Tuberculous lesions of peripheral lymph nodes

According to well-known literary data, extrapulmonary forms of tuberculosis in children are usually a manifestation of lymphogenous or hematogenous dissemination. For a severe disseminated process to occur in childhood, it is necessary to create certain conditions that weaken the child's body. This is primarily the massiveness of the infection against the background of poor-quality BCG vaccination or its absence, unfavorable socio-economic conditions and various concomitant diseases. The most typical for childhood are tuberculosis of the peripheral lymph nodes, meningitis and damage to the skeletal system.

Peripheral lymph node involvement

Peripheral lymph node lesions are most often caused by bovine mycobacteria. This should be taken into account when making a diagnosis in certain regions of Russia, especially in rural areas. Many authors associate the development of a specific process in the lymph nodes with the lymphotropism of MBT and the barrier function of the lymph nodes, rich in elements of the mononuclear phagocyte system, in which initial reactive (and then specific) changes most often occur. There are several points of view on the development of the disease. Through the mucous membranes of the oral cavity, eyes, skin, by contact or alimentary route, MBT penetrates the body with subsequent involvement in the inflammatory process of lymph nodes of various localizations - cervical, axillary, submandibular, etc.

According to our clinic, in 83.3% of cases, the lymph nodes of the cervical group were affected, in 11.2% - the axillary. Only in 5.5% of cases, the process was localized in the inguinal lymph nodes.

This confirms the lymphohematogenous route of infection spread from fresh foci of inflammation or reactivated old foci in the lungs or intrathoracic lymph nodes.

Based on clinical manifestations and the nature of tissue reactions, there are three main forms of tuberculosis of the peripheral lymph nodes:

• infiltrative - dense-elastic consistency, enlarged lymph nodes with signs of periadenitis;
• caseous (with or without fistulas) - often the involvement of several groups of lymph nodes in the inflammation is noted;
• indurative (fibrous or fibrous-caseous - as a result of the previous two forms).

Inflammation develops mainly against the background of intrathoracic tuberculosis, which together determines the severity of clinical symptoms and the degree of intoxication syndrome. Isolated forms of the disease are recorded in isolated cases. Low, and in some cases negative, sensitivity to tuberculin is noteworthy. The first symptoms of the disease are swelling, an increase in the size of any one group of lymph nodes (from small to 1.5-2 cm in diameter). Less often, two or three groups of lymph nodes are involved at the same time. Characteristic symptoms are painlessness, mobility, the absence of external signs of inflammation, and periadenitis. In the absence of specific treatment, new groups of lymph nodes are involved in the process, forming entire conglomerates. The progression of the process leads to the appearance of symptoms of inflammation - hyperemia, swelling, pain. Against this background, a fluctuation occurs in the center of the conglomerate, followed by the formation of a fistula, which is extremely unfavorable both for the child himself and for his environment in an epidemiological sense.

When making a diagnosis, it is important to assess the epidemiological situation, the characteristics of the clinical manifestations of the disease, decreased sensitivity to tuberculin, low titer of specific antibodies (only every third child has positive ELISA results, which is typical for this inflammation). In the peripheral blood, ESR is moderately increased, lymphocytosis, monocytosis. moderate leukocytosis.

If the disease is suspected, it is necessary to carefully collect anamnesis, taking into account phthisiopediatric aspects:

• premorbid background (frequency of colds, history of childhood infections - mumps, scarlet fever, measles, chickenpox, smallpox);
• contact with pets, especially cats;
• injuries, bruises, carious teeth;
• dynamics of sensitivity to tuberculin with the establishment of the fact and timing of infection with MBT;
• contact with a patient with tuberculosis (family, industrial) and its duration, implementation of chemoprophylaxis according to contact (its regimen, number of drugs).

To clarify the activity and nature of inflammation, it is advisable to use biochemical and immunological methods, including the ELISA method and clinical blood analysis. The lymph node tissue is examined for MVT (puncture biopsy or surgical material). The final stage of diagnostics of tuberculosis of the peripheral lymph nodes is the detection of MVT by bacterioscopy, sowing of the contents of the fistula, postoperative material, and biopsy material.

Differential diagnostics

Non-specific lymphadenitis. The disease develops against the background of exacerbation of chronic pathology of ENT organs or a regionally located infected wound, furuncle, etc. It is characterized by a pronounced clinical picture with an increase in body temperature, changes in the general blood test (increased ESR, leukocytosis, shift in the leukocyte formula to the left). Locally in the area of the lymph node - hyperemia of the skin, soreness, edema of the surrounding tissues and other classic signs of non-specific inflammation. Against the background of non-specific antibacterial therapy, pronounced positive dynamics are noted within 5-7 days, which allows excluding the tuberculosis process.

Felinosis is a benign lymphoreticulosis (cat scratch disease).

The causative agent of the disease is chlamydia, the carrier is cats. Infection occurs when the skin and mucous membranes are damaged. The incubation period is from 1 to 3 weeks. The disease often develops acutely, with a sharp rise in body temperature, an increase in regional lymph nodes, a reaction from the liver, spleen, and peripheral blood. When prescribing tetracycline antibiotics, rapid positive dynamics are noted.

Developmental defects - median and lateral cysts of the neck (occur much less frequently than BCG lymphadenitis and felinosis). Median cysts exist for a long time in the form of a soft elastic formation located above the thyroid cartilage near the hyoid bone. The size of the formation is from 1 to 4 cm, the skin under them is unchanged, mobile. The danger lies in the infection of the cyst. In this case, it quickly increases in size, is painful. A fistula is formed. Lateral cysts are much less common, they are localized between the larynx and the anterior edge of the sternocleidomastoid muscle. Puncture with subsequent examination of the material is of great importance in diagnostics - fluid with a large number of cells of the cylindrical or ciliated epithelium.

Toxoplasmosis. The disease is widespread among wild and domestic animals, birds. The causative agent is an intracellular parasite, classified as a protozoan. Peripheral lymph nodes are affected, most often the cervical, axillary or inguinal groups. The disease can be acute or latent. Unlike tuberculous lymphadenitis, toxoplasmosis does not cause abscess formation. The central nervous system, eyes, skin, lungs, and myocardium can be involved in the inflammatory process. There are observations of combined lesions. Diagnostics of toxoplasmosis is complex, taking into account clinical, epidemiological and laboratory data: detection of antibodies in the blood serum in a reaction with Feldman's dye, in RPC, RIGA, RIF, an intradermal test with toxoplasmin, as well as studies that allow detection of the pathogen in a puncture or biopsy of the lymph node using direct microscopy or a bioassay method when infecting experimental animals.