A rare case of tuberculosis tonsil

Complaints:

50 years old male patient came with complaints of:

1. Sore throat - 2 months

2. Painful swallowing - 2 months (odynophagia)

History:

1. Loss of weight and loss of appetite +

2. H/O left ear pain - 1 month

3. H/O cough - 1 month

He gave no history of hemoptysis, evening rise in temperature.

Personal history:

He is a known smoker and alcoholic.

On examination:

Patient is ill built.

Oral cavity:

Ulcerative lesion seen in the left tonsil. Anterior and posterior pillars are found to be eroded.

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Clinical photograph of the patient showing lesion in the left tonsil

Examination of neck:

Showed enlarged and tender palpable jugulodigastric node on the left side. It was mobile.

Differential diagnosis:

1. Carcinoma tonsil

2. Tuberculosis, Syphilis, Leprosy of tonsil.

Investigation:

Biopsy from the lesion was taken.

Histopathology report:

Section studied shows granulomatous lesion showing areas of caseous necrosis.

Epithelial giant cells and Langhan's giant cells seen.

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Figure showing histopathology of biopsied specimen.

X ray chest taken showed milliary mottling.

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X ray chest showing miliary mottling

Sputum for AFB: Demonstrated tuberculous acid fast bacilli.

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Figure demonstrating AFB in sputum.

Discussion:

Tuberculosis involving the tonsil is very rare. These days it is still rare because of
better milk processing techniques like pasteurization which eradicates the bovine
strain of tuberculosis. Even though tonsils are situated in an exposed area where
infected material like sputum and food stuffs come into contact this lesion is rare
because of the following features:

1. Antiseptic and cleansing action of saliva (first and foremost)

2. Presence of saprophytic organisms in the oral cavity which prevents growth of tubercle bacilli

3. The stratified squamous epithelial lining of the tonsil also offers some degree of protection

Tuberculosis of tonsils may be:

Primary - Due to ingestion of infected milk (Bovine strain)

Secondary - Due to pulmonary infection. The coughed out infected sputum
finds its way to the throat to involve the tonsils.

Diagnosis of tuberculosis of tonsil is not straight forward. It needs high degree of suspicion.

Pointers for the diagnosis of tuberculosis tonsil:

1. Asymmetric enlargement of tonsil

2. Tonsillar enlargement without exudate

3. Obliteration of crypts

4. Painful deglutition

5. Presence of enlarged mobile jugulodigastric nodes

Management:

This patient was managed with anti TB drugs.

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