From the Guidelines
Necrotizing granulomatous lymph nodes in the neck are most commonly caused by tuberculosis (TB), particularly Mycobacterium tuberculosis infection, as well as other granulomatous conditions such as sarcoidosis, and infectious conditions like nontuberculous mycobacterial infections and fungal diseases. The differential diagnosis for necrotizing granulomatous lymph nodes in the neck includes a range of conditions, such as:
- Tuberculosis (TB) 1
- Nontuberculous mycobacterial infections (like Mycobacterium avium complex) 1
- Fungal infections (such as histoplasmosis, coccidioidomycosis, and cryptococcosis) 1
- Cat scratch disease (Bartonella henselae) 1
- Sarcoidosis 1
- Certain malignancies, including lymphomas 1 The granulomatous inflammation represents the body's immune response to contain these infections or inflammatory processes, with the formation of organized collections of macrophages. The necrosis occurs when the center of these granulomas dies due to the persistent inflammatory process or direct damage from the pathogen.
Diagnosis and Treatment
Diagnosis typically requires excisional biopsy of the affected lymph node with histopathological examination, special stains for acid-fast bacilli and fungi, and cultures 1. Additional tests like tuberculin skin test, interferon-gamma release assays, chest X-ray, and CT scans may be needed to determine the underlying cause. Treatment depends on the specific etiology but often involves antimicrobial therapy for infectious causes or immunosuppressive medications for inflammatory conditions. According to the most recent evidence, the european position paper on rhinosinusitis and nasal polyps 2020 1 provides a comprehensive overview of the differential diagnosis and treatment options for granulomatous conditions, including necrotizing granulomatous lymph nodes in the neck.
From the Research
Causes of Necrotizing Granulomatous Lymph Node in the Neck
- Infectious causes:
- Tuberculosis: characterized by necrotizing granulomatous inflammation, often with caseation necrosis 2, 3
- Cat scratch disease: causes granulomatous lymphadenitis with monocytoid B lymphocytes, T cells, and macrophages 2
- Yersinia lymphadenitis: induces granulomas with central abscesses, typically affecting mesenteric lymph nodes 2
- Non-infectious causes:
- Sarcoidosis: a systemic disease with unknown cause, characterized by non-necrotizing granulomatous inflammation 2, 3
- Adult-onset Still's disease: a rare autoimmune disorder that can cause suppurative necrotizing granulomatous lymphadenitis 4
- Kikuchi-Fujimoto disease: a self-limiting condition with necrotizing lymphadenitis, often affecting young females 5
- Systemic lupus erythematosus: can cause necrotizing lymphadenitis, with characteristic morphological features such as plasma cell infiltration and vascular proliferation 5
Characteristics of Necrotizing Granulomatous Lymphadenitis
- Histological features: necrotizing granulomatous inflammation, with or without caseation necrosis, and presence of histiocytes, lymphocytes, and plasma cells 2, 3, 6
- Clinical presentation: fever, neck swelling, and lymphadenopathy, with or without systemic symptoms such as fatigue, weight loss, and night sweats 2, 5, 4, 3, 6
Diagnostic Considerations
- Imaging studies: ultrasound and CT scans can demonstrate enlarged cervical lymph nodes with hypervascular cortices and areas of necrosis 6
- Histopathologic examination: essential for confirming the diagnosis, with characteristic findings of necrotizing granulomatous inflammation and presence of histiocytes, lymphocytes, and plasma cells 2, 5, 4, 3, 6