Dental Extraction-Induced Flare-Up of Occult Cervical Tuberculous Lymphadenitis: Cytological Diagnosis of a Silent Tuberculous Node

Abstract

Introduction: Tubercular lymphadenitis is the commonest type of extrapulmonary tuberculosis (EPTB) which commonly involves the cervical lymph nodes. EPTB can present insidiously, with no specific systemic symptoms, which can pose significant clinical challenges. However, pulmonary tuberculosis may have clear systemic signs and symptoms, while EPTB may be more insidious with no specific systemic signs or symptoms, thus posing a significant clinical challenge for the clinician. Patients complain of painless, progressive cervical lymphadenopathy, sometimes accompanied by fever, night sweats, and weight loss. Fine-needle aspiration cytology (FNAC), molecular assays, such as GeneXpert and histopathological evaluation, are used for diagnosis. In such cases, when the clinical case is associated with local dental/oral factors, the differentiation from the reactive and acute bacterial lymphadenitis is especially difficult and requires a multi-disciplinary diagnostic approach. Treatment is based on the standard anti-tubercular therapy (ATT). Case-Summary: A 23-year-old female who had a 2-year history of a painless swelling in the left cervical region which became painful after molar extraction on the left side. No history of weight loss decreased appetite or systemic symptoms. On examination it was found to be a soft non-tender swelling (0.5 x 1 cm) with no overlying skin changes and immobile. On high-resolution ultrasonography (HRUSG), multiple hypoechoic lymph nodes with displaced hila were seen, indicative of an infectious etiology, probably tubercular. The diagnosis of tubercular lymphadenitis was supported by the diagnosis obtained from FNA of the lesion which showed granulomatous inflammation with epithelioid cells with mature lymphocytes. Discussion: The diagnosis is difficult because of the range of clinical manifestations of tubercular lymphadenitis. The use of FNA with imaging is a key factor in early diagnosis. Early treatment of ATT results in successful treatment and can avoid the development of complications like an abscess or sinus tract. Conclusion: To minimise morbidity, it is important to recognise TL early and properly manage it. FNAC and HRUSG help in making differential diagnosis for a better outcome, thus allowing ATT to be given appropriately.