|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 2 | Page : 94-95
Tubercular tonsilits: A rare clinical entity
Ajay Kumar Verma1, HP Singh2, Ved Prakash1, Surya Kant1, Nitesh Tayal1, Malti Kumari2
1 Department of Pulmonary Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of ENT and Pathology, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Web Publication||23-Jun-2014|
Department of Pulmonary Medicine, King George's Medical University, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Verma AK, Singh H P, Prakash V, Kant S, Tayal N, Kumari M. Tubercular tonsilits: A rare clinical entity. J Assoc Chest Physicians 2014;2:94-5
Tuberculosis (TB) is one of the most common infections worldwide. Oral cavity is an uncommon site for extrapulmonary TB. Among extrapulmonary TB involving oropharynx, larynx is the most common site.  TB of the tonsil in the absence pulmonary involvement is a rare entity with only a few cases reported worldwide.  Early detection and intervention is essential for cure.
A 35-year-old male presented to us with the complaints of sore throat and dry cough for past 4 months. There was no history of fever, hoarseness of voice, gastroesophageal reflux disease, and vomiting. Patient had taken repeated courses of antibiotics, but did not show any response. On oral examination, bilateral tonsils were enlarged and hyperemic. Rest of the oral cavity was apparently normal on gross appearance. There was no cervical lymphadenopathy and dental caries. The examination of chest was normal. Routine investigations revealed hemoglobin 13 g%, total leukocyte count 6900/mm 3 , and differential leukocyte count shows 65% polymorphs, 32% lymphocytes, and 3% eosinophils. Liver and renal function tests were normal. Mantoux test was positive with 16 mm × 18 mm induration. X-ray of the chest was within normal limits. The patient was human immunodeficiency virus seronegative. Punch biopsy was taken from both right and left tonsil. Histopathology revealed multiple lymphoid follicles, occasionally showing prominent germinal follicles along with multiple granulomas comprising of epithelioid cells, lymphocytes, plasma cells, histiocytes, and Langhan's giant cells [Figure 1]a and b]. The acid-fast bacilli were not detected. The patient was treated with 2HRZE/4HR daily regimen of isoniazid (300 mg), rifampicin (450 mg), ethambutol (800 mg), and pyrazinamide (1500 mg) for 2 months, followed by rifampicin (450 mg), and isoniazid (300 mg) for the next 4 months. He had responded well to the treatment. During follow-up symptom subsided and on examination, hyperemia and size of tonsils was decreased.
Oral and oropharyngeal TB lesions are uncommon, it is estimated that only 0.05-5% of total TB cases may present with oral manifestations.  Involvement of the oral cavity and oropharynx by TB can represent primary or, more often, secondary to pulmonary TB. The lesions of primary oral TB generally occur in younger patients.  Tonsillar TB commonly presents with sore throat and cervical lymphadenopathy.  Single or multiple ulcers with undermined edges may be seen over tonsils. Diagnosis of tonsillar TB is based on histopathological findings and more definitely by the identification of tubercle bacilli.  Differential diagnosis of oral and pharyngeal TB includes traumatic ulcers, aphthous ulcers, hematological disorders, syphilis, mid-line granuloma, Wegner's disease, and malignancy.  Treatment is in the form of anti-TB therapy. The clinician should have a high index of suspicion of the possibility of TB, especially in patients not responding to antibiotics and in developing countries like India where the incidence of TB is quite high.
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