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TUBERCULAR SUPRATROCHLEAR LYMPHADENITIS
P Madhok*, Vijai kumar**
*Hon. Surgeon, Arogya Nidhi Hospita, Mumbai 49. **Medical Director and Physician, Hinduja Clinic, Mumbai 16.
It is tempting to suggest that the gland may have been infected from a secondary source following an ulcer having developed. A rim of normal glandular tissue may point to it, though a haematogenous spread is not excluded. Once again the lack of support from ESR is highlighted. We agree with Aird, that FNAC is not helpful for diagnosis of tubercle in children. Probably the glands are small and caseous material too thick to come in a fine needle.INTRODUCTION
The supratrochlear lymph nodes lie in the superficial fascia above the medial epicondyle of the humerus, along the basilic vein. They drain the medial three fingers and the inner side of the palm.[1] The efferents drain in the axilla. Being wayside station, their involvement in disease is rare, though the older text books of medicine have referred to their palpability in secondary syphilis (shotty glands) tuberculous involvement has not been reported in the past twenty years. We draw attention to it in this case report.
CASE REPORT
NB, a male child of 10 years, presented with a lump with lt. lower arm of 2 months duration. It had waxed and waned in size and consistency, and the patient had had two bouts of fever during this period, which were relieved with broad spectrum antibiotics. O/E there was a soft lump in the lt. supra trochlear region. Mobile with no punctum and no lesion in the drainage area, no gland palpable elsewhere. General examination unremarkable. The child had received BCG in infancy. Nothing abnormal in previous, personal and family history. X-ray chest was normal, Hb - 12 gm, WBC 7000, ESR 04, Mantoux test Gr I positive, VDRL - negative FNAC (fine needle aspiration cytology) - non contributory.
It was decided to do excisional biopsy.
By the time patient came for surgery (a month later) an ulcer had appeared over the lump. The ulcer was stellate, with undermined margin, pale coloured flow and had serous discharge. The lump was still palpable underneath. The ulcer and lump were excised together. Wound healed by primary intention.
HISTOLOGY
Foci of haemorrhage and caseous necrosis, rimmed by epitheloid histiocytes, Langhans giant cells and residual lymphoid tissue - Diagnosis : tubercular lymphadenitis.
DISCUSSION
Supratrochlear lymph nodes are rare site of tuberculous involvement. Being superficial nodes the infection is expected from drainage area. FNAC did not help for diagnosis in our case.[2] Rarely it may be lympho-lymphatic or haematogenous. There was no evidence of such infection, though haematogenous spread from a microscopic focus can never be excluded. Could there be a secondary contamination of an existing wound by tubercle bacilli? Yeltin has drawn attention to the existence of some 10-15 types of mycobacteria that bahave like tubercle.[3] The group is called Mycobacteria avium intracellular scofulareum (MAIS). They are more prone to infect lymph glands, particularly in the neck. They can also be secondary invaders. This group responds better to surgical extirpation rather than conventional anti-tubercular treatment. In our case we did not grow anything from cultures. Also our patient received the classical three drugs treatment (rifampicin, isoniazid and ethambutol) for four months, following surgery. A recent follow up two years post-operation showed him to be disease free.
REFERENCES
1. Duplessis DJ. Synopsis of surgical anatomy, John Wright and Sons, 11th edition. 1975; 339.
2. Aird. New companion in surgical studies, Burnand and Y Young, Churchill Livingstone. 141.
3. Yeltin, Libbman. Ann of Thor Surg 1985; 39 : 266.
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