Tuberculous granuloma and cervical lymphadenopathy in an immunocompetent patient: a case report
Keywords:Tuberculous granuloma, Pulmonary TB, Cervical lymphadenopathy
Tuberculosis (TB) is one of the top 10 infectious diseases causing mortality worldwide. In 2019, approximately 10 million people were diagnosed with TB, with 5.6 million men, 3.2 million women, and 1.2 million children. One of the hallmarks of the course of TB is tuberculous granuloma. In this study, we reported a case of TB granuloma and further workup to exclude other etiologies. A 52-year-old man presented with a complaint of a lump on his left neck. There was a history of prolonged productive cough, weight loss, and shortness of breath. Chest radiograph and FNAB of the lump suggested pulmonary TB while the rapid molecular test was negative. The patient was also suspected of malignancy; but the trans-thoracal biopsy did not reveal any malignant cells. The patient was eventually diagnosed with granuloma due to primary TB with cervical lymphadenopathy. Tuberculous granuloma is one of the most common pulmonary granulomas and a hallmark of the course of TB. It is characterized by the immune system forming an environment to control the spread of the infection. In cases of tuberculous granuloma with negative rapid molecular test, further investigations should be conducted to find evidence of TB infection. Activated TB granuloma can spread to the surrounding tissues or organs. A negative rapid molecular test result does not necessarily exclude TB in endemic regions; thus, further investigations such as CT scans or histopathological examination are required to find features of TB infection.
WHO. Global Tuberculosis Report 2020. Available at: https://apps.who.int/iris/bitstream/handle/10665/336069/9789240013131-eng.pdf. Accessed on 15 Feb, 2021.
Narasimhan P, Wood J, MacIntyre C, Mathai D. Risk Factors for Tuberculosis. Pulmonary Med. 2013;1-11.
Kemenkes. Peraturan Menteri Kesehatan Republik Indonesia Nomor 67 Tahun 2016 tentang Penanggulan Tuberkulosis. Available at: http://hukor.kemkes.go.id/uploads/produk_hukum/PMK_No._67_ttg_Penanggulangan_Tuberkolosis_.pdf. Accessed on 15 Feb, 2021.
Tajima S, Koda K. Granulomatous inflammation of pulmonary squamous cell carcinoma: a rare phenomenon. Int J Clin Exp Pathol. 2015;8(6):7547-52.
Ohshimo S, Guzman J, Costabel U, Bonella F. Differential diagnosis of granulomatous lung disease: clues and pitfalls: Number 4 in the Series "Pathology for the clinician" Edited by Peter Dorfmüller and Alberto Cavazza. Eur Respir Rev. 2017;26(145):170012.
Rosen Y. Pathology of Granulomatous Pulmonary Diseases. Arch Pathol Lab Med. 2022;146(2):233-51.
Silva Miranda M, Breiman A, Allain S, Deknuydt F, Altare F. The tuberculous granuloma: an unsuccessful host defence mechanism providing a safety shelter for the bacteria? Clin Dev Immunol. 2012;2012:139127.
Rao M, Ippolito G, Mfinanga S. Latent TB Infection (LTBI) - Mycobacterium tuberculosis pathogenesis and the dynamics of the granuloma battleground. Int J Infect Dis. 2019;80S:S58-61.
Kiran D, Podell BK, Chambers M, Basaraba RJ. Host-directed therapy targeting the Mycobacterium tuberculosis granuloma: a review. Semin Immunopathol. 2016;38(2):167-83.
Heemskerk D, Caws M, Marais B. Tuberculosis in Adults and Children. London: Springer; 2015. Chapter 3, Clinical Manifestations. Available at: https://www.ncbi.nlm.nih.gov/books/NBK344404/. Accessed on 15 Feb, 2021.
World Health Organization. Molecular assays intended as initial tests for the diagnosis of pulmonary and extrapulmonary TB and rifampicin resistance in adults and children: rapid communication. World Health Organization. 2020. Available at: https://apps.who.int/iris/handle/10665/330395. License: CC BY-NC-SA 3.0 IGO. Accessed on 15 Feb, 2021.
Li S, Liu B, Peng M, Chen M, Yin W, Tang H et al. Diagnostic accuracy of Xpert MTB/RIF for tuberculosis detection in different regions with different endemic burden: A systematic review and meta-analysis. PLOS ONE. 2017;12(7):e0180725.
Noviyani A, Nopsopon T, Pongpirul K. Variation of tuberculosis prevalence across diagnostic approaches and geographical areas of Indonesia. PLOS ONE. 2021;16(10):e0258809.
Lee H, Kim J, Kim Y. Clinical and CT characteristics of Xpert MTB/RIF-negative pulmonary tuberculosis. PLOS ONE. 2021;16(5):e0250616.