What is the treatment for tuberculous lymphadenitis?

Treatment of Tuberculous Lymphadenitis

The standard treatment for tuberculous lymphadenitis consists of a 6-month regimen with an initial 2-month intensive phase of isoniazid, rifampin, pyrazinamide, and ethambutol, followed by a 4-month continuation phase of isoniazid and rifampin. 1

First-Line Treatment Regimen

Intensive Phase (First 2 Months)

• Isoniazid: 5 mg/kg (up to 300 mg) daily 2
• Rifampin: 10 mg/kg (up to 600 mg) daily 3
• Pyrazinamide: 15-30 mg/kg daily
• Ethambutol: 15-25 mg/kg daily (include until drug susceptibility results are available)

Continuation Phase (Next 4 Months)

• Isoniazid: 5 mg/kg (up to 300 mg) daily 2
• Rifampin: 10 mg/kg (up to 600 mg) daily 3

Dosing Options

• Daily dosing is preferred for both phases
• Alternatively, after daily therapy for 2 weeks, twice-weekly or three-times-weekly directly observed therapy (DOT) can be considered 1

Special Considerations

Drug Resistance

• If isoniazid resistance is detected: Add a later-generation fluoroquinolone to a 6-month regimen of daily rifampin, ethambutol, and pyrazinamide 1
• For multidrug-resistant TB (MDR-TB): At least 5 effective drugs should be used based on susceptibility testing 1
• For contacts of patients with MDR-TB: Consider treatment with fluoroquinolone (levofloxacin or moxifloxacin) alone or combined with a second medication to which the isolate is susceptible 1

Clinical Course and Monitoring

• Affected lymph nodes may enlarge and new nodes can appear during or after therapy without evidence of bacteriological relapse 1
• This paradoxical reaction does not indicate treatment failure and should be managed symptomatically 1
• Therapeutic lymph node excision is generally not indicated except in unusual circumstances 1
• For large fluctuant lymph nodes that appear about to drain spontaneously, aspiration may be beneficial 1
• Incision and drainage techniques should be avoided as they are associated with prolonged wound discharge and scarring 1

Duration of Treatment

• The 6-month regimen is adequate for uncomplicated tuberculous lymphadenitis 1, 4
• A meta-analysis showed that 6-month treatment resulted in a relapse rate of only 3.3% with a mean follow-up of 31 months 4
• Extending treatment to 9 months showed no significant additional benefit (relapse rate 2.7%) 4

HIV Co-infection

• For HIV-infected patients, the same regimen is recommended but treatment response should be monitored more closely 1
• If CD4 count is <100/μL, the continuation phase should consist of daily or three times weekly isoniazid and rifampin 5
• Be aware of potential drug interactions between rifampin and antiretroviral medications 1

Treatment Adherence

• Patient adherence is the major determinant of treatment outcome 6
• Directly observed therapy (DOT) should be considered, especially for intermittent dosing regimens 1
• Regular follow-up is essential to assess response and manage adverse effects 5

Common Pitfalls and Caveats

1. Paradoxical reactions: Lymph nodes may enlarge or appear during treatment - this is not treatment failure and rarely requires corticosteroids or surgical intervention 1, 7

2. Residual nodes: Approximately 10-15% of patients may have residual nodes at the end of treatment, which does not indicate treatment failure 7

3. Unnecessary surgery: Surgical procedures should be reserved only for:

   • Relief of discomfort caused by enlarged nodes
   • Drainage of tense, fluctuant nodes
   • Diagnostic purposes when diagnosis is uncertain 7

4. Premature treatment changes: Avoid changing treatment regimens based solely on physical changes in lymph nodes without evidence of bacteriological failure 7

5. Atypical mycobacteria: Ensure proper identification of the causative organism, as atypical mycobacteria may require different treatment approaches 8

By following this treatment approach, a cure rate exceeding 95% can be achieved when patients complete the full course of therapy for tuberculous lymphadenitis 5.