Figure 2: Distribution of patients by onset of symptoms.

This delay in consultation noted in our study is also observed by other authors [1,23,24]; it was on average 6 to 7 months.

Tuberculosis regardless of its location is the cause of general nonspecific clinical manifestations. The classic general signs of tuberculosis disease such as deterioration of the general condition and fever were almost constant (44/46) in our study. This is consistent with data from numerous studies reporting these clinical manifestations in 90 to 100% of patients [3,13,17,23,24]. Reported or objectified fever is a very common sign in tuberculosis disease. The latter, moreover, constitutes together with the deterioration of the general condition, the circumstances of discovery of tuberculosis, particularly in its paucisymptomatic or deep forms.

The lymphadenopathy was large with an average of 5.3 cm long axis [2 and 8 cm]. These macropolyadenopathies were isolated superficial (41/46), chronic (44/46), predominantly cervical (40/46). This frequency of cervical localization is reported by various authors [21,25,9] in 95%, 85.8% and 70.6% of cases, respectively.

According to Lacut [26], cervical locations are more frequent with rates close to 70% in immunocompetents patients. Profound involvement was not as rare (4/46). This was associated with cervical involvement and all were non-compressive and necrotic. This last trait, often described, is a major distinguishing feature of other causes of lymphadenopathy (lymphomas, lymph node metastases, neoplasia, among others).

The positivity of the tuberculin skin reaction is classically described in lymph node tuberculosis with an average of 17 mm [8 - 27mm] and phlyctenular in 67.4% (31/46) of cases. In HIV-seropositive patients, Hochedez [15] reported a positive skin reaction in 63% of cases. However, the latter despite being an important data in the diagnosis of extrapulmonary tuberculosis, its interpretation is not always easy due to errors by excess or by default. It is statically more often positive and phlyctenular in immunocompetent subjects [27]. Also, its negativity does not eliminate active lymph node tuberculosis [18].

Tuberculosis, especially in its extra-pulmonary location, occurs with predilection in immunocompromised individuals. In our study, HIV infection was found in 4 patients (8.7%). In sub-Saharan Africa, HIV infection is the main risk factor for tuberculosis disease; extra-pulmonary form often constituting a mode of revelation as was the case in our 4 patients.

Chronic kidney disease, diabetes, autoimmune disorders were also other risk factors for TB disease.

A biological inflammatory syndrome was noted in all our patients. The data observed in our study are in agreement with those reported by other authors [3,15,23] thus confirming what is classically described: tuberculosis, whatever its location, is accompanied by an inflammatory syndrome [27]..

The definitive diagnosis of lymph node tuberculosis is based on the isolation of the germ from the lymph node puncture fluid which remains the gold standard or on the lymph node biopsy which shows the tuberculous granuloma. However, the rarity of Koch bacillus (KB) in caseous lymph node lesions explains its negativity on direct examination in the majority of cases as evidenced by the results of our study during which the germ was isolated in 7 patients (15.2%), in agreement with the data observed by Abassi [28] in Morocco which was 17%.

Cytology, because of its easy and rapid implementation, remains recommended as a first-line diagnosis test in developing and highly endemic countries. In our study, the adenogram carried out in 18 patients concluded with tuberculous adenitis in 14 of them. However, this examination was supplemented by systematic lymph node biopsy. The latter confirmed the diagnosis in 38 patients (82.6%). This is similar to data reported in other studies [21,29].

In deep locations, ultrasound can be an important contribution to the etiological orientation. Satomi [30] in Japan, in a study comparing the different ultrasound aspects of neoplastic or lymphomatous lymphadenopathy in tuberculous lymphadenopathy reported in the latter an almost constant central necrosis. In our data, central necrosis was noted in all 6 patients with deep lymphadenopathy.

Therapeutic and evolutionary data

There is no consensus on how long to treat for lymph node TB. The duration of treatment in our study was on average 7.3 months. In the Bourzama study [29], the duration of treatment was 9 months in all patients and 6 to 10 months in the Belhadj study [5]. Hamzaoui [21] reported that 88% of his patients were treated for a period of 6 months. Hochedez [15] in France reported a median duration of treatment of 9 months. However, it has been observed that the 6-month treatment would be as effective as the 9-to-12-month treatment. The duration of treatment should be guided by the evolution of clinical and paraclinical signs.

The outcome under anti-tuberculosis treatment was favorable in 86,9% (40/46) of our patients. These results are similar to those found in Senegal by Bourzama [29] who noted a good evolution in all his patients (100%) but also in other previous studies [5, 15, 21, 25] which respectively reported 100%, 100 %, 95.2% and 87.5%. Classically, the evolution under regularly monitored anti-tuberculosis treatment is favorable in the majority of cases with recovery of patients marked by regression or even disappearance of lymphadenopathy. However, cases of relapse or treatment failure may be observed, in particular in cases of non-compliance with treatment or resistance of certain strains to major anti-tuberculosis drugs such as rifampicin and isoniazid [1].