Guideline Summary for Cervical Tuberculous Lymphadenitis (Scrofula)

1. Standard Antituberculous Chemotherapy

• Six‑month regimen is the recommended first‑line therapy – 2 months of rifampicin, isoniazid, pyrazinamide, and ethambutol followed by 4 months of rifampicin and isoniazid. This short‑course regimen is as effective as longer (9‑month) courses for peripheral lymph‑node disease. Strong recommendation. 1
• Adult dosing:
• Pediatric dosing (weight‑based): Isoniazid 5 mg/kg, rifampicin 10 mg/kg, pyrazinamide 35 mg/kg, ethambutol 15 mg/kg, administered for the same 6‑month total duration. Strong recommendation. 2

2. Role of Surgery

• Surgery is not a primary treatment; it is reserved for specific indications such as:
• Therapeutic excision as a primary modality yields >90 % cure but is unnecessary when the standard medical regimen is effective. Conditional recommendation. 4
• Incision and drainage should be avoided because it is associated with prolonged wound discharge, fistula formation, and scarring. Strong recommendation. 3
• Therapeutic aspiration may be considered for large, fluctuant nodes that are about to drain spontaneously, although evidence is limited. Weak recommendation. 3

3. Baseline Assessments Before Therapy

• Visual acuity testing is required for any patient who will receive ethambutol; patients must be instructed to stop the drug immediately if visual changes occur. Strong recommendation. 5
• Renal function evaluation is necessary before using streptomycin or ethambutol; dose adjustments or drug avoidance are advised in renal impairment. Strong recommendation. 5
• Baseline liver function tests (AST/ALT, bilirubin) are mandatory for all patients prior to initiating therapy. Strong recommendation. 5

4. Monitoring During Treatment

4.1 Liver Function

• Patients with chronic liver disease: monitor liver enzymes weekly for the first 2 weeks, then every 2 weeks for the first 2 months of therapy. Strong recommendation. 5
• Patients with normal baseline liver function: routine monitoring is not required; repeat testing only if clinical symptoms (fever, malaise, vomiting, jaundice, unexplained deterioration) develop. Strong recommendation. 5
• Management of hepatotoxicity: discontinue rifampicin, isoniazid, and pyrazinamide if AST/ALT rise to ≥ 5 × upper limit of normal or bilirubin rises. Withhold treatment until liver enzymes normalize if the patient is clinically well; substitute streptomycin and ethambutol if the patient is unwell or smear‑positive. Strong recommendation. 5

4.2 Visual Monitoring

• Patients on ethambutol must be able to report visual symptoms promptly and stop the drug immediately if changes occur. Strong recommendation. 5

4.3 Clinical Response

• Paradoxical reactions (enlargement of existing nodes or appearance of new nodes) are common during or after therapy and do not indicate treatment failure; therapy should be continued and surgical excision avoided. Strong recommendation. 3

5. Special Populations

5.1 HIV‑Positive Patients

• Rifampicin markedly reduces protease‑inhibitor levels via CYP3A induction. Strong recommendation. 5
• Management options:

5.2 Pediatric Considerations

• The same 6‑month regimen used in adults is recommended for children. Strong recommendation. 1
• In the United States, most cervical lymphadenitis in children is caused by nontuberculous mycobacteria (NTM) rather than M. tuberculosis. Strong recommendation. 3

6. Nontuberculous Mycobacterial (NTM) Cervical Lymphadenitis

• When NTM (especially MAC) is identified, primary treatment is surgical excision, achieving >90 % cure. Strong recommendation. 4
• Macrolide‑based medical therapy should be considered for extensive disease or when surgical response is poor. Conditional recommendation. 4

7. Common Pitfalls & Caveats

• Do not extend treatment beyond 6 months for uncomplicated tuberculous lymphadenitis unless pyrazinamide cannot be used (in which case extend to 9 months). Strong recommendation. 2
• Do not mistake paradoxical enlargement for treatment failure; continue the prescribed regimen. Strong recommendation. 3
• Do not perform incision and drainage, as it predisposes to chronic fistulas. Strong recommendation. 3
• Always obtain mycobacterial cultures before starting therapy to detect drug resistance (implicit guideline).
• Distinguish tuberculous from NTM infection because management strategies differ markedly. Strong recommendation. 4

All facts are derived from cited guideline statements and peer‑reviewed evidence; strength of recommendation follows the original source wording where provided.