PROBLEMS OF DIAGNOSIS AND THERAPY OF TUBE RCULOUS LYMPH-NODES IN HIV-NEGATIVE PATIENTS

Tuberculosis is the world's foremost cause of death from a single infe ctious agent in adults. During the past decade the nature and magnitud e of the problem of tuberculosis have dramatically changed. Much of wh at physicians have learned about this disease is no longer true and tu berculosis has become a new entity. Migration from developing areas wi th a high prevalence of tuberculosis to industrialized countries, and the problem of HIV infection, have introduced new components to the ep idemiology. We report three cases of young immigrants with lymph node tuberculosis. One patient was successfully treated with the usual 9-mo nth-regimen. The other 2 patients, however, developed new lymph nodes or enlargement of existing nodes during treatment. They underwent furt her examinations, including surgical biopsies, because of diagnostic u ncertainty (tuberculosis, superinfection or lymphoma). Finally the 2 p atients were successfully treated with antituberculous agents for 12 a nd 15 months. These cases prompted a review of the literature and a re evaluation of the management of lymph node tuberculosis, including the value of surgical biopsy in the diagnosis of tuberculous lymphadeniti s. We conclude that selective surgical biopsies should be recommended for differential diagnosis of tuberculous lymphadenitis. Histological examination (caseating epitheloid cell granulomas and giant cell forma tion) and microbiological examination (Ziehl-Neelsen staining and cult ure of native material) should be performed. Newer methods, such as am plification and detection of mycobacterial DNA, are rapid and sensitiv e tests helpful for diagnosis. Lymph nodes may increase in size and ne w nodes may appear both during and after chemotherapy, without indicat ing a failure of treatment or relapse. The usual treatment is a 9-mont h-regimen with rifamipicin, isoniazid, pyrazinamid and ethambutol. Pro longed or modified regimens are, however, necessary in some individual s.