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, 2, 3
First-Line Treatment Regimen
- The American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America recommend a 6-month regimen for all patients with tuberculous lymphadenitis caused by drug-susceptible organisms 1
- Standard adult dosing includes:
- Directly observed therapy (DOT) is recommended to ensure treatment adherence, particularly for intermittent regimens 2, 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 2, 3
- If susceptibility results are pending after two months, treatment including pyrazinamide and ethambutol should be continued until full susceptibility is confirmed 2, 3
- Affected lymph nodes may enlarge or new nodes can appear during or after treatment without any evidence of bacteriological relapse, which should not be considered treatment failure 1, 6
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, 2
- For multidrug-resistant (MDR) tuberculous lymphadenitis, treatment should follow guidelines for MDR-TB, which typically includes at least three effective drugs 1
Special Populations
HIV Co-infection
- The same 6-month regimen is recommended for HIV-infected patients with tuberculous lymphadenitis 2, 7
- Early initiation of antiretroviral therapy (ART) improves survival, with optimal timing within the first 8 weeks of starting antituberculous treatment 7
- For patients with CD4 counts <50 cells/mm³, ART should be initiated within the first 2 weeks 7
Children
- Weight-based dosing is recommended, with isoniazid at 10-15 mg/kg daily 2, 4
- The same 6-month regimen (2HRZE/4HR) is effective for children with tuberculous lymphadenitis 3
Pregnant Women
- Isoniazid, rifampin, ethambutol, and pyrazinamide can be used during pregnancy 4, 8
- Streptomycin should be avoided due to risk of ototoxicity to the fetus 8
- Prophylactic pyridoxine (10 mg/day) is recommended along with antituberculous therapy 8
Therapeutic Interventions for Complications
- Therapeutic lymph node excision is not indicated except in unusual circumstances 1
- For large lymph nodes that are fluctuant and appear to be about to drain spontaneously, aspiration may be beneficial, although this approach has not been examined systematically 1
- Incision and drainage techniques applied to cervical lymphadenitis have been associated with prolonged wound discharge and scarring 1
Common Pitfalls and Caveats
- Shorter rifamycin-based regimens (3-4 months) used for latent TB infection should not be confused with the 6-month regimen required for active tuberculous lymphadenitis 2, 9
- Do not mistake enlarging nodes or appearance of new nodes during treatment as treatment failure, as this is a common occurrence that usually resolves without additional intervention 1, 6
- Avoid unnecessary surgical procedures, which should be reserved only for specific complications 1, 6
- Do not confuse nontuberculous mycobacterial lymphadenitis (common in children in the US) with tuberculous lymphadenitis, as treatment approaches differ 1