What is the management of lymph node tuberculosis as per Indian guidelines under the National Tuberculosis Elimination Programme (NTEP)?

Management of Lymph Node Tuberculosis as per Indian NTEP Guidelines

Standard Treatment Regimen

Lymph node tuberculosis under India's National Tuberculosis Elimination Programme (NTEP, formerly RNTCP) is treated with a 6-month regimen consisting of 2 months of isoniazid, rifampicin, pyrazinamide, and ethambutol (intensive phase), followed by 4 months of isoniazid and rifampicin (continuation phase). 1, 2, 3

Treatment Administration Options

The NTEP allows flexibility in administration schedules:

• Daily therapy throughout the entire 6 months 3
• Daily for 2 months, then thrice-weekly for 4 months 3
• Thrice-weekly from the start 3
• Twice-weekly fully observed therapy (alternative option with comparable efficacy) 4

The thrice-weekly intermittent regimen is commonly used in India's programmatic setting, with directly observed treatment (DOT) being a core component. 5

Drug Dosing Considerations

• NTEP uses weight band-based dosing, which may result in lower milligram-per-kilogram doses than current WHO recommendations for some patients 5
• Despite this, reported treatment completion rates remain high (95%) in programmatic settings 5
• If pyrazinamide cannot be used, extend treatment to 9 months total (2 months of isoniazid, rifampicin, and ethambutol, followed by 7 months of isoniazid and rifampicin) 2, 3

Special Populations

HIV-Infected Patients

Treatment duration must be extended to 9 months and continued for at least 6 months after sputum conversion in HIV-infected patients with TB lymphadenitis. 2

Children

• Children under 15 years are managed using diagnostic algorithms and the same 6-8 month intermittent thrice-weekly regimens 5
• Peripheral lymph node disease is the most common presentation (46% of extrapulmonary TB cases) in children 5

Expected Clinical Course During Treatment

Paradoxical Responses (Critical to Recognize)

Lymph nodes may enlarge, new nodes can appear, or existing nodes may persist during or after completion of appropriate therapy without evidence of bacteriological relapse—this is NOT treatment failure. 1, 2, 3

Specific patterns include:

• Fresh nodes appearing during treatment (12% of patients) 6
• Existing nodes enlarging (13% of patients) 6
• Fluctuation developing (11% of patients) 6
• Discharge or sinus formation (7% of patients) 6

Management of Paradoxical Responses

• Observation is the recommended approach for persistent lymph nodes after completion of adequate therapy 1
• No additional anti-TB drugs are required in the absence of other signs of active disease 1
• For large fluctuant lymph nodes that appear about to drain spontaneously, aspiration may be beneficial 1, 3
• Avoid incision and drainage, as this is associated with prolonged wound discharge and scarring 1
• Therapeutic lymph node excision is not indicated except in unusual circumstances 1, 2, 3

Monitoring and Follow-up

During Treatment

• Response is judged primarily on clinical and radiographic findings due to difficulty obtaining follow-up specimens 1, 3
• Regular clinical assessment is essential 3
• Under NTEP, patients discharged from tertiary facilities should have referral forms completed for continuation of treatment at peripheral health facilities 7

After Treatment Completion

• Regular clinical follow-up to monitor residual lymph node size 1
• A 2 cm node after 9 months of treatment falls within expected response patterns and does not require intervention 1
• Relapse rates are low (2%) during 36 months post-treatment follow-up 4

When to Suspect Treatment Failure or Drug Resistance

Consider further evaluation if:

• Increasing node size with systemic symptoms despite completed therapy 1
• Treatment failure with documented adherence (suspect drug resistance) 1
• In areas with high isoniazid resistance prevalence (≥4%), ethambutol should be continued for the entire treatment course 2

Drug-Resistant TB Management

• For isoniazid-resistant TB: add a later-generation fluoroquinolone to a 6-month regimen of daily rifampicin, ethambutol, and pyrazinamide 3
• For MDR/RR-TB: newer regimens include BPaLM (bedaquiline, pretomanid, linezolid, moxifloxacin) for 6 months or 9-month all-oral bedaquiline-containing regimens 2
• Consultation with a TB expert is recommended for suspected or confirmed drug-resistant TB 3

Programme Performance in India

• Under NTEP, 98% of TB patients in tertiary facilities are treated with RNTCP-recommended regimens 7
• Overall treatment completion rates are 95% across all patient subgroups 5
• Extrapulmonary TB accounts for 63% of cases, with peripheral lymph node disease being most common 5

Common Pitfalls to Avoid

• Mistaking paradoxical lymph node enlargement as treatment failure and unnecessarily extending or changing treatment 2, 6
• Performing incision and drainage instead of simple aspiration for fluctuant nodes 1
• Failing to extend treatment duration to 9 months in HIV-infected patients 2
• Not ensuring proper linkage between tertiary and peripheral health facilities for treatment continuation 7