497 - TUBERCULOUS LYMPHADENITIS: A CASE REPORT

Abstract

Tuberculous lymphadenitis is the infection of lymph nodes by Mycobacterium tuberculosis. In the USA, about 8.5% of
the cases of tuberculosis (TB) were characterized by lymphadenitis. The peak occurs between 30 and 40 years of age, primarily in women. Extrapulmonary TB is usually diagnosed in immunocompromised patients. The diagnosis is given by
positivity in the AFB (Alcohol-Acid Resistant Bacillus) in Ziehl-Neelsen staining by sample collected by fine-needle puncture or lymph node excision. Cyto and histological analysis demonstrate epithelial cells, caseous necrosis, and necrotic
cells. Such findings, added to the presence of langerhan’s giant cells, favor the diagnosis of TB even in AFB and/or negative cultures. Mantoux test is usually positive. Culture is the definitive diagnosis. Surgical excision should be reserved for
diagnostic in HIV-seronegative patients. The picture involves progressive and painless growth of the lymph node chain,
which may reach 8–10 cm. One-sidedness occurs in most cases. Peripheral lymphadenopathy is common among breast
pathologies. The case is unusual due to the suspicion of axillary lymphadenopathy being of neoplastic origin from compatible histopathological and immunohistochemical analysis of a core biopsy. However, after the excision of lymph node
clusters, histopathology showed the absence of tumor and metastatic cells. The analysis of slides with palisaded epithelioid granulomas and caseous necrosis, however, is consistent with TB lymphadenopathy. However, some points made
such a verdict difficult such as negative fungal and alcohol-acid-resistant bacilli (AFB) research, as well as the presence
of lymphadenopathy in the contra lateral armpit and inguinal chains, the absence of cervical lymph node enlargement
and any other suggestive symptoms of associated extra-pulmonary tuberculosis. The other possibilities include non-TB
mycobacteria, Bartonella sp, fungi (Histoplasma) and parasites (Toxoplasma gondii), lymphomas, sarcomas, metastatic
carcinomas, sarcoidosis, cat-scratch disease, and congenital lymphatic malformations. Treatment should be performed
after the confirmation of diagnosis or when susceptibility to antimicrobials is suspected (empirical treatment). In the
first 2 months of the treatment, Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol were used; followed by 4 months
of Isoniazid and Rifampicin. The guidelines recommend surgical excision only in unusual situations, such as therapeutic
failure. Ulceration, fistulas, and abscesses are complications. A 26-year-old female, nursing mother, breastfeeding only
through the left breast due to a history of clefts in the right breast and with a family history of breast cancer, was referred
to the breast service due to the appearance of painless nodules in her right armpit with progressive growth. Previously, she
had been treated with Amoxicillin and Azithromycin, with no change in her condition. On physical examination, a lymph
node aggregate was found in the right axilla. She underwent ultrasound and mammography examinations, which showed
lymph nodes, measuring 2.9×1.3, 2×1.4, and 1.3×0.8 cm in the right armpit, compatible with BI-RADS IVc classification.
It was decided to suppress lactation with Cabergoline and proceed with core biopsy, which showed fibrofatty tissue with
chronic inflammation and epithelioid granuloma in the anatomopathological examination, and immunohistochemistry
showed the markers CKM (AE1/AE3/PCK26), GATA-3 (L50-823), and Mamoglobin A (304-1A5) all negative, compatible
with metastasis of primary breast cancer. After discussion, it was decided to proceed with the removal of the fused lymph
nodes at level I of the right axilla. The histopathological diagnosis showed epithelioid and palisade granulomas with caseous necrosis in the lymph nodes, with negative BAAR research. Also, laboratory examinations for syphilis, HIV, HCV, and
HBV were all negative and a clean chest x-ray. This patient will start treatment for TB.