What is the recommended treatment for Tuberculosis (TB) lymphadenitis?

Treatment of Tuberculous Lymphadenitis

The recommended treatment for tuberculous lymphadenitis is a 6-month regimen consisting of isoniazid, rifampin, pyrazinamide, and ethambutol for the initial 2 months, followed by isoniazid and rifampin for an additional 4 months (2HRZE/4HR). 1

Standard Treatment Regimen

• The standard 6-month regimen (2HRZE/4HR) is recommended by both the American Thoracic Society and the European Respiratory Society for tuberculous lymphadenitis 1
• This regimen includes:
  • Initial 2-month phase: daily isoniazid, rifampin, pyrazinamide, and ethambutol
  • Continuation 4-month phase: daily isoniazid and rifampin 2, 1
• Standard adult dosing includes:
  • Isoniazid: 5 mg/kg (up to 300 mg) daily 3
  • Rifampin: 10 mg/kg (450 mg if <50 kg, 600 mg if >50 kg) daily 2
  • Pyrazinamide: 35 mg/kg (1.5 g if <50 kg, 2.0 g if >50 kg) daily 2
  • Ethambutol: 15 mg/kg daily 2

Treatment Considerations

• Ethambutol may be omitted in patients with a low risk of isoniazid resistance (isoniazid resistance rate <4%) and in previously untreated patients who are known to be HIV-negative 2, 1
• If susceptibility results are pending after two months, treatment including pyrazinamide and ethambutol should be continued until full susceptibility is confirmed 2
• If pyrazinamide cannot be included in the initial regimen, treatment duration should be extended to 9 months 2
• Directly observed therapy (DOT) is strongly recommended, particularly for intermittent regimens, to ensure treatment adherence 1, 3

Alternative Regimens and Special Populations

• For HIV-infected patients with tuberculous lymphadenitis, the same 6-month regimen is recommended, but if isoniazid is chosen as part of the regimen, a 9-month duration is preferred 2, 1
• For children, the recommended regimen is the same, with weight-based dosing:
  • Isoniazid: 10-15 mg/kg (up to 300 mg) daily 1, 3
  • Other drugs should be dosed according to weight as well 2
• For pregnant women, streptomycin should be avoided due to risk of ototoxicity to the fetus 4
• Pyridoxine supplementation (10 mg/day) is recommended for pregnant women, diabetics, and others at risk of peripheral neuropathy 4

Management of Drug Resistance

• For isoniazid-resistant tuberculous lymphadenitis, a regimen of rifampin, ethambutol, and pyrazinamide for 6 months, with the addition of a fluoroquinolone, is recommended 1
• For multidrug-resistant TB (MDR-TB) lymphadenitis (resistance to at least isoniazid and rifampin), treatment must be individualized based on susceptibility testing 5
• Consultation with an expert in tuberculosis is strongly recommended for MDR-TB cases 5

Monitoring and Follow-up

• Patients should receive an initial clinical evaluation and follow-up evaluations at least monthly 2
• Baseline laboratory testing is not routinely indicated for all patients but should be considered for those with:
  • Suspected liver disorders
  • HIV infection
  • Pregnancy or immediate postpartum period
  • History of chronic liver disease
  • Regular alcohol use 2
• Patients should be educated about potential side effects and advised to stop treatment and seek medical evaluation if they occur 2

Common Pitfalls and Caveats

• Lymph nodes may appear or enlarge during treatment but usually resolve; this does not necessarily indicate treatment failure 6
• After completion of therapy, approximately 10% of patients may be left with residual nodes, which does not necessarily indicate relapse 6
• Surgical intervention should be reserved for specific situations such as discomfort from enlarged nodes or fluctuant nodes, rather than as primary treatment 6, 7
• The shorter regimens now recommended for latent TB infection should not be confused with the full 6-month regimen required for active tuberculous lymphadenitis 1