be highlighted after auramine or Dugommier staining. It is also a less expensive method. Its sensitivity is better (84%) with a specificity of 97%. [66] Indeed, diagnosis is rarely based on bacteriological studies. This is due to the paucibacillary nature of lymph node tuberculosis linked to poor lymph node oxygenation and the importance of cell-mediated defense mechanisms at this level. Diagnosis of extrapulmo tuberculosis
It allows the diagnosis of tuberculosis with negative microscopy, in particular makes it possible to establish an extra-pulmonary tuberculosis antibiogram where the diagnosis is difficult to reach by direct examination. [22]
For molecular biology study; using PCR, which is a technique that consists of detecting and amplifying a specific nucleic sequence of the Mycobacterium Tuberculosis complex. The best yield for this technique is obtained on respiratory samples, on the other hand there have been many false negatives for extra-pulmonary tuberculosis; which explains why this technique is not used by our patients. [23]
As for the expert gene, this test can diagnose TB and resistance to rifampicin. Unlike other techniques (in vitro culture, antibiotic susceptibility testing and conventional molecular techniques), the Xpert MTB/RIF test can be used in peripheral laboratories and does not require sophisticated equipment or highly trained personnel to perform. The test is based on real-time PCR. It targets specific nucleic acid sequences in the M. tuberculosis complex genome and simultaneously provides information on the most frequent mutations related to rifampicin resistance. Due to its good performance, speed and ease of use, this test should be used as a first-line test in HIV-infected patients and when multidrug-resistant TB (MDR-TB) is suspected in both adults and children. The sensitivity of the test to detect resistance to rifampicin (RIF) compared to that of the conventional culture-based antibiogram is 97.6%. The negative predictive value of the test was high, so strains that were not resistant to rifampicin can be considered as true susceptible strains. [24] The performance of this test in the diagnosis of lymph node tuberculosis has been demonstrated by various authors. In addition, it allows for early and appropriate management of tuberculosis by allowing rapid diagnosis and early detection of cases of rifampicin resistance. [23.24.25] WHO recommended lymph node aspiration for the diagnosis of tuberculosis in endemic countries with limited resources. [26]
According to the literature, fine needle aspiration is an inexpensive, rapid and minimally invasive technique that has been proven to diagnose tuberculous adenitis with a sensitivity equal to 88% and a specificity equal to 96%. [27.28] In our series, no patient has benefited from it.
However, it requires the presence of a trained cytologist and may delay the diagnosis of associated neoplastic pathologies (lymphoma, papillary thyroid cancer, etc.). [7]. In addition, several studies agreed on the preponderant role of cervicotomy in the diagnosis of lymph node tuberculosis, with a much greater sensitivity than that of cytology, which can reach 90 to 100% in clinically highly suspect cases. [26.27] All of these data could explain the use of cervicotomy and not needle aspiration to confirm the diagnosis in our series.
After confirmation of the diagnosis; The role of surgery in the management of cervical lymph node tuberculosis remains a subject of debate, as well as the type of surgery performed. Most authors used surgery initially for both diagnostic confirmation and treatment. In our series, all our patients were candidates for an exploratory cervicotomy, 100% of the cases.
This rate of recourse to surgery is comparable to that of the study by N. Benmansour at the University Hospital of Fez. In fact, a slightly smaller proportion described in R. Mani's series of 246 patients, 98% of whom were operated on: 47% underwent an adenectomy, 47% underwent a cellulo-lymphadenectomy and 4
In the Saharan region, smoking; consumption of unpasteurized milk; HIV remain among the main risk factors, hence the interest in spreading awareness and prevention means; As for the treatment of cervical lymph node tuberculosis, it remains above all medical. However, surgery has a double interest; diagnosis and therapy. The quicker and more complete the surgical procedure, the better the results and the lower the risk of resistance or recurrence.
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