What is the treatment for tubercular lymphadenitis?

Treatment of Tuberculous Lymphadenitis

The standard 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

First-Line Treatment Regimen

• The 2HRZE/4HR regimen (2 months of isoniazid, rifampin, pyrazinamide, and ethambutol, followed by 4 months of isoniazid and rifampin) is the recommended standard treatment for tuberculous lymphadenitis 1, 2
• Standard adult dosing includes:
  • Isoniazid: 5 mg/kg (up to 300 mg) daily 1
  • Rifampin: 10 mg/kg (450 mg if <50 kg, 600 mg if >50 kg) daily 1
  • Pyrazinamide: 35 mg/kg (1.5 g if <50 kg, 2.0 g if >50 kg) daily 1
  • Ethambutol: 15 mg/kg daily 1
• Directly observed therapy (DOT) is recommended to ensure treatment adherence, particularly for intermittent regimens 1, 3

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 HIV-negative 1
• In cases where positive culture for M. tuberculosis has been obtained but susceptibility results are pending after two months, treatment including pyrazinamide and ethambutol should be continued until full susceptibility is confirmed 1
• Tuberculous lymphadenitis typically responds well to chemotherapy, with uneventful resolution in approximately 70% of patients 4
• Nodes may appear or enlarge during treatment but usually resolve; fluctuation, discharge, sinus formation, and scar breakdown occur in a minority of cases 4

Management of Drug-Resistant Tuberculous Lymphadenitis

• For isoniazid-resistant tuberculous lymphadenitis, add a later-generation fluoroquinolone to a 6-month regimen of daily rifampin, ethambutol, and pyrazinamide 1, 5
• For multidrug-resistant (MDR) or rifampin-resistant (RR) tuberculous lymphadenitis, the following options should be considered:
  • The 6-month BPaLM regimen (bedaquiline, pretomanid, linezolid, moxifloxacin) is recommended for eligible patients 5
  • Alternatively, a longer individualized regimen should include at least three Group A agents (bedaquiline, levofloxacin/moxifloxacin, and linezolid) and at least one Group B agent (cycloserine/terizidone and/or clofazimine) 5
  • Levofloxacin is generally preferred over moxifloxacin due to fewer adverse events and less QTc prolongation 5

Special Populations

• For HIV-infected patients with tuberculous lymphadenitis, the same 6-month regimen is recommended, but treatment duration may need to be extended based on clinical and bacteriologic response 1, 2
• For children, dosing should be weight-based, with isoniazid at 10-15 mg/kg (up to 300 mg) daily 1
• For pregnant and breastfeeding women with drug-resistant TB, the 9-month all-oral regimen with linezolid is recommended instead of ethionamide 5

Monitoring and Follow-up

• Patients should be monitored monthly for treatment response and adverse effects 1
• After completing treatment, approximately 10% of patients may be left with residual nodes 4
• Post-treatment enlargement or appearance of new nodes is usually transient and does not necessarily indicate relapse 4

Common Pitfalls and Caveats

• Shorter rifamycin-based regimens (3-4 months) that are used for latent TB infection should not be confused with the 6-month regimen required for active tuberculous lymphadenitis 1
• Initial excision does not seem to affect treatment outcome; surgical procedures should be reserved for relieving discomfort caused by enlarged nodes or tense, fluctuant nodes 4
• Second-line anti-TB drugs used for drug-resistant TB can cause significant adverse effects that require close monitoring, including nephrotoxicity (aminoglycosides), cardiotoxicity (fluoroquinolones), gastrointestinal toxicity (ethionamide, para-aminosalicylic acid), and central nervous system toxicity (cycloserine) 6