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CASE REPORT
Year : 2014  |  Volume : 2  |  Issue : 2  |  Page : 61-63

Tuberculous lymph node calcification detected on routine panoramic radiography: An unusual case


1 Department of Dentomaxillofacial Radiology, Ondokuz May?s University, Samsun, Turkey
2 Department of Dentomaxillofacial Radiology, GATA, Dentistry Center, Ankara, Turkey

Date of Web Publication13-Aug-2014

Correspondence Address:
Gozde Canitezer
Department of Dentomaxillofacial Radiology, Faculty of Dentistry, Ondokuz May?s University, Samsun
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-3841.138650

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  Abstract 

Tuberculosis is one of the oldest and the most fatal diseases in the world. Cervical lymph node calcifications caused by tuberculosis are usually asymptomatic and may be found on a routine panoramic survey. This report describes the case of an asymptomatic 78-year-old patient whose panoramic radiograph showed bilaterally, irregularly shaped, massive, multiple calcified lymph nodes. We suggest that lymph node calcifications may have caused owing to delay in the diagnosis and the successful treatment.

Keywords: Tuberculosis, lymph node, panoramic.


How to cite this article:
Gunduz K, Canitezer G, Avsever H. Tuberculous lymph node calcification detected on routine panoramic radiography: An unusual case. J Oral Maxillofac Radiol 2014;2:61-3

How to cite this URL:
Gunduz K, Canitezer G, Avsever H. Tuberculous lymph node calcification detected on routine panoramic radiography: An unusual case. J Oral Maxillofac Radiol [serial online] 2014 [cited 2019 Dec 7];2:61-3. Available from: http://www.joomr.org/text.asp?2014/2/2/61/138650


  Introduction Top


Tuberculosis, a re-emerging infectious granulomatous disease caused mainly by Mycobacterium tuberculosis, is still one of the most significant health care problems worldwide. Less frequently, the disease may also be caused by other two species of bacteria, Mycobacterium bovis and Mycobacterium africanum[1] Tuberculosis is classified in two groups such as pulmonary and extra pulmonary. Extra pulmonary type of tuberculosis affects the central nervous system, the lymphatic system, the circulatory system, the genitourinary system, the gastrointestinal system, bones, joints and the skin. [1],[2] Lymph calcifications are frequently seen in tuberculosis. The other well-known diseases which cause lymph calcifications include sarcoidosis, rheumatoid arthritis, systemic sclerosis, fungal infections, metastatic thyroid carcinoma and metastases from distant calcifying neoplasm. [2] Calcified lymph nodes are generally asymptomatic and they first discovered as incidental findings on panoramic radiographic examinations. The most commonly involved nodes are the submandibular, superficial and deep cervical lymph nodes. They are seen less commonly in preauricular and submental areas. They usually do not require treatment. [2]


  Case Report Top


A 78-year-old Caucasian male patient referred to Oral Diagnosis and Radiology Clinic, Gulhane Military Medical Faculty, Ankara, Turkey with a chief complaint of slight pain on the right side of mandibula and total edentulism of maxilla and mandibula. The medical history is not significant for any serious disease. On extra-oral examination a swelling on the left submandibular area was found. On intraoral examination the mucosal tissues were found normal in appearance. Panoramic radiographic examination revealed a horizontal impacted third molar tooth in the right side of mandible, and unexpectedly revealed bilaterally multiple discrete irregular calcified bodies in the both sides of the submandibular region [Figure 1]. The calcified body in the right side measured 30 × 12 mm, and on the other side measured 8 × 18 mm. He had no subjective symptoms; he was unaware of the existence of the calcified bodies. Questioning elicited no information regarding the presence of any discomfort or swellings in the involved areas. According to the patient's past history he had suffered pulmonary tuberculosis at the age of 20. The other findings in the medical history were non-contributory. The patient's tuberculin test was positive and the complete blood count and biochemistry tests were all within normal limits. A computed tomography scan was ordered and axial non-enhanced computerized tomography (CT) showed multiple calcific lymph nodes at the level IIA-IIB and in the superficial lobe of the right parotid gland [Figure 2]. The patient was informed about the radiographic findings and decision was given to make total prosthesis and observe the patient.
Figure 1: Panoramic radiographs showing bilateral radiopaque masses inferior
to the angulus mandible


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Figure 2: Axial scans of CT shows bilateral lymph nodes calcifi cation at the
level IIA-IIB and in the superfi cial lobe of the right parotid gland


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  Discussion Top


As one of the oldest diseases, tuberculosis is a common and often deadly infectious granulomatous disease caused by M. tuberculosis.[1],[3] Tuberculosis has been present in humans since the ancient times. The earliest unambiguous detection of M. tuberculosis is in the remains of bison dated 18,000 years before the present. [4] Incidence of tuberculosis rises with some immunosuppressive diseases such as leukemia, HIV or diabetes. Also, some socioeconomic conditions such as war, poverty, hunger, immigration make incidence higher. One third of the world's population has been exposed to the tuberculosis pathogen. But all over the world eight million people, 40 % of whom die each year infected with tuberculosis. [5] According to the World Health Organization (WHO) in 2004 incidence rate has varied from 356 per 100,000 people in Africa to 41 per 100,000 people in America. [6] The incidence of tuberculosis in 2000 was reported as 27 per 100,000 people in Turkey. [5],[7]

Although the tuberculosis is classified as pulmonary and extrapulmonary, 75 % of this is pulmonary. While pulmonary tuberculosis mostly occurs among males extrapulmonary tuberculosis mostly occurs among females. [8],[9] Systemic symptoms of tuberculosis are fever, chills, night sweats, appetite and weight loss, pallor and tendency to exhausting easily. [8] Smoking, genetic or hormonal features, alcohol consumption are attributing factors for tuberculosis. [9] In the past, the most common cause of tuberculosis was ingesting unpasteurized bovine milk infected with M. bovis. It is reported that consumption of pasteurized milk significantly decreased the prevalence of such lymph node tuberculosis. [10],[11] The patient in the present case has declared that he was living in a village and ingested unpasteurized milk in his childhood. We suggest that lymph node tuberculosis may have been the result of ingesting milk infected with M. bovis.

Extrapulmonary tuberculosis can affect virtually any organ system but in many studies it is reported that lymph nodes are affected more commonly. [7],[10],[12],[13],[14] Lymph node tuberculosis is most commonly encountered in cervical lymph nodes. [10],[12],[15],[16] But, cervical lymph node calcification is a rare condition. Tuberculosis calcifications mostly occur in the nodes of chest and abdomen. [17] Eisenkraft and Som [18] have reported that only 1% of the 2300 neck CT scans revealed cervical lymph node calcification. The range of the incidence of cervical lymph node calcification in lymph node tuberculosis was reported as 6-7 % in other studies. [19],[20] Calcified lymph nodes were generally characterized by scars and swellings in neck area, but the patient in the present case showed no scars but swelling on the left submandibular area.

Differential diagnosis of lymph node calcification must be done with Bacille Calmette-Guerin vaccination, sarcoidosis, cat-scratch disease, rheumatoid arthritis and systemic sclerosis, histoplasmosis, lymphoma previously treated with radiation therapy, fungal infections and metastases from distant calcifying neoplasms. [2]

Cervical calcified lymph nodes were first encountered as incidental findings on panoramic radiographic surveys. Differential diagnosis of calcifications on panoramic radiographs included lymph node calcifications, sialolith, radiopaque lesions of the bone, superimposed myositis ossificans, idiopathic calcification, ghost images, foreign bodies, carotid atheromas, calcified stylohyoid ligament complex, tonsillithiasis and phlebolithiasis. [2],[21] Because treatment is unnecessary for symptom-free calcified lymph nodes and the patient in the present case was unwilling to undergo any further examination, surgical removal of the calcified lymph nodes was not done.

In conclusion, the patient's past history and anamnesis should be carefully noted and encountered lymph node calcifications should be considered in the differential diagnosis of radiopaque nodes found on panoramic radiographs.

 
  References Top

1.Ito FA, de Andrade CR, Vargas PA, Jorge J, Lopes MA. Primary tuberculosis of the oral cavity. Oral Dis 2005, 11: 50-3.  Back to cited text no. 1
    
2.White SC, Pharoah MJ. Oral Radiology Principles and Interpretation. 6th ed. St. Louis, Missouri: Mosby Elsevier; 2009. p. 526-7.  Back to cited text no. 2
    
3.Ishikawa K, Hoshinaga K, Maruyama T, Izumitani M, Shiroki R. Mycobacterium tuberculosis infection of bilateral cervical lymph nodes after renal transplantation. Int J Urol 2001;8:640-2.  Back to cited text no. 3
    
4.Rothschild B, Martin L, Lev G, Bercovier H, Bar-Gal G, Greenblatt C, et al. "Mycobacterium tuberculosis complex DNA from an extinct bison dated 17,000 years before the present". Clin Infect Dis 2001;33:305-11.  Back to cited text no. 4
    
5.Ilgazli A, Boyaci H, Basyigit I, Yildiz F. Extrapulmonary tuberculosis: clinical and epidemiologic spectrum of 636 cases. Arch Med Res 2004;35:435-41.  Back to cited text no. 5
    
6.World Health Organization(WHO). Tuberculosis Fact sheet No: 104, Global and regional incidence. March 2006.  Back to cited text no. 6
    
7.Öztop A, Ünsal I, Özgü A, Özgüven S, Köse I, Çakmak R. 1999-2002 Yýllarý Arasýnda Kahramanlar Verem Savaþý Dispanseri'ne Yapýlan Tüberkülozlu Hasta Bildirimlerinin Degerlendirilmesi. Toraks Dergisi 2005;6:243-50.  Back to cited text no. 7
    
8.Kara MI, Yeler D, Yeler H, Ay S. Panoramic Radiographic Appearance of Massive Calcification of Tuberculous Lymph Nodes. J Contemp Dent Pract 2008;9:108-14.  Back to cited text no. 8
    
9.Cailhol J, Decludt B, Che D. Sociodemographic factors that contribute to the development of extrapulmonary tuberculosis were identified. J Clin Epidemiol 2005;58:1066-71.  Back to cited text no. 9
    
10.Aydin U. Tuberculous lymph node calcification detected on routine panoramic radiography: A case report. Dentomaxillofac Radiol 2003;32:252-4.  Back to cited text no. 10
[PUBMED]    
11.Wright SM. Massive calcification following tuberculosis. Oral Surg Oral Med Oral Pathol 1988;65:262-4.  Back to cited text no. 11
[PUBMED]    
12.Talukder MS, Huq MH, Haque A, Sarker CB. Extrapulmonary tuberculosis in surgical specimens. Mymensingh Med J 2002;11:104-6.  Back to cited text no. 12
    
13.Hayati IN, Ismail Y, Zurkurnain Y. Extrapulmonary tuberculosis: A two-year review of cases at the General Hospital Kota Bharu. Med J Malaysia 1993;48:416-20.  Back to cited text no. 13
    
14.Moudgil H, Leitch AG. Extra-pulmonary tuberculosis in Lothian 1980-1989: Ethnic status and delay from onset of symptoms to diagnosis. Respir Med 1994;88:507-10.  Back to cited text no. 14
    
15.Jha BC, Dass A, Nagarkar NM, Gupta R, Singhal S. Cervical tuberculous lymphadenopathy: Changing clinical pattern and concepts in management. Postgrad Med J 2001;77:185-7.  Back to cited text no. 15
    
16.Geldmacher H, Taube C, Kroeger C, Magnussen H, Kirsten DK. Assessment of lymph node tuberculosis in northern Germany: A clinical review. Chest 2002;121:1177-82.  Back to cited text no. 16
    
17.Gormly K, Glastonbury CM. Calcified nodal metastasis from squamous cell carcinoma of the head and neck. Australas Radiol 2004;48:240-2.  Back to cited text no. 17
    
18.Eisenkraft BL, Som PM. The spectrum of benign and malignant etiologies of cervical node calcification. AJR Am J Roentgenol 1999;172:1433-7.  Back to cited text no. 18
    
19.Lee Y, Park KS, Chung SY. Cervical tuberculous lymphadenitis: CT findings. J Comput Assist Tomogr 1994;18:370-5.  Back to cited text no. 19
    
20.Kim YJ, Sung KJ, Kim MS, Hong IS. CT manifestations of cervical tuberculous lymphadenitis. J Otolaryngol 1993;22:321-5.  Back to cited text no. 20
    
21.Wood NK, Goaz PW, Lehnert JF. Periapical radiopacities. In: Wood NK, Goaz PW, editors. Differential Diagnosis of Oral and Maxillofacial Lesions. 5 th ed. St Louis, Missouri: Mosby-Year Book; 1997. p. 474.  Back to cited text no. 21
    


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