Introduction
Tuberculosis is one of the most important infectious diseases that is
considered among the top ten causes of mortality worldwide. According to
the reports by the World Health Organization (WHO), about 10 million new
cases of tuberculosis were diagnosed in 2018, of which 1 million were
children; 1.6 million related mortalities were also reported in the same
year. Currently, it has been estimated that one-fourth of the world’s
population is suffering from the latent TB infection (LTBI), 5-10% of
whom will encounter active TB in future [1-2]. The statistics
regarding Mycobacterium tuberculosis (Mtb ) drug resistance
is also very worrying; 558,000 rifampicin-resistant cases were specified
in that year, 82% of whom were multi-drug resistant TB (MDR-TB).
According to this report, Iran is also included among the endemic
tuberculosis countries [2-3]. The rate of incidence of tuberculosis
in Iran is about 22 per 100,000 and the mortality rate is 3.5 per
100,000. According to the reports, the rate of rifampicin and MDR-TB
resistance has been reported in Iran at about 1.3-5% [4-5].
While most of the clinical manifestations of tuberculosis are in the
pulmonary basis, however, Mtb is capable of affecting all the
organs, which is termed extra-pulmonary TB (EPTB). In this respect,
cervical tuberculous lymphadenitis is the most common form of EPTB,
accounting for 25-30% of the cases [6]. The incidence rate for the
EPTB in Iran has also been reported to be approximately 2.5 cases per
100,000 people per year, which are mainly children [7]. Cervical
tuberculosis lymphadenitis (CTL) typically involves the lymph nodes of
the jugular, posterior triangle, and supraclavicular region, and the
observed clinical manifestations of cervical tuberculosis lymphadenitis
include fever, weight loss, rarely coughing, night sweat, chills,
malaise, suppurative lymphadenitis, granulomatous inflammation, neck
mass (1-3 cm), fistula formation and caseous necrosis. However, cervical
tuberculosis lymphadenitis is confused with the diseases such as
malignancy, fungal infection, tularaemia, actinomycosis, sarcoidosis,
and non-tuberculosis mycobacteria (NTM) lymphadenitis [8-11].
Studies have shown that the accuracy and sensitivity of the diagnosing
methods for cervical tuberculosis lymphadenitis, such as Ziehl-Neelson
(ZN) staining, microbiological culture and PCR, have little diagnostic
value and are not reliable, particularly in the medication-resistant
cases. The physician may be mistaken for the misdiagnosis due to failing
to respond to the anti-tuberculosis treatment [12-15].
Based on the WHO recommendations, category III tuberculosis has been
used since the beginning of 1997 to treat the cervical tuberculosis
lymphadenitis cases [9]. The development of drug resistance TB
(particularly in TB endemic regions) has led to poor treatment outcomes
in recent years [16]. Thus, there is a new alternative treatment
beside the anti-TB therapy that has been introduced for adults, which is
surgery. These invasive techniques also have their own risks and need to
be modified and standardized according to the cervical tuberculosis
lymphadenitis guidelines [9,16-17]. According to review of the
literature, there are numerous reports about cervical tuberculosis
lymphadenitis in children [18-19]. However, there are only 5 reports
regarding MDR-CTL infection throughout the worldwide. All of these cases
had between 19-35 years of age, who recovered by administration of the
second-line anti-TB agents [20-24]. We were informed about the first
case of congenital cervical tuberculosis lymphadenitis in a 2-months old
infant, who was infected by MDR-Beijing Mtb strain. The aim of
the present study was to describe an unusual report of cervical
MDR-tuberculosis lymphadenitis in a 2-months age infant from Mashhad,
Iran.