What is the treatment for tuberculous adenitis?

Treatment of Tuberculous Adenitis

Tuberculous adenitis should be treated with the standard 6-month short-course regimen: rifampicin and isoniazid for 6 months, supplemented by pyrazinamide and ethambutol for the first 2 months. 1

Standard Treatment Regimen

Initial Intensive Phase (First 2 Months)

• Administer four drugs daily: rifampicin, isoniazid, pyrazinamide, and ethambutol 1
• The fourth drug (ethambutol) may be omitted only in patients with low risk of isoniazid resistance—specifically, those in communities with documented isoniazid resistance rates less than 4%, no previous tuberculosis treatment, not from high-prevalence countries, and no known exposure to drug-resistant cases 2, 3
• Fixed-dose combination tablets should be used whenever possible to improve adherence and prevent accidental monotherapy, which can lead to drug resistance 1

Continuation Phase (Next 4 Months)

• Continue rifampicin and isoniazid daily for an additional 4 months after completing the intensive phase 1
• This continuation phase should only begin after confirming susceptibility to isoniazid and rifampicin 1

Evidence Supporting 6-Month Duration

The British Thoracic Society guidelines explicitly state that tuberculous adenitis should be treated with the standard 6-month regimen, the same duration used for respiratory tuberculosis 1. This recommendation applies to both adults and children 1. While there are no controlled trials specifically examining treatment for extrapulmonary tuberculosis in children, present recommendations are based on trials in adults that demonstrate excellent outcomes with this regimen 1.

Special Populations

Children

• Use the same 6-month regimen with weight-adjusted dosing 1
• Isoniazid: 5 mg/kg up to maximum 300 mg/day (WHO/IUATLD recommendation) 1
• Rifampicin: 10 mg/kg; <50 kg: 450 mg daily, >50 kg: 600 mg daily 1
• Pyrazinamide: 35 mg/kg; <50 kg: 1.5 g daily, >50 kg: 2.0 g daily 1
• Ethambutol: 15 mg/kg daily 1
• Supplemental pyridoxine is not necessary except for breast-fed infants and malnourished children 1

Pregnancy

• Standard treatment should be given to pregnant women with all first-line drugs (rifampicin, isoniazid, pyrazinamide, ethambutol) 1
• None of the first-line drugs has been shown to be teratogenic in humans 1
• Streptomycin and other aminoglycosides must be avoided due to ototoxicity to the fetus 1
• Patients can breastfeed normally while taking antituberculosis drugs 1
• Women should be counseled that rifampicin reduces the effectiveness of oral contraceptives 1

Liver Disease

• All first-line drugs can be used, but baseline and frequent monitoring of liver function is required 1
• In patients with chronic liver disease (alcoholism, chronic active hepatitis, cirrhosis, hepatitis B or C positive), surveillance should be particularly frequent in the first 2 months: weekly liver function tests for the first 2 weeks, then at 2-week intervals 1
• The addition of pyrazinamide to regimens containing rifampicin and isoniazid does not increase morbidity despite all three being potentially hepatotoxic 1

Diabetes Mellitus

• Use the same standard regimen 1
• Rifampicin reduces the efficacy of sulphonylureas, so doses of oral hypoglycemic agents may need to be increased 1

HIV Co-infection

• The standard 6-month regimen is effective for HIV-positive patients with tuberculous adenitis 3
• However, clinical and bacteriologic response must be critically assessed, and therapy should be prolonged if there is evidence of slow or suboptimal response 3

Drug-Resistant Disease

Isoniazid-Resistant Tuberculosis

• Use rifampicin, ethambutol, and pyrazinamide for 6 months, with addition of a fluoroquinolone 4, 5
• If isoniazid resistance is demonstrated during treatment, continue rifampicin and ethambutol for a minimum of 12 months 3

Multidrug-Resistant Tuberculosis (MDR-TB)

• Treatment must be individualized based on drug susceptibility testing 3
• Consultation with a tuberculosis expert is strongly recommended 4, 3
• Use at least 5 effective drugs based on susceptibility patterns 6

Treatment Monitoring and Adherence

• Directly observed therapy (DOT) should be implemented whenever possible as it is the central element of successful tuberculosis management 6, 3
• Fixed-dose combinations provide more convenient administration and improve adherence 6
• Monitor for clinical improvement; patients not responding after 3 months require reevaluation 6
• The major cause of therapeutic failure is patient noncompliance with medication 7, 8

Critical Pitfalls to Avoid

• Never add a single drug to a failing regimen—this rapidly leads to drug resistance 8
• Never omit ethambutol in the initial phase unless isoniazid resistance is highly unlikely (community resistance <4%) 2, 3
• Do not extend treatment beyond 6 months for uncomplicated tuberculous adenitis—this is unnecessary and reduces adherence 1
• Do not confuse tuberculous adenitis with tuberculous meningitis, which requires 12 months of treatment 1