Lymph node nucleus

Introduction to lymphatic tuberculosis Lymphatic tuberculosis, known as sputum in Chinese medicine, is a toxic block tissue embodied in the muscle surface, which is formed by the condensation of scorpion venom and heat in both liver and lung. Western medicine means that the human body has specialized in clearing poison and poisoning to protect blood vessels, and the lymphatic system of the tissue encounters poisonous bacteria that cannot be removed from the body and the body, and aggregates and accumulates in the formation of tumor tissue. basic knowledge The proportion of sickness: 0.01% Susceptible people: no special people Mode of infection: respiratory transmission Complications: tuberculosis

Lymphatic tuberculosis

There are two causes of lymph node tuberculosis:

One is infection of the primary tumor caused by Mycobacterium tuberculosis through the upper respiratory tract or with food in the mouth and nasopharynx, especially the tonsil gland. The posterior lymphatic vessels reach the shallow deep lymph nodes of the neck. Most of the sites are unilateral lymph nodes. Affected throat. Lymphatic tuberculosis continues to develop after the onset of severe disease, and forms a cold abscess or ulcer.

The other is that the tuberculosis in the blood after the original tuberculosis infection enters the medial cervical lymph node with the blood, causing cervical lymph node tuberculosis; it can also be infected from the lumbar and abdominal lymph nodes, and then the infection of the deep lymph nodes, which is more common in the pathogenesis of cervical lymph node tuberculosis. common.

Lymphatic tuberculosis prevention

Control the source of infection

The main source of infection of tuberculosis is tuberculosis patients, especially those with positive tuberculosis, who receive reasonable chemotherapy in the early stage. The tuberculosis in the tuberculosis is reduced in the short term, and even disappears, almost 100% can be cured, so early detection of patients, especially bacteria positive And timely giving reasonable chemotherapy is the central link of modern flood control work.

The method of early detection of patients is to timely X-ray chest X-ray and bacteriological examination of the following groups:

(1) Chronic cough, hemoptysis is not treated by antibiotics.

(2) Contactors around patients with open tuberculosis.

(3) Family members of children with strong positives in the test.

(4) Factory workers, especially silicosis patients.

(5) Regular chest X-ray examination of people in areas with more TB, early detection of some asymptomatic patients.

Cut off the route of infection

Tuberculosis is mainly transmitted through the respiratory tract. Therefore, it is forbidden to spit. The cockroaches, daily necessities, and surrounding things of the bacteria-positive patients should be disinfected and properly treated. The indoors can be disinfected daily by ultraviolet radiation or once every other day for 2 hours. The used utensils should be boiled. Disinfect for 10-15 minutes, and be exposed to the sun for 4-6 hours. The toilet can be soaked for 5% to 5%-10% for 2 hours. It is best to burn the sputum on paper or soak it with 20% bleach solution. -8 hours.

BCG

BCG is a non-virulent live vaccine. After inoculation in human body, the person who is not infected with tuberculosis can obtain specific immunity against tuberculosis, and the protection rate is about 80%. It can be maintained for 5-10 years, so it is necessary to replant the sputum test after a few years. The vaccination target is the infection of tuberculosis without sputum, and the sputum test is negative. The younger the better, usually within three months after birth, mainly for newborns and infants, primary and middle school students and citizens of minority areas who newly enter the city. Inoculation and re-inoculation were carried out in patients with negative lignin test. The inoculation method was intradermal injection and skin scratching, and intradermal injection was preferred. The effect of BCG vaccination is certain, especially the incidence of children including acute miliary tuberculosis and tuberculous meningitis is significantly reduced, but the immunity produced by BCG is relatively relative, and other preventive measures should be emphasized.

Lymphatic tuberculosis complications Complications, tuberculosis

Cervical lymph nodes; rapid onset of childhood tuberculosis and limited child endurance is prone to complications. If not treated in time, it can be extended to all organs of the body (such as lung, bone, brain, etc.) and deteriorate.

Lymphatic tuberculosis symptoms Common symptoms Lymph node tuberculosis Progressive neck mass Tuberculosis poisoning Lymph node degeneration Loss of appetite Loss weight Low heat night sweats

More on the side of the neck or on both sides of the sputum, gradually grow up, no pain, no itching, push and slide, no obvious tenderness, such as low body resistance, gradually increase, the skin becomes purple, and finally breaks the watery sample Pus and discharge yellow turbid cheese-like pus, Chinese medicine called "mouse sores." Repeated ulceration is less, some patients may have symptoms of systemic poisoning such as low fever, stealing, loss of appetite, and weight loss.

Lymphatic tuberculosis typing

Lymphatic tuberculosis classification: cheese-type tuberculosis, proliferative tuberculosis, mixed tuberculosis, and non-reactive tuberculosis.

Disease classification

Tuberculosis is generally named after parts and organs. According to the location of the lymphatic tuberculosis, there are mainly the following:

Cervical lymph node

This is the most common form of lymphatic tuberculosis, with more women than men. According to Japanese statistics, men are the most in the 30-year-old age group and women are the 50-year-old age group. The location of the disease is more common on the right side. Western medicine believes that this disease is caused by the invasion of tubercle bacilli through the mouth (caries or tonsils), from the lymphatic vessels to the submandibular or axillary lymph nodes; it can also be caused by the spread of blood in the lungs and intestinal tuberculosis. Chinese medicine believes that this disease is caused by emotional stagnation, liver qi stagnation, spleen deficiency and phlegm. Liver stagnation heats up, fights heat, and respects the veins of the neck. Also the factors are weak, lung and kidney yin deficiency, causing yin deficiency and anger, bonfire condensed into sputum.

Axillary lymphatic tuberculosis

The disease is rare in clinical practice. Patients often complain of swollen lymph nodes in the axillary fossa, and pain is seen. There are also calcifications in the axillary or upper chest wall during chest X-ray examination.

Inguinal lymphatic tuberculosis

Inflammation of the inguinal lymph nodes, mostly from the lower limbs or genital trauma. However, tuberculosis spreads throughout the body and can occasionally occur. It can start with swelling that is only accompanied by mild pain. If it is not actively treated, it can self-destruct.

Abdominal lymphadenopathy

Generally, abdominal lymphadenopathy occurs successively due to systemic dissemination or on the basis of intestinal tuberculosis. In the main complaint, there may have been no digestive symptoms in the past, and no lesions were found in the lungs. There are also those who have had symptoms of intestinal tuberculosis in the past, or because they have been treated for tuberculosis.

Hilar lymphatic tuberculosis

When the body has not yet developed an allergic reaction, the tuberculosis in the primary primary infection of the lung invades the lymph node by the lymphatic flow. There are many lymph nodes from the hilar to the mediastinum. When the disease progresses, the mediastinal lymph nodes also become diseased, forming various degrees of cheeseification, from the lung lymph node flow through the hilar mediastinal lymph nodes, and finally from the right venous horn lymph into the pulmonary vein, so tuberculosis easily with it into the bloodstream. Therefore, hilar lymphatic tuberculosis is in a state prone to potential bacteremia.

Lymphatic tuberculosis examination

1, clinical examination

First of all, pay attention to whether the bilateral lymph nodes are symmetrical, whether there is local swelling or fistula formation. Then lymph node palpation is performed. Pay attention to the location, size, texture, activity, presence or absence of tenderness or pulsation of the mass, and compare it with the two sides.

2, imaging examination

In addition to understanding the location and extent of the tumor, CT scan can help to determine the relationship between the mass and the body's tissue structure, providing an important reference for surgical treatment, but smaller tumors often cannot be developed. In order to find the primary lesion, X-ray film examination or X-ray film examination of iodized oil can be performed as appropriate.

3, pathological examination

(1) Puncture biopsy method: a small needle is inserted into the mass, and the tissue obtained after vigorous suction is subjected to cytopathological examination. Applicable to most neck lumps, but the tissue obtained is less. When the test is negative, it should be combined with clinical examination for further examination.

(2) Cut biopsy: it should be used with caution. Generally only when the diagnosis is not confirmed after repeated examinations. A single lymph node should be removed completely during surgery to prevent the spread of the lesion. When suspected tuberculous cervical lymphadenitis, after the biopsy is cut, it may lead to long-term failure of the wound, and attention should be paid to prevention. For patients with clinically diagnosed parotid-derived or neurogenic benign tumors, due to the deep tumor location, preoperative biopsy is not easy to obtain positive results, but it has the disadvantage of making the tumor adhere to surrounding tissues and increasing the difficulty of surgery. Pathological examination was performed after surgical removal of the tumor.

Lymphatic tuberculosis diagnosis

Diagnostic points

According to the history of tuberculosis exposure, local signs, especially when a cold abscess has formed or has formed a long-term unhealed sinus or ulcer, a clear diagnosis can be made; if necessary, chest fluoroscopy can be used to determine whether there is tuberculosis. The tuberculin test can help diagnose.

If only cervical lymph nodes are swollen without cold abscess or ulcer formation, there are multiple enlarged lymph nodes of different sizes on one or both sides of the neck, which are generally located at the anterior and posterior margins of the sternocleidomastoid muscle. The initially swollen lymph nodes are hard and painless and can be promoted. The lesion continues to develop inflammation around the lymph nodes, causing adhesions between the lymph nodes and the skin and surrounding tissues; each lymph node can also adhere to each other and fuse into a mass to form a nodular mass that is difficult to push. Case-like necrosis occurs in the advanced lymph nodes, and liquefaction forms a cold abscess. After the abscess ruptures, it will flow out the bean dregs or the thin soup-like pus, and finally form a long-term unhealed sinus or chronic ulcer. The skin of the ulcer is dark red, the granulation tissue is pale and edematous, and the above-mentioned different stages of the lesion can occur simultaneously in the lymph nodes of the same patient. The patient's ability to resist disease and tuberculosis of the lymph nodes after appropriate treatment can stop development and calcification.

Diagnose based on

(1) The lymph nodes are swollen, nodular, and painless. More common in children and youth.

(2) The initial stage is isolated nodules, which are smooth and movable. Later, the nodules merge into blocks, irregular, and the activity is poor. The mass can form an abscess, which has a sense of fluctuating. After the rupture, it can form a sinus tract, and sneak along with the lower part of the skin, and it will not heal for a long time.

(3) The secretions are thin, often containing cheese-like substances, and the wound granulation is unhealthy.

(4) There may be systemic symptoms such as low fever, night sweats, fatigue, and weight loss.

(5) Some patients may have a history of tuberculosis or lesions such as the lungs.

(6) Taking the diseased tissue for PCR detection, it may be a positive result.

(7) Pathological biopsy can confirm the diagnosis.

Differential diagnosis of lymphatic tuberculosis

(1) Differential diagnosis of lymphadenopathy caused by lymphatic tuberculosis and sexually transmitted diseases

1, soft squat

A focal infectious disease caused by Haemophilus Ducreyi. The genital painful small papules quickly collapse to form superficial ulcers, with irregular edges, redness around, and often merge with each other. The inguinal lymph nodes are swollen, tender and stick together to form an abscess and a sense of undulation. The skin above the abscess is red and bright, and can be broken to form a sinus. Should be differentiated from abscess lymph node tuberculosis. The diagnosis is mainly established by clinical manifestations and sexual life history, and can be differentiated from lymph node tuberculosis. Bacterial culture of this disease is difficult.

2, sexually transmitted lymphogranuloma

The disease is caused by the immunotype of the genus Chlamydia, which is more common in tropical and subtropical regions. The initial symptoms are unilateral tenderness of the inguinal lymph nodes, which develops a large, tender and fluctuating mass that adheres to deep tissues and inflammation of the upper skin, which can form fistulas. May be associated with systemic symptoms such as fever, headache, joint pain. Diagnosis of sexual life history, clinical manifestations and complement fixation test, conditions can be used for immunofluorescence microscopy.

3, AIDS

There is a subtype of AIDS-related syndrome, which is characterized by persistent systemic lymphadenopathy and lymphadenopathy that often lasts for more than 3 months. There is no history of any disease or medication that can cause lymphadenopathy in the near future. Check for AIDS virus antibody (HIV) positive. 1 In the near future (3 to 6 months), the weight loss is more than 10%, and the high fever is 38°C for more than one month; 2 in the near future (3 to 6 months), the weight loss is more than 10%, and the diarrhea continues (3~ daily) 5 times) more than one month; 3 Pneumocystis carinii pneumonia (PCR); 4 Kaposi's sarcoma (KS); 5 obvious mold or other conditional pathogen infection.

If the HIV antibody-positive person has weight loss, fever, and diarrhea symptoms close to the above 1 standard and has any of the following, the AIDS patient can be confirmed experimentally: 1CD4+/CD8 lymphocyte count ratio <1, cell count decreased; 2 systemic lymphadenopathy 3 obvious symptoms and signs of central nervous system occupying lesions, dementia, loss of discrimination or motor dysfunction.

Although there is a systemic lymphadenopathy, according to the history of the disease (selling blood or accepting the history of blood products, intravenous drug use, sexual abuse, etc.) and the above clinical manifestations and laboratory tests are not difficult to identify lymph node tuberculosis. Biopsy lymph node reactive hyperplasia.

(B) differential diagnosis of lymph node tuberculosis and connective tissue disease and rheumatism lymphadenopathy

1. Allergic subsepticemia

Children are more common than adults, clinical manifestations are: 1 long-term repeated fever; 2 repeated transient pleomorphic rash and joint pain; 3 lymph nodes, liver, splenomegaly; 4 blood, bone marrow culture negative; 5 antibiotic treatment is invalid, and Adrenal cortex hormones are effective.

2, sarcoidosis

A multisystem granulomatous disease of unknown cause. Can cause superficial lymph nodes such as the neck, the pulley, the armpits and other lymph nodes, sometimes up to the size of the walnut, hard, never soften, no adhesion, no adhesion to the skin. Diagnosis basis: 1 clinical manifestations of multiple organ damage; 2X-ray examination showed nodular alveolitis, pulmonary infiltration may be associated with hilar and mediastinal lymphadenopathy; 3 pathological examination revealed epithelioid cell granuloma, but no cheese-like changes 4 skin Kviem test positive, tuberculin skin test negative.

3. Systemic lupus erythematosus

Partial systemic lupus erythematosus (SLE) patients may have local or systemic lymphadenopathy, but lymphadenopathy is not a diagnostic clue for SLE. When patients, especially young women, develop fever, accompanied by skin erythema, polyarthritis, kidney damage, intermittent Pleural inflammatory pain, leukopenia, hyperglobulinemia, anti-DNA antibody positive, etc., diagnosis is not difficult. SLE is difficult to distinguish from other connective tissue diseases in the early stages. According to the history, tuberculin test and puncture or histopathological examination, it is not difficult to identify with lymphatic tuberculosis.

(3) Differential diagnosis of lymph node tuberculosis and tumor-induced lymphadenopathy

1. Malignant lymphoma

Malignant lymphoma is divided into two major categories of Hodgkin's disease and non-Hodgkin's lymphoma. They are painless progressive lymphadenopathy, early non-adhesive, and active. They occur in the neck, mediastinum and retroperitoneum. Lymph nodes, texture medium and hard as rubber. With the development of the disease, the scope of invasion is extremely wide, and it quickly merges into a block, without mobility. At this time, palpation has a cartilage-like feeling. Patients with Hodgkin's disease may be accompanied by systemic symptoms such as periodic fever, night sweats, and itchy skin, as well as significant swelling of the liver. Corrosive symptoms may occur in the adjacent organs due to enlarged lymph nodes, such as hoarseness, difficulty breathing, and Horner's syndrome. Pathological examination of peripheral blood and lymph nodes found that RS cells are the main diagnostic basis. Non-Hodgkin's lymphoma is predominantly painless lymphadenopathy, most occurring in the cervical lymph nodes, followed by the infraorbital and inguinal lymph nodes. If the onset of extranodal lymphoid tissue (gastrointestinal tract, tonsil, nasopharynx, lungs, spleen, liver, bones, skin, etc.), early misdiagnosis. When the deep lymph nodes are enlarged, the corresponding compression symptoms can also occur early. About 1/3 of patients have systemic symptoms such as fever, night sweats, weight loss, and anemia. Advanced lymphoma can invade the bone marrow, liver, skin and even the central nervous system and cause corresponding clinical manifestations. Pathological biopsy is the main basis for the diagnosis of lymphoma. When only mediastinal and abdominal lymph nodes are enlarged, CT or ultrasound-guided biopsy can be performed. If necessary, chest and abdominal cavity exploration can be performed (see Chapter 8 for differential diagnosis of hematogenous disseminated pulmonary tuberculosis).

2, chronic lymphocytic

Leukemia can cause extensive lymphadenopathy in the whole body, and it is more obvious in chronic lymphocytic leukemia, and the neck is more obvious. The enlarged lymph nodes are hard, inelastic, and non- tender. In the late stage, they can adhere to each other in a string, without mobility, without abscess formation, and the diameter can reach 2 to 3 cm, often accompanied by fever, hemorrhage, anemia, hepatosplenomegaly. The diagnosis of leukemia is mainly through the lymph nodes, but through the examination of peripheral blood and bone marrow to make a diagnosis. Leukemia patients generally have obvious hematological abnormalities. Blood and bone marrow examinations are generally difficult to break, but accurate classification often requires the use of histochemistry and immunohistochemistry.

3, plasma cell tumor

Many plasma cell tumors may have lymphadenopathy. Patients with multiple myeloma may have a large number of M proteins, osteolytic lesions and abnormal bone marrow cells in the blood and urine. It is not difficult to establish a diagnosis. Primary macroglobulinemia serum IgM is often >20g/L, lymphoid plasma cell infiltration in the bone marrow, heavy chain disease has four different heavy chain types, clinical manifestations vary, but can be detected by immunoelectrophoresis The presence of a monoclonal heavy chain and lymph node biopsy can be distinguished from lymph node tuberculosis, lymphoma, and myeloma.

4, malignant histiocytosis

Long-term fever, mainly high fever, with progressive systemic failure, weight loss, anemia, lymph nodes, liver, splenomegaly, complete blood cell reduction. Most of the lymph nodes in the whole body occur in the late stage of the disease and are easily misdiagnosed in the early stage. The diagnosis is mainly based on the presence of an abnormal number of abnormal tissue cells, multinucleated giant tissue cells in the bone marrow or peripheral blood. Diagnosis can also be established by pathological biopsy of lymph nodes, liver, spleen, and other affected sites. In recent years, it has been confirmed by immunohistochemistry that many of the malignant histiocytosis diagnosed in the past are T lymphomas, and the true evil group is only a minority.

5, Langerhan histiocytosis

For a group of diseases with unknown etiology and lymphoid and histiocytosis, the lesions often involve organs such as liver, spleen, lymph nodes, lungs and bone marrow. Divided into three types: 1 - (Letterer-Siwe) disease: seen in infants under 2 years old, with high fever, red maculopapular rash, respiratory symptoms, liver and spleen and lymphadenopathy as the main performance; 2 Han-Xue-Ke ( Hand-Schuller-Christian disease: more common in children and young people, with three characteristics of skull defect, exophthalmos and diabetes insipidus; 3 eosinophilic granuloma: more common in children, with long bone or flat bone dissolution of bone as the main Performance (see Chapter VIII Differential Diagnosis of Hematogenous Spreading Pulmonary Tuberculosis).

6, lymph node metastasis

For older and unexplained lymphadenopathy, special attention should be paid to the metastasis of certain primary tumors. The lymph nodes metastasized by cancer generally do not exceed 3cm, the texture is hard, the growth is fast, there is no tenderness, the adhesion to the substrate is poor, and the surface is uneven. Painless lymphadenopathy of the neck should pay attention to the metastasis of nasopharyngeal carcinoma and thyroid cancer. Breast cancer is often first transferred to the axillary lymph nodes. The supraclavicular lymph node metastasis can come from the stomach, bronchus, esophagus, mediastinum, pancreas and other organs. In general, the right supraclavicular lymph node metastasis has many years from respiratory cancer, while the left supraclavicular lymph node metastasis is mostly from digestive system cancer. . And often a late sign. Inguinal lymph node metastasis can be seen in genitourinary cancer. X-ray, CT, MRI, B-ultrasound, radionuclide scanning and some serological tests such as alpha-fetoprotein, carcinoembryonic antigen and other tests can help to find the primary tumor, but the diagnosis still requires histopathological basis.

(D) differential diagnosis of lymph node tuberculosis and lymph node enlargement caused by chronic infection

1. Chronic non-specific lymphadenitis

When cervical lymph node tuberculosis is in the proliferative phase (nodular), this type is easily confused with chronic cervical lymphadenitis. Chronic lymphadenitis often involves several lymph nodes in the lower layer of the lower jaw. The volume is small, and more infections can be found. For example, the head lesion can be transmitted to the ear and the mastoid lymph nodes. The oral and pharyngeal lesions can cause submandibular and sacral lesions. The lower lymph nodes are enlarged. Lymph node biopsy or needle aspiration pathology and cytology can confirm the diagnosis, such as tuberculosis can have pathological changes of tuberculosis, such as non-specific chronic lymphadenitis can be seen neutrophils, monocytes, plasma cell infiltration.

2. Nontuberculous mycobacterial lymphadenitis

The disease mainly invades the lymph nodes near the jaw and the upper jaw, mostly caused by Mycobacterium. Particularly good for children under 5 years of age, often without pulmonary tuberculosis, often need to distinguish from nodules and ulcers of cervical lymphatic tuberculosis. Non-tuberculous mycobacterial lymphadenitis is more common in the United States than tuberculous lymphadenitis, and is an important cause of cervical lymphadenitis. In the United States, nontuberculous mycobacterial lymphadenitis is 10 times more common than typical tuberculous lymphadenitis.

The symptoms of this disease are slightly faster than tuberculous lymphadenitis, and the enlarged lymph nodes are not red or painful, even if the lymph nodes increase by more than 3 cm. The anti-tuberculosis treatment is worse than tuberculous lymph node tuberculosis, and it is not cured for a long time. Its diagnosis is mainly based on bacteriological examination and classification of bacteria.

3. Infectious mononucleosis

This symptom often begins with the above symptoms, acute lymph node enlargement, common neck lymphadenopathy, especially in the left posterior neck group, the enlarged lymph nodes are moderately hard, non-adhesive, no suppuration, tenderness. May be associated with fever, angina, rash, lymphocytes up to 50% to 90%, and atypical lymphocytes, heterophilic agglutination test positive as high as 80% to 90%. Pathological examination can confirm the diagnosis.

4, filariasis

Ban and Malay worm infections can cause chronic lymphatics and lymphadenitis, with systemic or local superficial or deep lymphadenopathy, most commonly inguinal lymph nodes. If combined with lymphatic obstruction in the lower extremities, it can cause lower extremity rubber swelling. Eosinophilia in the blood increased, and the microfilaria in the peripheral blood was examined at night to confirm the diagnosis.

5. Toxoplasmosis (protozoa)

Single or a group of lymph nodes can be seen in the unilateral neck, mild tenderness or no pain, no pus, may have general malaise or low fever or no symptoms. Diagnosis depends on pathogen examination, toxoplasma test and complement fixation test.

6, leptospirosis (spiral disease) (see differential diagnosis of hematogenous disseminated pulmonary tuberculosis)

Rats and pigs are the main source of infection. In the early stage (heptospirosis), the clinical manifestations are fever; prominent headache, generalized muscle pain, especially gastrocnemius. General malaise, especially leg softness is obvious, sometimes walking is difficult, resulting in unable to get out of bed; conjunctival hyperemia, persistent, no secretions and photophobia; gastrocnemius tenderness; superficial lymph node enlargement, early onset More common in the groin, axillary lymph nodes, mostly soybeans or broad beans, tenderness, but no congestion and inflammation, no suppuration. Early diagnosis of this disease is difficult, and clinical diagnosis requires a positive pathogen or serological test results. The performance in the mid-term and recovery period is complex (see Chapter VIII for differential diagnosis of blood-borne pulmonary tuberculosis). Therefore, combined with epidemiological history, early clinical features and laboratory findings, a comprehensive analysis can be distinguished from lymph node tuberculosis.

7, fungal infection

Foot fungal infections can cause chronic inguinal lymphadenopathy. Histoplasmosis is common in hilar lymphadenopathy. Sporotrichosis is a chronic deep mycosis, and the affected tissue is papillary-like lesions, which can collapse, purulent and cause local lymphadenopathy. Identification with lymph node tuberculosis is not difficult, fungal smear and culture can be diagnosed.

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