Primary Tuberculosis – Tonsils

CASE REPORT

ARTICLE A rare site for Primary Tuberculosis - Tonsils

Shah Prasmit Amit1*, Singh Vikas Shyamraj2, Sudhamani S3, Bhalekar Surekha4,
Loungani Lavina5
1
Department of Pathology, DY Patil University School of Medicine,Nerul, Navi Mumbai
2
Department of Pathology, DY Patil University School of Medicine,Nerul, Navi Mumbai
3
Department of Pathology, DY Patil University School of Medicine,Nerul, Navi Mumbai
4
Department of Pathology, DY Patil University School of Medicine,Nerul, Navi Mumbai
5
Department of Pathology, DY Patil University School of Medicine,Nerul, Navi Mumbai

ABSTRACT
Tuberculosis is one of major cause of ill health and death in India. Even though tonsils is a recognized site for
Tuberculosis, primary or isolated Tuberculosis in the tonsils in the absence of Pulmonary Tuberculosis is a very rare
clinical entity. A Seventeen year old female presented with recurrent episodes of upper respiratory tract infection
since six months. Examination showed bilateral enlargement of tonsils. Histopathology revealed features of
Tuberculosis. Early detection and surgical removal is necessary for cure. We report this case because of its rarity.

Keywords: Tonsil, Pulmonary Tuberculosis, Granuloma.

INTRODUCTION Physical examination revealed that patient was

Tuberculosis
INTRODUCTION in humans is caused by of moderate built without any lymphadenopathy.
Mycobacterium Tuberculosis and Oral examination showed bilateral enlargement
Luxation of globe may occur with or without complete or incomplete avulsion of optic nerve or disinsertion of one or
Mycobacterium Bovis. Tuberculosis has variable of the tonsils. Posterior pharyngeal wall was
more extra ocular muscles. Intraorbital foreign body may cause various signs and symptoms according to the orbital
clinical presentation
space involved. which
Penetrating often
injury with leadsforeign
vegetative to body
clear. Routine
can cause investigations
localized were
or generalized within normal
infection
misdiagnosis. Incidence
,mechanical effects of Primary
and sympathetic Tuberculosis
ophthalmitis. limits except Erythrocyte sedimentation
in lung is as high as 98%, but incidence of rate(ESR) which was 60 mm/ 1 sthour (Normal =
tuberculosis in tonsil is less than 5%. Moreover upto 20 mm/1st hour). Chest radiography was
Tuberculosis in tonsil without any evidence of normal and patient was HIV seronegative.
Pulmonary Tuberculosis is still Bilateral tonsils were removed and sent for
rarer.1Extrapulmonary tuberculosis represents histopathological examination.
25% of tubercular morbidity with the most Histopathology revealed tonsils displaying
common site being lymph nodes. Thus it is normal epithelium with deeper tissue showing
diagnostic challenge for an many epithelioid cell granulomas, Langhan’s
Otorhinolaryngologist. We report a case of giant cells, caseous necrosis and mononuclear
Primary Tuberculosis of tonsil in a healthy cells surrounded by fibrosis.[Figure 1][Figure 2]
female which was clinically mimicking chronic Ziehl Nelson staining for Acid Fast Bacilli was
tonsillitis.2 negative. Patient was then started with anti-
CASE REPORT tuberculous drugs. Patient is being followed up
A Seventeen year old female presented with for six months and showed evidence of
recurrent episodes of upper respiratory tract improvement.
infections since six months. Patient also had DISCUSSION
complaints of occasional fever and difficulty in Diagnosis of Tuberculosis requires high degree
swallowing. No history of Tuberculosis or HIV of suspicion. This is an era of advanced medical
or Diabetes Mellitus or Hypertension. Family sciences where complete treatment of
history revealed Tuberculosis to her brother ten tuberculosis is possible. Thus losing the patient
years back, who had completed the treatment with tuberculosis due to delay in the diagnosis is
and has no evidence of recurrence. not at all justifiable.1
*Corresponding Author: Tuberculosis of oral cavity is uncommon while
Prasmit Amit Shah that occurring in tonsils is extremely rare.
Assistant Professor, Dept.of Pathology, Vayisoglu et al studied forty eight cases of
DY Patil University School of Medicine, Tuberculosis of head and neck between January
Nerul, Navi Mumbai-400706 2000 to June 2009 and found only two cases of
E-mail: prasmit198@gmail.com primary Tonsillar Tuberculosis.
53 Int J Int Med Res. 2016; 3(3): 53-55 e ISSN: 2393-9869 p ISSN: 2350-0360

Figure 1: H & E stained section 10x showing multiple epithelioid cell granulomas (Black
Arrows) and zone of lymphocytes
Figure 2: H & E stained section 10x showing multiple Langhan’s Giant cells (Black Arrows),
caseous necrosis and zone of lymphocytes
Shrock et al similarly did a retrospective study
on head and neck Tuberculosis and concluded
that tonsillar tuberculosisis rare and rarely
manifest with organ specific symptoms. 3Tongue
and Palate are the common sites whereas
Tuberculosis of Tonsil is very rare with the
reported incidence of less than 5%. 2
Risk factors include patient with weak immune
system due to diseases like Diabetes-Mellitus
and HIV. People with Diabetes Mellitus have
two to three times more risk when compared to
people without Diabetes mellitus. 4 In our case
patient was seventeen year old young HIV
seronegative and non diabetic.
Other predisposing factors include poor dental
hygiene, dental extraction, leukoplakia and
54 Int J Int Med Res. 2016; 3(3): 53-55
Primary Tuberculosis – Tonsils
periodontitis.1No such predisposing factors were
present in our case.However, history of
tuberculosis in close family contact with brother
is seen in this case. But further detailed
interrogation revealed that he had sputum
positive pulmonary tuberculosis ten years back
and had completed full course of therapy.
Tuberculosis of tonsil can result from infection
by contact with tuberculous material. Miller in
1963 concluded that pasteurization of milk
decreased the incidence of intestinal
tuberculosis. 2
Tonsil is made up of rich lymphoid tissue and is
situated at a site where infected sputum is
always drenched. But still Tuberculosis of tonsil
is reportedly very rare because of following
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possible reasons: (A) Antiseptic and cleansing
action of Saliva. (B) Presence of Saprophytes in
the oral cavity. (C) Inherent resistance to the
Tuberculous infection. (D) Presence of thick and
protective squamous epithelial covering. 2
It is also postulated that the infection is acquired
by inhalation and harbouring of bacilli in the
Waldeyer ring.Most common clinical
presentations include sore throat, painful
deglutition and cervical lymphadenopathy. In
our case patient presented with recurrent upper
respiratory tract infection with sore throat but
there was no evidence of ulcerations or cervical
lymphadenopathy. 1
Arbol pointers are used to hint towards the
diagnosis of Tonsillar Tuberculosis. These
pointers are as follows: (A) Unexplained
granular or asymmetric enlargement of tonsil.
(B) Tonsillar enlargement without exudates. (C)
Painful deglutition (D) Presence of enlarged
Jugulodigastric lymph nodes. (E) Obliteration of
crypts.1However, all these features are non-
specific and diagnosis can be missed. Our case
presented with unexplained enlargement of
tonsil, enlargement without exudates and painful
deglutition and therefore clinically could not be
suspected as tuberculosis. Chakravarti et al
reported a case of concomitant tuberculous
lesions in the palatine tonsil and posterior
oropharyngeal wall. Tuberculosis of oral cavity
can be either primary or secondary with tongue
and palate being common sites. Tonsillar
granulomata can be seen in patients with poor
immunity due to chronic alcoholism, HIV etc.
and tuberculosis of tonsils might be suspected if
both tonsils are enlarged unequally associated
with cervical lymphadenopathy.2
Final diagnosis is based on hisopathological
findings. Ziehl Nelson staining for Acid fast
bacilli further helps in the diagnosis.1However,
bacilli may be negative on AFB stain or culture
as in our case. Differential diagnosis of oral
pharyngeal tuberculosis includes the following:
Syphillis, Actinomycosis, midline granulomas,
Wegener’s disease, carcinoma, Aphthous ulcers
or traumatic ulcers.5In this case the positive
history of contact and distinctive soft
granulomas, consisting of central caseous
necrosis with typical Langhan’s giant cells and
55 Int J Int Med Res. 2016; 3(3): 53-55
Primary Tuberculosis – Tonsils
epithelioid cells, the diagnosis of tubereculosis
was straight forward.
CONCLUSION
Thus to conclude even though rare, a long
standing history of sore throat, with history of
tuberculosis in close contact should alert the
clinician of the possibility of tuberculosis of
tonsils is one of the differential diagnosis
especially in the places where incidence is high.
Tonsillectomy followed by antituberculous
drugs is the gold standard of treatment and gives
good results.
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Lingaiah J. Primary Tuberculosis of Tonsil
in a Diabetic Patient-A Case Report.
International Journal of Otolaryngology and
Head & Neck Surgery 2015;4:190-5.
5. Chakravarti A, Pal S, Sahni JK. Primary
tuberculosis of tonsil and posterior
oropharyngeal wall. Indian Journal of
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