Tubercular Epitrochlear Lymphadenopathy

To the Editor:

A 3-year-old girl was brought to us with progressively enlarging painless swelling over the anterior aspect of her left lower arm of six months' duration. She had no history of injury to the elbow. There was no complaint of restriction of movement at the elbow joint. She did not have fever, cough, or loss of weight. There was no history of tuberculosis in her family.

Local examination revealed a firm, non-tender, nodular mass over the anteromedial aspect of the left lower arm and cubital fossa (Fig. 1). There was no distal neurovascular deficit. There was no palpable adenopathy elsewhere in the body. Systemic examination was unremarkable. A radiograph of the elbow showed a soft-tissue mass medial to the distal humerus with no bony changes. Fine-needle aspiration cytology examination of the mass demonstrated tubercular lymphadenitis. Ziehl–Neelsen staining identified acid-fast bacilli in the smear. Her Mantoux test was strongly positive (20-mm induration). Her chest radiograph was normal. Serological tests for human immunodeficiency virus (HIV) -I and -II were nonreactive. She was prescribed isoniazid (5 mg/kg), rifampicin (10 mg/kg), and pyrazinamide (25 mg/kg) for two months. She responded well, with marked diminution in the size of the lymph nodes at the end of the regimen. Thereafter, she took isoniazid (5 mg/kg) and rifampicin (10 mg/kg) for four months. At the end of six months, there was nearly complete resolution of the lymph nodes.

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FIG. 1.

Clinical photograph showing epitrochlear lymphadenopathy.

Extrapulmonary tuberculosis accounts for 15%–20% of cases of tuberculosis in immunocompetent patients and more than 50% of the cases in HIV-positive patients [1]. Tubercular lymphadenopathy is the most common form of extrapulmonary tuberculosis. Cervical lymph nodes are most often involved followed by the axilla [2].

Epitrochlear lymphadenopathy as a manifestation of isolated extrapulmonary tuberculosis is extremely rare. To the best of our knowledge, there are only three reports of isolated tubercular epitrochlear lymphadenopathy available in the English-language literature. In a study of 118 cases of tubercular lymphadenitis, Hooper reported the first case of epitrochlear lymphadenitis [3]. In a study of 113 children with tubercular lymphadenitis, Seth et al. observed another case of epitrochlear lymphadenopathy. The cervical region was the most commonly affected (80%) followed by axillary (12%) and inguinal (7%) region in this study [4]. Crum reported a third case of tubercular epitrochlear lymphadenitis in an immunocompetent adult [5].

Epitrochlear lymph nodes usually are enlarged as a part of generalized lymphadenopathy. Isolated epitrochlear enlargement is uncommon but may be seen in malignant melanoma, lymphoma, cat-scratch disease, leprosy, or leishmaniasis. Tuberculosis should be kept in mind as a differential diagnosis of isolated epitrochlear lymphadenopathy, especially in developing countries where tuberculosis is a major health problem.