What is the recommended management for a patient with tuberculous lymphadenitis?

Management of Tuberculous Lymphadenitis

The recommended 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 4 months (2HRZE/4HR). 1

Standard Treatment Regimen

Initial Phase (2 months)

• Administer four drugs daily: 1
  • Isoniazid 5 mg/kg (maximum 300 mg) 2, 1
  • Rifampin 10 mg/kg (450 mg if <50 kg; 600 mg if ≥50 kg) 2, 1
  • Pyrazinamide 35 mg/kg (1.5 g if <50 kg; 2.0 g if ≥50 kg) 2, 1
  • Ethambutol 15 mg/kg 2, 1

Continuation Phase (4 months)

• Continue two drugs daily: 1
  • Isoniazid 5 mg/kg 1
  • Rifampin 10 mg/kg 1

When to Omit Ethambutol

• Ethambutol may be omitted in previously untreated patients who are HIV-negative and have no known contact with drug-resistant tuberculosis, provided the community isoniazid resistance rate is documented to be less than 4%. 2, 1

Treatment Delivery and Monitoring

Directly Observed Therapy (DOT)

• DOT is strongly recommended to ensure treatment adherence, particularly for intermittent regimens. 1
• All twice-weekly or thrice-weekly regimens should always be administered as DOT. 2

Monitoring Schedule

• Evaluate patients monthly for treatment response and adverse effects. 1
• If positive culture for M. tuberculosis is obtained but susceptibility results are pending after 2 months, continue pyrazinamide and ethambutol until full susceptibility is confirmed. 2, 1

Drug-Resistant Tuberculous Lymphadenitis

Isoniazid-Resistant Disease

• Add a later-generation fluoroquinolone (levofloxacin or moxifloxacin) to a 6-month regimen of daily rifampin, ethambutol, and pyrazinamide. 1

Multidrug-Resistant (MDR) or Rifampin-Resistant (RR) Disease

• For eligible patients, use the 6-month BPaLM regimen: bedaquiline, pretomanid, linezolid, and moxifloxacin. 1
• Alternatively, construct an individualized longer regimen including at least three Group A agents (bedaquiline, levofloxacin/moxifloxacin, and linezolid) plus at least one Group B agent (cycloserine/terizidone and/or clofazimine). 1
• Levofloxacin is generally preferred over moxifloxacin due to fewer adverse events and less QTc prolongation. 1

Special Populations

HIV-Infected Patients

• Use the same 6-month regimen as for HIV-negative patients. 1
• Treatment duration may need extension based on clinical and bacteriologic response. 1

Children

• Use weight-based dosing: isoniazid 10-15 mg/kg daily (maximum 300 mg). 1
• The same 6-month regimen applies, with appropriate dose adjustments. 2

Pregnant and Breastfeeding Women

• For drug-susceptible disease: use the standard 6-month regimen; all first-line drugs can be used safely during pregnancy. 3
• For drug-resistant disease: use the 9-month all-oral regimen with linezolid instead of ethionamide. 1

Critical Pitfalls to Avoid

• Never confuse shorter rifamycin-based regimens (3-4 months) used for latent TB infection with the 6-month regimen required for active tuberculous lymphadenitis. 1
• Never add a single drug to a failing regimen, as this leads to resistance to the added drug. 2
• Active tuberculosis must be ruled out before treating latent TB infection through history, physical examination, chest radiography, and bacteriologic studies when indicated. 2
• Ethambutol should not be used in children whose visual acuity cannot be monitored. 3

Alternative Regimens

When Pyrazinamide Cannot Be Used

• Extend treatment to 9 months total: isoniazid, rifampin, and ethambutol for 2 months, followed by isoniazid and rifampin for 7 months. 2

Intermittent Dosing Options

• Twice-weekly or thrice-weekly regimens are acceptable alternatives but must always be given as DOT. 2, 1
• These regimens have been shown to be highly efficacious with success rates of 94-96% at 36 months follow-up. 4