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Primary tuberculosis of the tonsil
International Journal of Pediatric Otorhinolaryngology Extra (2006) 1, 150—153
www.elsevier.com/locate/ijporl
CASE REPORT
Primary tuberculosis of the tonsil Rogelio Chavolla b, German Fajardo Dolci a, ´s Herna ´ndez b, Antonio Ysunza a,*, Jorge Francisco Moise ´s Solorio a Beatriz Cuevas b, Minerva Lazos b, Jesu a b
´xico D.F., Mexico Department of Otolaryngology, Hospital Gea Gonzalez, 4800 Calzada Tlalpan, Me ´xico D.F., Mexico Department of Otolaryngology, Hospital General de Mexico, Me
Received 25 February 2006; received in revised form 28 March 2006; accepted 30 March 2006
KEYWORDS Tonsil; Tuberculosis; Upper respiratory tract; Infection
Summary Tuberculosis (Tb) has been called the great simulator, its vast number of clinical manifestations often makes differential diagnosis a difficult task. Tb is an endemic illness in Mexico. This disease is caused by Mycobacterium tuberculosis in most of the cases. These pathogens are acid-alcohol resistant bacteria that produce chronic lesions. The most frequent lesion is the granuloma. The bacilli can affect any system or organ producing non-specific clinical features and manifestations including fatigue, weight loss, fever, and chronic cough. The initial infection is located in the lungs in 98% of the cases [C.R. Olvera, G.L.E. Pe ´rez, C.J. Villalba, Drug resistant tuberculosis in Mexico. The experience of the National Institute of Respiratory Diseases of Mexico, Int. J. Tuberc. Lung Dis. (1997) S-52; C.R. Olvera, G.L.E. Pe ´rez, Resistencia secundaria en tuberculosis, Rev. Inst. Nal. Enf. Resp. Mex. 6 (1993) 185—190]. Dissemination of the bacilli throughout the body with secondary affection of different organs causes military Tb. This variant of the Tb infection causes a higher mortality rate. The number of inoculated bacilli mostly determines evolution of this illness. Other factors are its multiplication, and the resistance and sensibility of the host [O. Celik, S. Yalcin, A. Hancer, P. Celik, R. Ozercan, Tuberculous tonsillitis, J. Otolaryngol. 24 (5) (1995) 307—309]. There have been reports of secondary Tb affecting the Waldeyer’s ring. Here we present a case of a 16-year-old male patient with primary Tb of the tonsil. # 2006 Elsevier Ireland Ltd. All rights reserved.
1. Introduction The epidemiology of tuberculosis has recently changed with an increasing incidence of unusual presentations. The disease is more common among populations in which Tb is considered endemic, such * Corresponding author. E-mail address: [email protected] (A. Ysunza).
as Southeast Asia and Africa. It has also been reported that Tb is frequent among Native American Indians [4,5]. In Mexico, some regions are considered endemic [1,2]. Approximately 95% of infections in adults are caused by Mycobacterium tuberculosis, atypical forms cause the rest of the cases. In children, the situation is the opposite, the cause being atypical mycobacteria in 92% of the cases and M. tubercu-
1871-4048/$ — see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pedex.2006.03.006
Primary tuberculosis of the tonsil
151
losis in the rest of the cases [6,7]. Despite the contact of pulmonary secretions and the mucosal membranes of the upper respiratory tract with a high bacillary load, Tb of the head and neck (excluding laryngeal forms) is exceptional and constitute only 2—6% of the cases of Tb outside the lungs, and 0.1—1% of all forms of Tb [5]. Although involvement of the oral cavity is usually secondary to pulmonary tuberculosis, evidence of pulmonary involvement is present in less than 20% of the cases of Tb of the pharynx. A case of tuberculous tonsillitis, which is considered a rare clinical entity, is presented in this report.
2. Case report A 16-year-old male patient, who was born in Mexico City, was referred to the ENT department of a primary health care center in the surroundings of Mexico City. The patient reported that he has always lived in Mexico City. He also reported that he had not traveled recently. The patient referred that 6 months ago, he began to notice a sensation of obstruction on the pharynx. Further on, the patient showed mild swallowing difficulty, fluctuating hoarseness, malaise, cephalea, afternoon fevers, chills, and night sweats. He reported a 53-lb weight loss in the last 2 months. A few days later he presented cough and green sputum. A chronic hypertrophic tonsillitis was diagnosed. Treatment was started with several antibiotics without significant improvement. At that point, the patient was referred to the Otolaryngology and Head and Neck Surgery Department of the Hospital General de Mexico. On the initial examination he looked severely ill with pale skin. On the oropharynx he showed hypertrophic exudative (yellowish exudates), and hyperemic tonsils. Nose and ears examinations were unremarkable. On examination of the neck, a hard and painless bilateral cervical adenopathy was noticed. It was approximately 1 cm in diameter. Pulmonary examination was unremarkable. Moreover, a chest X-ray was found normal. A neck CT scan was performed. The study reported bilateral nodal illness of probable limphoproliferative origin. This finding led to a probable diagnosis of non-Hodgkin lymphoma of the Waldeyer’s ring. With this diagnosis, a tonsillectomy was performed for obtaining a histopathologic study. The postoperative study reported epitheloid cells, granulomas, multinucleated giant cells, plasmatic cells, and areas of necrosis. Ziehl—Nielsen staining allowed the identification of acid-alcohol resistant bacilli in the histiocytes and necrotic
Fig. 1 Tonsil tissue with a huge granuloma surrounded by Langhans’ giant multinucleated cells. Caseum necrosis can also be identified inside the granuloma. H.E. 50.
areas. Tuberculous tonsillitis was the final diagnosis (see Figs. 1 and 2). Microscopic examination of sputum and urine reported absence of acid-alcohol resistant bacilli. Renal function test were reported within normal limits. Blood and urine cultures were negative. The rest of the laboratory tests were unremarkable. With these results, 1 week after the surgery, the patient was started with a triple scheme, including Rifampin, Pirazinamid and Isoniazid for 2 months. He was then treated with Rifampin and Isoniazid for another 4 months. The patient was discharged from the hospital 2 days after surgery. He was followed weekly as an outpatient for one month. Furthermore, the patient was followed with monthly revisions for a period of 1 year. During this follow-up period, the patient remained asymptomatic. He was then advised to
Fig. 2 Tonsil tissue with lymphoid follicles and peripheral granulomas. H.E. 100.
152 return for a routine revision at the ENT department every 6 months.
3. Discussion Tb infection is usually asymptomatic due to rapidly developed immunity. Furthermore, there is a healing process which usually leaves no residual lesion. However, calcificated ganglia can be occasionally found in the lungs and in the tracheobronchial system. Approximately 95% of infected patients enter into a quiescent or latent phase. Further on, the patient is at constant risk of reactivation, especially patients with a compromised immune system, including patients with diabetes mellitus, patients undergoing transplantation protocols, and HIV infected patients, among others [8]. In 5% of the cases, the initial infection progresses to pulmonary Tb directly. Other patients progress to other types of Tb outside the lungs. The dissemination of the bacilli is made through the lymphatic or circulating systems [9]. After laryngeal location, tuberculous otitis media is the most frequent form of Tb in the head and neck. Tuberculosis of the middle ear should be suspected in cases of chronic otitis media refractory to conventional treatment [10]. Tb of the oral cavity and pharynx is rare. Most references in the literature are case reports. The most reported locations are: tongue, gum, and palate. As with laryngeal forms, pulmonary lesions are frequently reported. In a review 42 cases, Mignona et al. reported a third of their cases as primary forms. The oral mucosa is relatively resistant to bacilli invasion and only occurs in 0.05—0.1% of the cases of Tb. A disruption of local mucosa is usually necessary for the invasion to take place [6— 11]. In the early decades of life (children, adolescents and young adults), the manifestations of Tb are usually more severe. Thus, in these age groups, prognosis becomes poorer. Spread from host to host depends on several factors, including its virulence, exposure of bacilli to the sun and UV light, and the chance of droplet spread [12]. In the related scientific literature, the numbers of cases with a demonstrated Tb affection of the Waldeyer’s ring are scarce. In general, they are considered as secondary Tb with a primary pulmonary focus. At this stage, the reported clinical manifestations of the disease are tonsillar hypertrophy, and painful ulceration. Systemic signs of tuberculosis are usually not seen during this clinical period. If hematogenous dissemina-
R. Chavolla et al. tion occurs, the clinical manifestations can appear throughout the body. In these cases, the disease can easily mimic several other pathologies [3—13]. The diagnosis in the case presented herein was quite difficult since the initial presentation of Tb on the Waldeyer’s ring has been described as rare. The clinical and radiological features misled us to suspect the diagnosis of a lymphoproliferative illness, i.e. non-Hodgkin lymphoma. The diagnosis of an active Tb is usually accomplished by demonstrating the presence of acidalcohol resistant bacilli after specific staining of sputum or other body fluids. This demonstration justifies the initial phase of pharmacological treatment. It should be pointed out that traumatic ulceration, actinomicosis, syphilitic ulcers, Wegener’s granulomatosis, and carcinomas should be considered as differential diagnosis [14]. For a definitive diagnosis of tuberculous tonsillitis, excision of the enlarged tonsils is necessary for obtaining histopathologic confirmation [15].
References [1] C.R. Olvera, G.L.E. Pe ´rez, C.J. Villalba, Drug resistant tuberculosis in Mexico. The experience of the National Institute of Respiratory Diseases of Mexico, Int. J. Tuberc. Lung Dis. (1997) S-52. [2] C.R. Olvera, G.L.E. Pe ´rez, Resistencia secundaria en tuberculosis, Rev. Inst. Nal. Enf. Resp. Mex. 6 (1993) 185—190. [3] O. Celik, S. Yalcin, A. Hancer, P. Celik, R. Ozercan, Tuberculous tonsillitis, J. Otolaryngol. 24 (5) (1995) 307—309. [4] C. Ugar, S. Huseyin, V. Cetin, B. Tulay, A. Seyhan, T. Suat, Tuberculosis tonsillitis, Otolaryngol. Head Neck Surg. 126 (4) (2002). [5] S. Manolidis, S. Frenkiel, A. Yoskovitch, Mycobacterial infections of the head and neck, Otolaryngol. Head Neck Surg. 109 (1993) 427—433. [6] K.R. Cleary, J.G. Batsakis, Mycobacterial disease of the head and neck. Current perspective, Ann. Otol. Rhinol. Laryngol. 104 (1995) 830—833. [7] K. Konish, H. Yamane, H. Iguchi, Study of tuberculosis in the field of otorhinolaryngology in the past 10 years, Acta Otolaryngol. 538 (suppl.) (1998) 244—249. [8] C.T. Derk, R.J. DeHoratius, Tuberculous tonsillitis in a patient receiving etanercept treatment, Ann. Rheumatic Dis. 62 (2003) 372. [9] WHO, OMS Division of Communicable Diseases, Tuberculosis Unit, Guidelines for tuberculosis treatment in adults and children in National Tuberculosis Programmes, WHO, Geneva, 1991 (WHO/TUB/91.161). [10] B.P. Vareldzis, J. Grosset, I. De Kantor, J. Crofton, A. Laszlo, M. Felten, et al., Drug-resistant tuberculosis: laboratory issues, Tuber. Lung Dis. 75 (1994) 1—7. [11] C.R. Olvera, G.L.E. Pe ´rez, C.J. Villalba, Tuberculosis multirresistente en Me ´xico 1994—1997, Int. J. Tuberc. Lung Dis. 9 (S1) (1999) 119—120.
Primary tuberculosis of the tonsil [12] Sistema Nacional de Salud, Programa Nacional de Prevencio ´n y Control de la Tuberculosis, Registro y Seguimiento de Casos, 1996. [13] Secretarı´a de Salud, Manual de Normas y Procedimiento para la Prevencio ´n y Control de la Tuberculosis, Me ´xico, 1996.
153 [14] P.A. Selwyn, D. Hartel, V.A. Lewis, E.E. Schoenbaum, High risk of active tuberculosis in HIV infected drug users with cutaneous anergy, JAMA 262 (1992) 504—509. [15] R.E. Chaisson, G. Stotkin, Tuberculosis and human immunodeficiency virus, J. Infect. Dis. 159 (1989) 96—100.
www.elsevier.com/locate/ijporl
CASE REPORT
Primary tuberculosis of the tonsil Rogelio Chavolla b, German Fajardo Dolci a, ´s Herna ´ndez b, Antonio Ysunza a,*, Jorge Francisco Moise ´s Solorio a Beatriz Cuevas b, Minerva Lazos b, Jesu a b
´xico D.F., Mexico Department of Otolaryngology, Hospital Gea Gonzalez, 4800 Calzada Tlalpan, Me ´xico D.F., Mexico Department of Otolaryngology, Hospital General de Mexico, Me
Received 25 February 2006; received in revised form 28 March 2006; accepted 30 March 2006
KEYWORDS Tonsil; Tuberculosis; Upper respiratory tract; Infection
Summary Tuberculosis (Tb) has been called the great simulator, its vast number of clinical manifestations often makes differential diagnosis a difficult task. Tb is an endemic illness in Mexico. This disease is caused by Mycobacterium tuberculosis in most of the cases. These pathogens are acid-alcohol resistant bacteria that produce chronic lesions. The most frequent lesion is the granuloma. The bacilli can affect any system or organ producing non-specific clinical features and manifestations including fatigue, weight loss, fever, and chronic cough. The initial infection is located in the lungs in 98% of the cases [C.R. Olvera, G.L.E. Pe ´rez, C.J. Villalba, Drug resistant tuberculosis in Mexico. The experience of the National Institute of Respiratory Diseases of Mexico, Int. J. Tuberc. Lung Dis. (1997) S-52; C.R. Olvera, G.L.E. Pe ´rez, Resistencia secundaria en tuberculosis, Rev. Inst. Nal. Enf. Resp. Mex. 6 (1993) 185—190]. Dissemination of the bacilli throughout the body with secondary affection of different organs causes military Tb. This variant of the Tb infection causes a higher mortality rate. The number of inoculated bacilli mostly determines evolution of this illness. Other factors are its multiplication, and the resistance and sensibility of the host [O. Celik, S. Yalcin, A. Hancer, P. Celik, R. Ozercan, Tuberculous tonsillitis, J. Otolaryngol. 24 (5) (1995) 307—309]. There have been reports of secondary Tb affecting the Waldeyer’s ring. Here we present a case of a 16-year-old male patient with primary Tb of the tonsil. # 2006 Elsevier Ireland Ltd. All rights reserved.
1. Introduction The epidemiology of tuberculosis has recently changed with an increasing incidence of unusual presentations. The disease is more common among populations in which Tb is considered endemic, such * Corresponding author. E-mail address: [email protected] (A. Ysunza).
as Southeast Asia and Africa. It has also been reported that Tb is frequent among Native American Indians [4,5]. In Mexico, some regions are considered endemic [1,2]. Approximately 95% of infections in adults are caused by Mycobacterium tuberculosis, atypical forms cause the rest of the cases. In children, the situation is the opposite, the cause being atypical mycobacteria in 92% of the cases and M. tubercu-
1871-4048/$ — see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pedex.2006.03.006
Primary tuberculosis of the tonsil
151
losis in the rest of the cases [6,7]. Despite the contact of pulmonary secretions and the mucosal membranes of the upper respiratory tract with a high bacillary load, Tb of the head and neck (excluding laryngeal forms) is exceptional and constitute only 2—6% of the cases of Tb outside the lungs, and 0.1—1% of all forms of Tb [5]. Although involvement of the oral cavity is usually secondary to pulmonary tuberculosis, evidence of pulmonary involvement is present in less than 20% of the cases of Tb of the pharynx. A case of tuberculous tonsillitis, which is considered a rare clinical entity, is presented in this report.
2. Case report A 16-year-old male patient, who was born in Mexico City, was referred to the ENT department of a primary health care center in the surroundings of Mexico City. The patient reported that he has always lived in Mexico City. He also reported that he had not traveled recently. The patient referred that 6 months ago, he began to notice a sensation of obstruction on the pharynx. Further on, the patient showed mild swallowing difficulty, fluctuating hoarseness, malaise, cephalea, afternoon fevers, chills, and night sweats. He reported a 53-lb weight loss in the last 2 months. A few days later he presented cough and green sputum. A chronic hypertrophic tonsillitis was diagnosed. Treatment was started with several antibiotics without significant improvement. At that point, the patient was referred to the Otolaryngology and Head and Neck Surgery Department of the Hospital General de Mexico. On the initial examination he looked severely ill with pale skin. On the oropharynx he showed hypertrophic exudative (yellowish exudates), and hyperemic tonsils. Nose and ears examinations were unremarkable. On examination of the neck, a hard and painless bilateral cervical adenopathy was noticed. It was approximately 1 cm in diameter. Pulmonary examination was unremarkable. Moreover, a chest X-ray was found normal. A neck CT scan was performed. The study reported bilateral nodal illness of probable limphoproliferative origin. This finding led to a probable diagnosis of non-Hodgkin lymphoma of the Waldeyer’s ring. With this diagnosis, a tonsillectomy was performed for obtaining a histopathologic study. The postoperative study reported epitheloid cells, granulomas, multinucleated giant cells, plasmatic cells, and areas of necrosis. Ziehl—Nielsen staining allowed the identification of acid-alcohol resistant bacilli in the histiocytes and necrotic
Fig. 1 Tonsil tissue with a huge granuloma surrounded by Langhans’ giant multinucleated cells. Caseum necrosis can also be identified inside the granuloma. H.E. 50.
areas. Tuberculous tonsillitis was the final diagnosis (see Figs. 1 and 2). Microscopic examination of sputum and urine reported absence of acid-alcohol resistant bacilli. Renal function test were reported within normal limits. Blood and urine cultures were negative. The rest of the laboratory tests were unremarkable. With these results, 1 week after the surgery, the patient was started with a triple scheme, including Rifampin, Pirazinamid and Isoniazid for 2 months. He was then treated with Rifampin and Isoniazid for another 4 months. The patient was discharged from the hospital 2 days after surgery. He was followed weekly as an outpatient for one month. Furthermore, the patient was followed with monthly revisions for a period of 1 year. During this follow-up period, the patient remained asymptomatic. He was then advised to
Fig. 2 Tonsil tissue with lymphoid follicles and peripheral granulomas. H.E. 100.
152 return for a routine revision at the ENT department every 6 months.
3. Discussion Tb infection is usually asymptomatic due to rapidly developed immunity. Furthermore, there is a healing process which usually leaves no residual lesion. However, calcificated ganglia can be occasionally found in the lungs and in the tracheobronchial system. Approximately 95% of infected patients enter into a quiescent or latent phase. Further on, the patient is at constant risk of reactivation, especially patients with a compromised immune system, including patients with diabetes mellitus, patients undergoing transplantation protocols, and HIV infected patients, among others [8]. In 5% of the cases, the initial infection progresses to pulmonary Tb directly. Other patients progress to other types of Tb outside the lungs. The dissemination of the bacilli is made through the lymphatic or circulating systems [9]. After laryngeal location, tuberculous otitis media is the most frequent form of Tb in the head and neck. Tuberculosis of the middle ear should be suspected in cases of chronic otitis media refractory to conventional treatment [10]. Tb of the oral cavity and pharynx is rare. Most references in the literature are case reports. The most reported locations are: tongue, gum, and palate. As with laryngeal forms, pulmonary lesions are frequently reported. In a review 42 cases, Mignona et al. reported a third of their cases as primary forms. The oral mucosa is relatively resistant to bacilli invasion and only occurs in 0.05—0.1% of the cases of Tb. A disruption of local mucosa is usually necessary for the invasion to take place [6— 11]. In the early decades of life (children, adolescents and young adults), the manifestations of Tb are usually more severe. Thus, in these age groups, prognosis becomes poorer. Spread from host to host depends on several factors, including its virulence, exposure of bacilli to the sun and UV light, and the chance of droplet spread [12]. In the related scientific literature, the numbers of cases with a demonstrated Tb affection of the Waldeyer’s ring are scarce. In general, they are considered as secondary Tb with a primary pulmonary focus. At this stage, the reported clinical manifestations of the disease are tonsillar hypertrophy, and painful ulceration. Systemic signs of tuberculosis are usually not seen during this clinical period. If hematogenous dissemina-
R. Chavolla et al. tion occurs, the clinical manifestations can appear throughout the body. In these cases, the disease can easily mimic several other pathologies [3—13]. The diagnosis in the case presented herein was quite difficult since the initial presentation of Tb on the Waldeyer’s ring has been described as rare. The clinical and radiological features misled us to suspect the diagnosis of a lymphoproliferative illness, i.e. non-Hodgkin lymphoma. The diagnosis of an active Tb is usually accomplished by demonstrating the presence of acidalcohol resistant bacilli after specific staining of sputum or other body fluids. This demonstration justifies the initial phase of pharmacological treatment. It should be pointed out that traumatic ulceration, actinomicosis, syphilitic ulcers, Wegener’s granulomatosis, and carcinomas should be considered as differential diagnosis [14]. For a definitive diagnosis of tuberculous tonsillitis, excision of the enlarged tonsils is necessary for obtaining histopathologic confirmation [15].
References [1] C.R. Olvera, G.L.E. Pe ´rez, C.J. Villalba, Drug resistant tuberculosis in Mexico. The experience of the National Institute of Respiratory Diseases of Mexico, Int. J. Tuberc. Lung Dis. (1997) S-52. [2] C.R. Olvera, G.L.E. Pe ´rez, Resistencia secundaria en tuberculosis, Rev. Inst. Nal. Enf. Resp. Mex. 6 (1993) 185—190. [3] O. Celik, S. Yalcin, A. Hancer, P. Celik, R. Ozercan, Tuberculous tonsillitis, J. Otolaryngol. 24 (5) (1995) 307—309. [4] C. Ugar, S. Huseyin, V. Cetin, B. Tulay, A. Seyhan, T. Suat, Tuberculosis tonsillitis, Otolaryngol. Head Neck Surg. 126 (4) (2002). [5] S. Manolidis, S. Frenkiel, A. Yoskovitch, Mycobacterial infections of the head and neck, Otolaryngol. Head Neck Surg. 109 (1993) 427—433. [6] K.R. Cleary, J.G. Batsakis, Mycobacterial disease of the head and neck. Current perspective, Ann. Otol. Rhinol. Laryngol. 104 (1995) 830—833. [7] K. Konish, H. Yamane, H. Iguchi, Study of tuberculosis in the field of otorhinolaryngology in the past 10 years, Acta Otolaryngol. 538 (suppl.) (1998) 244—249. [8] C.T. Derk, R.J. DeHoratius, Tuberculous tonsillitis in a patient receiving etanercept treatment, Ann. Rheumatic Dis. 62 (2003) 372. [9] WHO, OMS Division of Communicable Diseases, Tuberculosis Unit, Guidelines for tuberculosis treatment in adults and children in National Tuberculosis Programmes, WHO, Geneva, 1991 (WHO/TUB/91.161). [10] B.P. Vareldzis, J. Grosset, I. De Kantor, J. Crofton, A. Laszlo, M. Felten, et al., Drug-resistant tuberculosis: laboratory issues, Tuber. Lung Dis. 75 (1994) 1—7. [11] C.R. Olvera, G.L.E. Pe ´rez, C.J. Villalba, Tuberculosis multirresistente en Me ´xico 1994—1997, Int. J. Tuberc. Lung Dis. 9 (S1) (1999) 119—120.
Primary tuberculosis of the tonsil [12] Sistema Nacional de Salud, Programa Nacional de Prevencio ´n y Control de la Tuberculosis, Registro y Seguimiento de Casos, 1996. [13] Secretarı´a de Salud, Manual de Normas y Procedimiento para la Prevencio ´n y Control de la Tuberculosis, Me ´xico, 1996.
153 [14] P.A. Selwyn, D. Hartel, V.A. Lewis, E.E. Schoenbaum, High risk of active tuberculosis in HIV infected drug users with cutaneous anergy, JAMA 262 (1992) 504—509. [15] R.E. Chaisson, G. Stotkin, Tuberculosis and human immunodeficiency virus, J. Infect. Dis. 159 (1989) 96—100.