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Tuberculosis Involving Other Sites

 

Tuberculous Lymphadenopathy

Abdominal tuberculosis (see Fig. 5.50)

Tuberculous lymphadenitis (scrofula) is by no means rare in many parts of the tropics; one study in Uganda showed that 41% of all enlarged cervical nodes were tuberculous. While tuberculosis is the most common cause of lymphadenopathy under the age of 30 years (unless the patient has Burkitt's lymphoma) there will also be a significant number of elderly patients in whom cervical lymphadenopathy is tuberculous in origin. Ultrasonography can accurately demonstrate the lymphadenopathy (as can CT or MRI), but cannot establish the etiology. Most lymph nodes will appear as hypoechoic masses with a regular outline; often multiple enlarged nodes are present. Ultrasonography is most useful for the accurate follow-up of resolution during treatment. During the acute stage there are no changes of radiological significance; when the infection has healed, calcification frequently follows. Calcified lymph nodes may be seen not only in the neck, but in the axilla, around the shoulder, in the inguinal region, in the popliteal fossa, and elsewhere (Fig. 5.103). All must be differentiated from other causes of soft tissue calcification, e. g., parasites, or, in the limbs, from tumoral calcinosis. This is usually possible because calcified tuberculous granulomas are irregular in size and shape but, more importantly, their anatomical situation may suggest the diagnosis.

Calcified tuberculomas may be seen in the liver and spleen, but have little clinical and no radiological significance (see previous section on "Tuberculosis of the Liver, Spleen, and Pancreas"). A tuberculous granuloma can calcify anywhere and only histological examination will differentiate its nature. Even this may be difficult because of the fibrosis.

Tuberculosis of the Breast

Although not common anywhere, tuberculosis of the breast is not rare in the tropics and significant series have been reported. The most common presentation is a mass in the breast of a 30- to 40-year-old woman. It is usually painful, but if there is a sinus tract leading from the "mass" (which is the tuberculous breast abscess) to the skin (Fig. 5.104), the surface ulceration is often painless unless secondarily infected. Many tuberculous breast lesions are quite chronic and have been felt by the patient for some months; a few may be more acute, with a history of only a few days, and such rapid onset occurs particularly in the lactating breast. The clinical diagnosis is usually of a carcinoma or, in the more acute cases, a pyogenic breast abscess.

Mammography shows the palpable mass as a diffuse density, which, when there is fluid, may change in shape and density on the two standard mammographic projections. There may be one or more sinus tracts connecting the mass to the thickened, overlying skin. In some patients the skin bulges (Fig. 5.104 C), probably at the stage before the sinus tract has formed. The underlying breast stroma is coarse, and may be reticulated. There is almost always nipple retraction. The breast size is often reduced. Ultrasonography can be used to confirm the fluid, but does not give much further information.

In some patients there will be minimal regional lymphadenopathy, but in others the lymph nodes are normal. The usual mammographic diagnosis is "chronic breast inflammation or breast abscess," but many of the masses will suggest malignancy. Recognition of the sinus tract and the skin thickening should suggest tuberculosis, particularly when there is little surface pain clinically. Unfortunately, many sinus tracts become secondarily infected and there is then a pyogenic breast abscess: only histology will show the underlying tuberculosis. (The differential diagnosis, apart from malignancy and pyogenic abscess, will include, in the painless lesion, syphilis, mycotic infections, and parasites such as guinea worm.)

Tuberculosis of the Parotid Gland

Tuberculosis of the parotid gland is uncommon, but can be the presenting symptom of tuberculosis. There may be associated tuberculous cervical lymph nodes, but in the majority of patients there is no systemic symptom of tuberculosis and the chest radiographs are normal. Clinically, parotid tuberculosis resembles a tumor, and biopsy to establish the diagnosis is usually necessary. However, CT scanning may show characteristic thick-walled, smooth, round, rim-enhancing lesions, usually with central lucency. The clinical mass will be shown on scanning to be multiloculated; the thick enhancing rim surrounding the low-density central tissue is often corrugated and irregular. If the enhanced rim is thin, biopsy becomes essential. Contrast sialography does not add significant information and may be contraindicated because in some cases it has exacerbated the inflammatory reaction.

There may be similar lesions in the lymph nodes, and there may be lymph node tissue within the parotid glands.

Ocular Tuberculosis

Ocular tuberculosis is rare and usually associated with pulmonary or skeletal infection. Scleral tuberculosis has been reported but has no imaging significance.

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Copyright: Palmer and Reeder