Treatment of Tuberculous Lymphadenitis
Treat tuberculous lymphadenitis with the standard 6-month regimen: 2 months of isoniazid, rifampin, pyrazinamide, and ethambutol (2HRZE), followed by 4 months of isoniazid and rifampin (4HR). 1, 2
First-Line Treatment Regimen
The same treatment principles used for pulmonary tuberculosis apply to tuberculous lymphadenitis, with a 6-month four-drug regimen as the standard of care. 1, 2
Initial Intensive Phase (First 2 Months)
- Administer four drugs daily: isoniazid, rifampin, pyrazinamide, and ethambutol (2HRZE) 1, 2, 3
- Standard adult dosing: 1, 2
- Isoniazid: 5 mg/kg (maximum 300 mg) daily
- Rifampin: 10 mg/kg daily (450 mg if <50 kg; 600 mg if ≥50 kg)
- Pyrazinamide: 35 mg/kg daily (1.5 g if <50 kg; 2.0 g if ≥50 kg)
- Ethambutol: 15 mg/kg daily
Continuation Phase (Next 4 Months)
- Continue isoniazid and rifampin only (4HR) for the remaining 4 months 1, 2, 3
- Daily dosing is strongly recommended for optimal efficacy 3
When to Modify the Standard Regimen
Omitting Ethambutol
- Ethambutol may be omitted only if: 1, 2
- The patient is previously untreated AND
- HIV-negative AND
- Local isoniazid resistance rate is <4% AND
- No known exposure to drug-resistant TB
Extending Treatment Duration
- If pyrazinamide cannot be included in the initial regimen, extend total treatment duration to 9 months (2HRE/7HR) 1, 3
Special Populations
HIV Co-infection
- Use the same 6-month regimen (2HRZE/4HR) 1, 2
- Add pyridoxine (vitamin B6) 25-50 mg daily to all HIV-infected patients receiving isoniazid to prevent peripheral neuropathy 1, 3
- Monitor clinical and bacteriologic response carefully, as response may be slower 1
- Critical drug interaction: Rifampin significantly reduces levels of protease inhibitors and NNRTIs; consider rifabutin substitution with appropriate dose adjustments when using these antiretrovirals 3
Pregnant Women
- Use the standard 6-month regimen (2HRZE/4HR) 1
- All first-line drugs (isoniazid, rifampin, pyrazinamide, ethambutol) are safe in pregnancy 4
- Do NOT use streptomycin due to fetal ototoxicity 4
- Add prophylactic pyridoxine 10 mg daily 4
Children
- Use the same 6-month regimen with weight-based dosing 1, 2
- Isoniazid dosing for children: 10-15 mg/kg (maximum 300 mg) daily 1, 2, 5
- Consider omitting ethambutol in young children who cannot be monitored for visual acuity changes 6
Drug-Resistant Disease
Isoniazid-Resistant TB
- Add a later-generation fluoroquinolone (levofloxacin or moxifloxacin) to a 6-month regimen of rifampin, ethambutol, and pyrazinamide 7, 1, 2
Multidrug-Resistant TB (MDR-TB)
- MDR-TB (resistance to at least isoniazid AND rifampin) requires individualized treatment based on drug susceptibility testing 7, 1
- Consultation with a TB expert is essential 7, 6
- Use at least five effective drugs in the intensive phase and four drugs in the continuation phase 1
Treatment Adherence and Monitoring
Directly Observed Therapy (DOT)
- DOT is strongly recommended for all patients with tuberculous lymphadenitis to ensure treatment adherence 1, 2, 8
- Consider virtual DOT using digital technologies as a patient-centered alternative 8
Monitoring Schedule
- Monitor patients monthly for treatment response and adverse effects 1, 2
- Assess for hepatotoxicity, especially during the first 2 months 3
Critical Pitfalls to Avoid
Common Errors
- Do NOT confuse the 6-month treatment regimen for active TB lymphadenitis with the shorter 3-4 month regimens used for latent TB infection 1, 2
- Do NOT use the old 8-month retreatment regimen (2SHRZE/HRZE/5HRE) for previously treated patients; instead, perform drug susceptibility testing to guide therapy 9
Important Drug Interactions
- Rifampin induces metabolism of many medications, requiring dose adjustments for: 1, 3
- Oral contraceptives (use alternative contraception)
- Anticoagulants (monitor INR closely)
- Antiretroviral drugs (especially protease inhibitors and NNRTIs)