Isolated tuberculous lymphadenitis presenting as bilateral buboes.

Inguinal and femoral buboes are defined as localized enlargement of lymph nodes in the groin that are painful, and may or may not be fluctuant. We report a case of 42-year-old female who presented with bilateral inguinal swelling of 6 months duration. After a complete evaluation, she was found to be a case of isolated inguinal tuberculous lymphadenitis. There was complete resolution with standard antituberculous therapy. Isolated inguinal tuberculous lymphadenitis though a rare entity in developed countries is not uncommon in developing nations. In this era of syndromic management of sexually transmitted diseases, which carries its own pros and cons, this case report emphasizes the need to look beyond the venereal causes and calls for thorough evaluation and management.

INTRODUCTION

Tuberculous lymphadenitis remains a common extrapulmonary manifestation of tuberculosis (TB). Tuberculous lymphadenitis most commonly involves cervical group of lymph nodes and involvement of inguinal group of lymph nodes is uncommon.[1] We report a case of isolated tuberculous lymphadenitis involving bilateral inguinal lymph nodes in a 42-year-old female. Primary or isolated inguinal tuberculous lymphadenitis that too bilateral, without pulmonary or cutaneous TB is a less common presentation.

CASE REPORT

A 42-year-old female, homemaker presented with complaints of swelling in both inguinal region for 6 months. Swelling developed initially on the left and then on the right side. Both the swellings ruptured spontaneously one after the other in the order of their appearance, discharging serous material, associated with dull aching pain. Not associated with any genital ulcer, vaginal discharge, and lower abdominal pain. There was no history of fever, weight loss, and cough with expectoration. She is a married woman with no premarital or extramarital contact history.

On examination, the patient was thin built with no signs of anemia, icterus, cyanosis or clubbing. She had bilateral palpable matted lymph nodes in the inguinal region. The one on the right side measured about 8 cm × 4 cm, oval in shape, with well-defined margins and irregular surface. On the left side the swelling was minimal with ill-defined margins and discharging sinus [Figure 1]. Skin over both the inguinal nodes showed healed scars. Examination of the external genitalia revealed no specific finding. Systemic examination did not reveal any abnormality.

Figure 1

Matted lymph nodes in the right inguinal region. Discharging sinus and healed scars on the left side

Investigations showed hemoglobin 10.6 g%, total leukocyte count 7600/cmm, neutrophil 63%, lymphocyte 30%, eosinophil 4%. Erythrocyte sedimentation rate was 36 mm/h. Serum total protein, albumin and globulin ratio were within normal limits. Urine routine was normal. Chest X-ray, ultrasonography abdomen and pelvis, PAP smear were not contributory. Serological screening for retroviral status and syphilis were non-reactive. Mantoux test was highly positive showing induration of 25 mm (+++) [Figure 2]. Fine needle aspiration cytology (FNAC) of the lymph node showed presence of Langhans giant cells, epithelioid cells and lymphocytes suggestive of tuberculous lymphadenitis. She was not willing for lymph node biopsy. Category I anti-tubercular treatment comprised of 2 months intensive phase with isoniazid, rifampicin, pyrazinamide, ethambutol and 4 months continuation phase with isoniazid and rifampicin was instituted. Patient was followed-up periodically, and there was complete resolution by the end of treatment [Figure 3].

Figure 2

Mantoux test showing highly positive reaction with induration measuring 25 mm

Figure 3

Complete resolution of bilateral buboes with antituberculous treatment

DISCUSSION

Hippocrates was the first to describe that certain genital ulcers are accompanied by swelling in groin which were termed as buboes. Inguinal and femoral buboes are defined as localized enlargement of lymph nodes in the groin that are painful and may or may not be fluctuant.[2] In sexually transmitted diseases (STD) clinics common causes for inguinal buboes are chancroid and lymphogranuloma venerum. Other venereal causes include syphilis, secondary bacterial infection of genital scabies, pediculosis pubis. Apart from the above said venereal causes other important causes for inguinal buboes include TB, plague, cat-scratch disease, pyogenic infection of the leg, atypical mycobacterial infections, lymphomas, persistent generalized lymphadenopathy of AIDS.

Peripheral lymphadenopathy accounts for nearly 30% of all types of extrapulmonary TB and it remains the most common cause among all types.[3] Classically tuberculous lymphadenopathy involves cervical group of lymph nodes, a common presentation in pediatric age group.[1] Studies show cervical group is the most common site to be involved whose incidence ranges from 74% to 90%, followed by axillary group in 14–20% cases, and inguinal group in 4–8% of cases.[4] Another study by Subrahmanyam, which included 105 cases of the peripheral lymphadenitis due to TB showed involvement of inguinal nodes only in 3 cases.[5] Most of the reported cases of tuberculous adenitis, including inguinal localisation were associated with TB elsewhere in the body.[6] Isolated inguinal tuberculous lymphadenopthy is a less common presentation with only few case reports, usually localized to one side.[789] However, there was bilateral involvement in the present case.

Pathogenesis of inguinal tuberculous lymphadenopathy is unclear. Among the two proposed hypothesis one revolves around the fact that hematogenous dissemination from a subclinical pulmonary focus and isolated secondary involvement of the inguinal nodes and the other states that lymphatic spread from endosalpinx around the round ligament to the inguinal nodes.[6]

Fine-needle aspiration cytology is a reliable diagnostic tool in the diagnosis of TB adenitis. Dandapat et al., in 1990 found 66 cases out of 88 (83%), positive on FNAC.[10] Further, FNAC avoids the risk of development of scar or fistula, a frequent complication associated with surgical biopsy.[6] Report of National consultation on diagnosis and treatment of pediatric TB held on January 2012 at LRS institute of TB, New Delhi also recommends biopsy, only if FNAC is inconclusive. In the present case the diagnosis was established by FNAC, also the patient was not compliant for lymph node biopsy.

In general, chemotherapy regimens that are effective in pulmonary TB will be effective in tuberculous lymphadenitis as well. Institution of appropriate medical treatment might avoid aggressive surgical procedures. In the present times, where syndromic management of STD is in vogue, which carries its own pros and cons, this case report emphasize the need to look beyond the venereal causes and calls for thorough evaluation and management.