Vol.2, No.5, 291-293 (2013) Case Reports in Clinical Medicine
Non-caseating submental tuberculous
lymphadenopathy: A case report
M. E. Asuquo1*, V. I. Nwagbara1, S. Akpan1, G. Ebughe2, T. Ugbem2, I. M. Asuquo3
1Department of Surgery, University of Calabar/University of Calabar Teaching Hospital, Calabar, Nigeria;
*Corresponding Author: mauefas@yahoo.com, mauefas54@gmail.com
2Department of Pathology, University of Calabar/University of Calabar Teaching Hosp ital, Calabar, Nigeria
3Department of Curriculum and Teaching, Faculty of Education, University of Calabar, Calabar, Nigeria
Received 10 May 2013; revised 20 June 2013; accepted 10 July 2013
Copyright © 2013 M. E. Asuquo et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Chronic peripheral ly mphadenop athy in adult s is
an indication of pathology of which tuberculosis
is the commonest in the developing countries.
Presented is a 36-year-old with a huge chronic
Submental lymphadenopathy in a seronegative
patient of 7 years duration. Histology revealed
non-caseating tuberculosis. Tuberculosis should
be considered in Submental lymphadenopathy.
Despite the long duration, the absence of cold
abscess, and or sinus formation may be an in-
dication of the non-caseating tuberculous lym-
Keywords: Tuberculosis; Submental L ymph Node;
Non-Caseating Granuloma
Chronic peripheral lymph node enlargement in adults
is an indication of an underlying disease that may pose a
diagnostic dilemma to physicians [1]. The commonest
lymph node group affected is reported to be the cervical,
the clinical manifestation varies with the challenges of
diagnosis not unusual [2,3]. Tuberculosis (TB) has been
reported as a common cause of chronic lymphadenopa-
thy in the develop ing countries and one of the most com-
mon of all extra pulmonary (TB) [4,5]. However, in the
developed countries with the rarity of infections, malign-
nancies are reported as the predominant cause of periph-
eral lymphadenopathy [1]. In developing countries in
Asia and Africa where tuberculous infection is common
and other granulomatous infections rare, the presence of
granulomatous features on histology are suggestive of
TB [3]. We present this case of florid non-caseating Su b-
mental tuberculous lymphadenopathy in a human im-
munodeficiency virus (HIV) seronegative patient to high-
light its unusual presentation; diagnostic challenge due to
ulceration from topical herbal medication, florid lesion in
an unusual group of lymph no de without any identifiab le
primary lesion.
A 36 years old applicant (engineer) presented to the
surgical out patient department (SOPD) as a referral from
the general out patient department with a 7-year history
of an anterior neck swelling. The swelling began as a
nodule, which he felt but was not visible, however in-
creased gradually to the size at presentation. There was
no associated fever, cough, and night sweats. There was
no history of trauma or dental pain, mass was painless
and not associated with pain or difficulty in swallowing.
There was no swelling in any other part of the body. He
sought treatment in some hospital facilities (private and
government) to no avail. Two months prior to presenta-
tion, he applied topical herbal preparation that resulted in
a wound hence his presentation to the University of
Calabar Teaching Hospital (UCTH), Calabar.
Examination revealed a young man in relative good
health, afebrile, and not pale. There was a firm, painless,
lobulated, ulcerated, and immobile mass in the Submen-
tal region of the neck. It measured 8 cm × 6 cm. The
edge of the ulcer was slopping with the floor that showed
granulation tissue with some spots with sloughs and
fixed to the underlying structure, Figures 1(a) and (b).
Examination of the oral cavity, ear nose, and throat, chest
and abdominal examination were normal. A clinical di-
agnosis of Submental lymphad enopathy was made.
Full blood count (FBC) showed: haemoglobin 12.9
g/dl, white blood cell 6.5 × 199/l (neutrophils 40%, eosi-
nophils 2%, and lymphocytes 58%), human immunode-
ficiency virus (HIV) serology was negative and urinaly-
Copyright © 2013 SciRes. OPEN ACCESS
M. E. Asuquo et al. / Case Reports in Clinical Medicine 2 (2013) 2 91-293
Figure 1. (a) Clinical photograph of submental lymphadeno-
pathy (Anterior view); (b) Clinical photograph submental lym-
phadenopathy (Lateral view).
sis was normal. Chest X-ray was normal, ultrasonogra-
phy reported, predominantly solid heterogeneous mass,
lobulated in outline. It appeared to arise from the subcu-
taneous tissue encroaching on the muscle plane, possibly
lymphoproliferative disorder, or fibrolipoma. Fine needle
aspiration biopsy (FNAB) reported a haemorrhagic back-
ground with mature lymphocytic infiltrate and occasional
histiocytes. Histopathology report showed numerous non-
caseating granulomas consisting of epitheloid cells, lym-
phocytes, plasma cells, and fibroblasts, interspersed by
occasional multinucleate giant cells. The surrounding stro-
ma was fibrocollagenous—non-caseating granuloma, Fig-
ures 2 (a) and (b).
Follow up in the SOPD while awaiting result of his-
tology revealed healing of the ulcer with the mass per-
sistent. Following the diagnosis of Submental tubercu-
lous (non-caseating) lymphadenopathy, he was referred
to the endemic disease unit for further management.
Tuberculosis ranks second as the leading infectious
cause of death in the world after HIV [6]. The emergence
of HIV introduced a new component to the ep idemiology
of TB with extra pulmonary TB including lymphade-
nopathy TB being more common [7]. Several reports
from the tropics describe TB and other infectious aetiol-
ogy as major causes of lymph node enlargement [8]. The
Figure 2. (a) Non-caseating granuloma H & E ×40; (b) Non-
caseating granuloma H & E ×100.
Copyright © 2013 SciRes. OPEN ACCESS
M. E. Asuquo et al. / Case Reports in Clinical Medicine 2 (2013) 2 91-293
Copyright © 2013 SciRes. OPEN ACCESS
commonest site of tuberculous lymphadenopathy re-
ported was cervical. Its involvement of cervical lymph
nodes has been known a long time as Scrofula or the
Kings Evil [9]. Olu-Eddo and Omoti reported lympha-
denopathy as the single commonest cause of cervical
lymphadenopathy constituting 35% of cases [4], and in
Saudi Arabia, Al-Sohaibani reported 28% [10]. This com-
munication describes a huge tuberculous lymphadeno-
pathy in an HIV seronegative patient in an uncommon
location for tuberculous cervical lymphadenopathy.
Tuberculous lymphadenopathy is largely confined to
the cervical lymph nodes mostly because tonsils and ade-
noids provide an easy portal of entry for inhaled myco-
bacteria [5]. It may also result from lymphatic or ha-
ematogenous dissemination from an original focus in the
lungs [5], our patient had no identifiable dental or oral
lesion. However, some lesions may be healed without
being detected and may be the case in our patient whose
evaluation revealed no primary focus despite the huge
Submental lymphadenopathy.
Majority of TB is diagnosed on clinical grounds with
or without histological appearance of the biopsy [5]. Ac-
tive lesions are seen as characteristic granulomatous in-
flammatory reaction that forms caseating and non-caseat-
ing tubercles [6]. Our patient’s histologic features were
consistent with non-caseating TB, Figure 2. It is less
common (20%) and described as hypertrophic. The firm
consistency was in keeping with the clinical evaluation
despite the long duration of the lesion; this variety was
unlikely to form cold ab scess and eventually a sinus seen
in the caseating form. The non-caseating TB is seen in
patients with good immunity [11], consistent with our
In the authors’ setting tradition al healers, enjo y a lot of
patronage especially with long standing lesions. Topical
herbal medication induced chemical inflammation of the
skin and ulceration and was capable of misdirecting cli-
nical judgement and therapy. Delay in presentation and
diagnosis was due to the inability of previous consulta-
tions to result in a proper diagnosis while the morbidity
associated with topical herbal medication, ulceration,
prompted presentation. Health education is pivotal for
early presentation. Physicians should subject chronic cer-
vical lymphadenopathy to histologic evaluation for di-
agnosis and proper treatment as this is crucial for sat-
isfactory outcome.
Huge Submental chronic lymphadenopathy may be
tuberculous. The effect of topical herbal medication on
clinical evaluation should not be underestimated like-
wise the morbidity. Diagnosis is histologic, long-standing
chronic lymphadenopathy without suppuration in a sero-
negative patient should arouse the diagnosis of non-
caseating TB.
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