QJM Advance Access originally published online on November 24, 2007
QJM 2007 100(12):800-801; doi:10.1093/qjmed/hcm090
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Tonsillar and lymph node tuberculosis revealing asymptomatic pulmonary tuberculosis
Sir,Tonsillar tuberculosis is a rare presentation of extrapulmonary tuberculosis. Although tuberculosis of the tonsils is nowadays an uncommon finding, tonsillar granulomas are occasionally seen by histopathologists, and can sometimes contain tuberculous organisms. Occasionally, tonsillar tuberculosis may precede the diagnosis of pulmonary tuberculosis.1
We present the case of a 40-year-old patient admitted for evaluation of hoarseness and difficulty in swallowing, firstly diagnosed as recurrent angina. He had also had chronic bilateral cervical lymphadenopathy for the last three years. All preceding investigations were normal.
Clinical examination was normal, but head and neck examination revealed enlarged ulcerated palatine tonsils and laryngeal oedema. Tonsillectomy and microlaryngoscopy were performed, and the histology revealed granulomas without caseous necrosis. Lung X-ray showed some bilateral non-specific mediastinal lesions. Angiotensin convertase was normal.
Despite the normality of these standard assessments, thoracic tomodensitometry and bronchial fibroscopy with bronchopulmonary washing were done, and apical and mediastinal pulmonary lesions were observed. Pathological findings included caseous granuloma and positive culture for acid-fast bacilli (Mycobacterium tuberculosis), permitting the diagnosis of pulmonary tuberculosis with tonsillar involvement. Moreover, the presence of acid-fast bacilli in the bronchial lavage suggested the diagnosis of a possibly reactivated pulmonary tuberculosis. Anti-tuberculous therapy resulted in rapid improvement of the pulmonary lesions and resolution of the pseudo-anginal symptoms. Cervical lymphadenopathy progressively regressed.
Tuberculosis is occasionally found in the head and neck, where it generally presents as tonsillitis, laryngitis, or pharyngitis.2,3 In a retrospective series of 22 tonsillar granulomas, tuberculosis was diagnosed only in three cases (14%).4 Nowadays, this localization is thought to appear mostly in immunodeficient patients, as with the co-infection with tuberculosis in the upper respiratory/digestive tract and human immunodeficiency virus recently described.5 The presenting symptoms and abnormal tonsillar findings of tonsillar tuberculosis are similar to those of malignant tumours, and hence it is sometimes difficult to differentiate the two pathologies. Sporadically, tonsillar tuberculosis could represent the first manifestation of pulmonary tuberculosis.1 Chronic lymphadenopathy could also occasionally be the inaugural symptom of tuberculosis, either isolated, or in association with other clinical manifestations.6 In a series of 16 cases of chronic lymphadenopathy disclosing tuberculosis, other associated symptoms were observed in 12 patients (75%).6
In our patient, who was immunocompetent, histopathological and bacteriological lung investigations established a diagnosis of tonsillar and lymph node tuberculosis associated with asymptomatic pulmonary localization. This is further evidence that tonsillar tuberculosis and/or chronic lymphadenopathy may represent the first manifestation of tuberculosis. The possibility of tonsillar tuberculosis should be considered when unexplained enlarged tonsils are observed, and should be remembered for the differential diagnosis of atypical recurrent angina, even in immunocompetent patients.
Department of Internal Medicine
Rouen University Hospital
Rouen
France
email: cristina.belizna{at}wanadoo.fr
References
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2. Yamamoto K, Iwata F, Nakamura A, Iwashima Y, Miyaki T, Yamada H, Kurachi M, Sato Y, Tsukada K, Takeuchi T, Joh T, Yokoyama Y, Itoh M. Tonsillar tuberculosis associated with pulmonary and laryngeal foci. Intern Med (2002) 41:664–6.[Web of Science][Medline]
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4. Kardon DE, Thompson LD. A clinicopathologic series of 22 cases of tonsillar granulomas. Laryngoscope (2000) 110:476–81.[CrossRef][Web of Science][Medline]
5. Srirompotong S, Yimtae K, Srirompotong S. Tuberculosis in the upper aerodigestive tract and human immunodeficiency virus coinfections. J Otolaryngol (2003) 32:230–3.[CrossRef][Web of Science][Medline]
6. Chetchotisakd P, Mootsikapun P, Anunnatsiri S, Jirarattanapochai K, Choonhakarn C, Chaiprasert A, Ubol PN, Wheat LJ, Davis TE. Disseminated infection due to rapidly growing mycobacteria in immunocompetent hosts presenting with chronic lymphadenopathy: a previously unrecognized clinical entity. Clin Infect Dis (2000) 30:29–34.[CrossRef][Web of Science][Medline]
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