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Submadibular Abscess with Velopharyngeal Insufficiency: Unusual Clinical Presentation of Tuberculosis
Swati Tandon*,Purodha Prasad, Vikram Wadhwa and Ishwar Singh
Maulana Azad Medical College, India
Submission: February 20, 2017; Published: June 16, 2017
*Corresponding author: Swati Tandon, Maulana Azad Medical College, Delhi, India, Tel:9891778593; Email:firstname.lastname@example.org
How to cite this article: Swati T. Submadibular Abscess with Velopharyngeal Insufficiency: Unusual Clinical Presentation of Tuberculosis. Int J Pul & Res Sci. 2017; 1(5): 555576. DOI:10.19080/IJOPRS.2017.02.555576
Tuberculosis is a major public health problem in India. The rising incidence of multi drug resistant tuberculosis and unusual presentations of the disease is posing a great challenge for clinicians. We report an interesting case of 27 year old male who initially presented with submandibular abscess, subsequently developed velopharyngeal insufficiency during hospital stay and finally diagnosed as a case of extrapulmonary tuberculosis.
Tuberculosis is one of the oldest diseases known to affect humans. There are two forms of tuberculosis: pulmonary and extrapulmonary. Extrapulmonary tuberculosis involves all sites other than lungs. Diagnosis of extrapulmonary tuberculosis is challenging as samples obtained from these sites may be paucibacillary, thus decreasing the sensitivity of diagnostic tests . We report a case of unusual presentation of disseminated extrapulmonary tuberculosis, where patient initially presented as an acute submandibular abscess, then developed palatal perforation and later had massive pleural effusion. Pleural fluid analysis ultimately leads to the diagnosis of tuberculosis.
A 27 year old male presented to ENT emergency of our hospital with diffuse swelling below the chin for 6 days. The swelling initially started as a furuncle which gradually progressed to involve the whole region below the chin. It was associated with pain and difficulty in eating. There was no breathing difficulty or fever. There was no history of trauma. There was no history of contact or past tuberculosis. On clinical examination, patient was thin built, cachexic and a febrile.
On local examination of neck, a diffuse 8x8cm swelling was seen in neck below the mandible extending from one angle of mandible to other. It was tender, skin overlying was erythematous and hyper pigmented, and temperature was raised. It was fluctuant and on aspiration pus was aspirated. A provisional diagnosis of acute submandibular abscess was made and incision and drainage was done with 10 ml drainage of pus. Floor of mouth was raised which subsided on drainage of abscess. Pus was sent for Gram staining, ZN staining (for TB) and culture sensitivity. Acid fast bacilli (AFB) were negative on ZN staining. On culture, pseudomonas was isolated and appropriate intravenous antibiotics were started according to sensitivity report. Hematological investigations including complete blood count, kidney function tests, liver function tests and urine routine microscopy was done, which were within normal limits. No immunodeficiency was detected. On second day, patient complained of nasal regurgitation and regurgitation of water through right ear. Voice of the patient also appeared hyper nasal. Nasal examination was unremarkable. On oropharyngeal examination, approx. 1cm ulcer with perforation was seen at the junction of the right anterior pillar and soft palate with pus on its margins. Patient denied any history of trauma or drug allergy. On examination of right ear, pus was seen filling the external auditory canal with non visualization of tympanic membrane. On cleaning the pus, slough was seen in antero-inferior wall of external auditory canal in the cartilaginous portion with pus coming through it. Tympanic membrane was found intact. Pus in the ear was thought to be due to spread of infection via the parotid space into the external auditory canal (EAC) via fissure of Santorini. Approx. 10-15ml pus drained from the submandibular incision site on second day. Patient was continued on i.v. antibiotics.
Nasogastric tube was inserted for feeding and biopsy
was taken from the ulcer margins which showed chronic
inflammation without any granulomas and was negative for acid
fast bacilli. On third day, patient started complaining of purulent
cough with mild respiratory difficulty. Chest physician opinion
was sought who ordered chest x ray, montoux, sputum for AFB
smear and started patient on tab. levofloxacin for 7days. On
chest X ray, normal lung parenchyma with blunting of bilateral
CP angles were seen indicating pleural effusion for which
ultrasound guided pleural tap was done which revealed 4cm
pleural thickness on right side and 5cm on left side. Montoux
was 10mm, sputum for AFB was negative and ESR was raised
Analysis of pleural fluid revealed raised lymphocytic count
raised LDH and ADA s/o tuberculosis. Thus, a diagnosis of
extrapulmonary tuberculosis was made and patient was started
on ATT. Initially, patient did not respond and respiratory distress
worsened. Repeat chest x ray revealed massive pleural effusion
for which chest drains were inserted bilaterally. 1000ml pus
was drained from right side and 450ml from left side. Gradually
patient started improving.
Chest drains were removed after 3 days. Submandibular
wound also started healing and healthy granulation tissue was
formed on 10th day. Anterior pillar perforation also healed by
10th day (Figure 1 & 2). Patient’s general condition improved
and was discharged after 2 weeks on ATT. On follow up of
8weeks, patient is doing well and neck wound has healed.
The major pitfalls in the diagnosis of EPTB are atypical
clinical presentations simulating other inflammatory conditions,
resulting in delay of treatment. Therefore, a high index of
suspicion is necessary to make an early diagnosis. In developing
countries, the lack of diagnostic resources adds to the problems.
In clinical practice, the cutaneous reaction to PPD commonly
known as montoux test is used as an aid to diagnose TB but its
value as a diagnostic tool is limited in adults in India, since about
40% of the adult population is infected with TB. In our case,
montoux was 10mm suggestive of TB.
Smear examination for AFB, culture and histopathological
examination remain as the classical diagnostic tests for TB.
Laboratory diagnosis of TB is a tedious process because
it depends on the growth of organisms. ZN staining for
demonstration of acid fast bacilli on smears is a rapid method
but it is less sensitive. In a study, ZN staining was compared
with fluorescent (auramine rhodamine-AR) staining for
demonstration of acid fast bacilli and it was observed that ZN
staining showed 23.4% AFB smear positivity; 32.7% in sputum
and 1.4% in extra-pulmonary specimens, whereas, Auramine
Rhodamine staining showed 31.87% AFB smear positivity,
41.6% in sputa and 9.9% in extrapulmonary cases. The staining
methods were also compared and evaluated against culture on
LJ medium, (taken as ‘gold standard’): AR was 86.6% sensitive
and ZN 67.3% sensitive .
Culture is the gold standard method but it’s major
disadvantage is it is time consuming and takes 3 to8 weeks.
The most recent advances have been development of molecular
tools for amplifying DNA and RNA in clinical samples. A new
nucleic acid amplification test called transcription mediated
amplification has been developed . These tests enable rapid
identification of bacilli in few hours and are highly sensitive
and specific. Also, since they involve amplification of bacilli
DNA and RNA, they are very useful in paucibacillary specimens.
Histopathological examination for mycobacterial lesions has
also been described as a diagnostic tool. It has been found that
microscopic examination of tissue sections frequently results
in few or no bacilli seen, even if the lesions appear active
histologically. This might be due to the effects of the fixative fluid
and/or organic solvent, both of which are conventionally used to
make tissue sections for histopathology, on the acid-fast staining
of bacteria . We also suspect the same in our case.
Measurement of adenosine deaminase (ADA) activity is
one of the most widely used biomarkers in body fluids forthe diagnosis of EPTB. ADA is an enzyme involved in purin
metabolism. Activity of this enzyme increases in TB patients
because of the stimulation of T-cell lymphocytes by mycobacterial
antigens. Detection of ADA in pleural fluid ultimately helped in
establishing the diagnosis in our case.
TB of upper airway and oral cavity is usually secondary to
pulmonary TB. Cases of primary oral TB have been described
in literature . On the other hand oral TB can be the first
sign of pulmonary TB . In our case, oral TB was one of
the manifestations of extrapulmonary TB. Antituberculosis
treatment is the mainstay in the management of EPTB.
Our case highlights the varied and unusual presentations
of extrapulmonary tuberculosis. It also highlights the
limitations of diagnostic tests routinely used for diagnosing
TB. Extrapulmonary manifestation of TB can affect any part of
body; therefore high clinical suspicion is needed to diagnose
such cases early so as to prevent complications and spread of
infection to others.