Forty-four cases of tubercular lymphadenopathy and sinuses, who were taking anti-tubercular treatment for more than 6 months and not responding to it, were randomly selected in this study. Overall cure rate in cases of lymphadenopathy was 93.99% , sinus 77.77% and cold abscess 100%. Mean age of the patients was 30.13 (Male: female1:4.5). Most common site of lymphadenopathy was cervical , smear was positive in 19(43.18%) cases and culture in 25(56.81%) cases. Low Level Nitrogen Laser Therapy may be used as an adjuvant to anti-tubercular drugs in cases of chronic non-responding tubercular lymphadenopathy and sinuses

Bajpai, Ashok

Bhargava, Salil

Gupta, P. K.

Jain, Nageen Kumar

English

Publications of the IAS Fellows

Indian Journal of Tuberculosis
Short Communication
A STUDY OF LOW LEVEL NITROGEN LASER THERAPY IN THE TREATMENT OF
NON-RESPONDING TUBERCULAR LYMPHADENOPATHY AND SINUSES
Ashok Bajpai1, Salil Bhargava2, P.K.Gupta3 and  Nageen Kumar Jain4
(Original received on 22.11.2005.  Revised version received on 20.4.2006. Accepted on 20.6.2006)
Summary: Forty-four cases of  tubercular lymphadenopathy  and  sinuses,  who were  taking anti-tubercular treatment  for
more than 6 months  and not   responding  to it,  were randomly selected in this study. Overall cure rate   in cases of
lymphadenopathy  was  93.99% ,  sinus 77.77% and cold abscess 100%.   Mean age of the patients was 30.13 (Male:
female1:4.5).  Most common site of lymphadenopathy was cervical , smear was positive in 19(43.18%) cases and culture
in 25(56.81%) cases. Low Level Nitrogen Laser Therapy  may be used  as an adjuvant to anti-tubercular drugs in cases of
chronic non-responding tubercular lymphadenopathy and sinuses.
Key Words: Tubercular Lymphadenopathy, Low Level Nitrogen, Laser Therapy.
[Indian J Tuberc 2006; 53:229-231]
1. Professsor of Chest & TB and Head 2. Associate Professor 3. Senior Scientist* 4. Research Assistant
Department of Medicine, MGM Medical College, Indore (Madhya Pradesh)
* Department of Atomic Energy, Centre for Advanced Technology (CAT), Indore
Correspondence: Dr. Ashok Bajpai, Professor of TB & Chest and Head, Department of Medicine, MGM Medical College, Indore-452001 (Madhya
Pradesh); Ph.: 0731-2524514; E-mail: bajpai_ashok@hotmail.com
INTRODUCTION
Resurgence of tuberculosis and  the
emergence of MDR  strains have led to a growing
realization of an urgent need for developing  an
effective treatment modality  for this disease. The
cure rates of the patients with tubercular
lymphadenopathy with 6 months chemotherapy has
been found to be about 50%-90%.  However,  many
of these cases are due to drug resistance tuberculosis
and Non-tubercular Mycobacteria  (NTM).
Treatment of these cases is very difficult,  as they
do not respond properly to the  routine chemotherapy.
They require longer duration of chemotherapy along
with second line drugs i.e  12-24 months of treatment
in various studies1-2.  Recurrence  even after surgical
excision  is seen in 2%-15% cases of  TB
lymphadenopathy3.  In about 20%, patients develop
abscess  and sinuses.
We have successfully treated  42 cases of
tubercular lymphadenopathy with or without non- healing
tubercular sinuses or tubercular  cold abscess,   which
were not responding to given medical and surgical
treatment, with the use of Intralesional Laser Therapy
along with anti-tubercular drugs.
MATERIAL  AND  METHODS
Longitudinal  study entitled “The Role of
Low Level  Nitrogen Laser Therapy in not-responding
Tubercular Lymphadenopathy and Sinuses”  has been
studied for a period of four years  from 2001 to
2004 and follow-up was done for a period of two
years.
Four patients  lost to follow-up were
excluded  from the study. Inclusion criteria for the
study  were patients received  ATT  for > 6 months
showing no response,  Acid Fast Bacilli (AFB) grown
in culture  after 6 months of ATT, abscess  formation,
sinuses tract formation, Age group > 15 years but  <
65 years  with diagnosis of lymphnode tuberculosis.
Detailed medical history was taken and
physical examination was done.  All patients gave
informed consent to participate in the study.
In all  the patients we did histological and
microbiological analysis for the presence of
Indian Journal of Tuberculosis
mycobacteria in the lymph node tissue. Pus aspiration
from lymph node for AFB microscopy  and culture
and  FNAC  were  used to investigate tuberculosis.
Routine tests included  complete haemogram, Blood
sugar, screening test for Human Immunodeficiency
Virus, Australia antigen, Mantoux  test  and sputum
examination for AFB.
After  confirmation of  the diagnosis,  we
gave intralesional laser therapy along with ATT. 2mW
nitrogen laser  was given  for 780 sec, twice weekly
for  total 10 sittings, laser used in this study was a
pulsed laser with a pulse duration   of   7 ns, energy
30 microjouls and an average power output of 2mW
at the tip of  the fiber.  The Jalco Canula (16 G, 50
mm length) was first introduced  inside the lymph
node and through it the fiber of the laser equipment
was introduced about 5 mm inside the lesion. Then
the laser was started and was given for 780 sec.
RESULTS
Mean age of the patients was 30.13 years
(range 15-65 yrs). There were eight males and  36
females.  Mean duration of  illness was 13.2 months.
Mean duration of treatment received before laser
therapy was  8.61 months.
Clinically,  the main symptoms at the time
of  presentation were  fever and weight loss. Cervical
lymph node alone was involved in 30 patients,
cervical and axillary  in  one patient, axillary in one
and  cervical and intra abdominal cold abscess  in
one patient. Single  lymph node was present in 25,
multiple discreet  nodes were seen in 9 cases.
Lymph node with discharging sinus was
seen in 8 cases and only lymph nodes  abscess was
present in 25 cases.
Total number of patients  of  post-operative
sinuses were  9, 5 thoracic  region, two in inguinal
region, one in abdomen, and one in mid-arm.
Two cases were of  cold abscess.
Acid Fast bacilli  were demonstrated  by
smear in 19 (43.18%) cases. AFB culture  was
positive in 25(56.81%) cases. FNAC revealed a
positive diagnosis in all cases. Criteria for diagnosis
of tuberculosis  in FNAC were  taken as presence of
epithelioid cell, multi-nucleated giant cells, Caseous
necrosis, necrotic cells, granulomatous inflammation
and presence of AFB in necrotic smear.
Associated chest lesion on radiograph was
evident in 10 cases, parenchymal tuberculosis in 6
cases, pleural effusion in 4 cases and CNS
tuberculoma was found in one case.
During the treatment  with laser therapy,
the lymph node resolved  after five sittings in  4
(12.12%), seven sittings in 11 (33.3%) , 8 sittings
in  6 (18.18%), 10 sittings in rest of the patient
10(30.03%)(Table-1). However, we gave 10
sittings of laser therapy to all  the patients, two
patients (6.06%) of lymphadenopathy  did not
respond  because  lymph node was  deep seated.
They were subjected to surgical intervention.
Patients with tubercular sinuses responded more
dramatically  with  cessation of  discharge and
obliteration of  tract after  7 sittings.  However,
there was  recurrence in  two patients (22.22%),
in one patients after 2 ½ months and other patients
after 6 months. Both were again  put on laser
therapy and then cured.
Table:  Resolution of lymphnode, closure of sinus according to number of sittings
ASHOK  BAJPAI  ET  AL
Type of lesion 5 
sittings 
7 
sittings 
8 
sittings 
10 
sittings 
Not 
improved Total 
Lymphadenopathy 4 11 6 10 2 33 
Post operative Sinuses  0 5 0 2 2 9 
Cold abscess 0 0 0 2 0 2 
Total  4 16 6 14 4 44    
 
230
Indian Journal of Tuberculosis
At the end of 5 sittings, 8 patients (24.24%)
became asymptomatic (they became afebrile ,
appetite improved, patients started feeling better  and
started  gaining weight ), 13 patients (39.39%) after
7 sittings , 5 patients (15.15%) after 8 sittings and 5
patients (15.15%), at the end of 10 sittings.   Thus
overall  results in cases of lymphadenopathy are
93.99%, sinuses 77.77% and cold abscess 100%.
All  the patients received  a full course of anti-
tubercular treatment according to culture and
sensitivity reports.  In cases of culture negative,
patients received empirical therapy. Follow-up was
done for a period of 2 years.
DISCUSSION
In  continuation of the  pioneering work of
Finsen on  treatment of  skin TB  by   UV light4 and
in vitro reports  on  bactericidal effect of UV light
on tubercular bacilli 5, Eshanchanov et al  reported
the  use  of UVA   radiation  from nitrogen laser
(337-nm )  for the  treatment of   patients with PTB6.
In vitro experiments have also  been carried out to
understand the  therapeutic mechanisms involved.
It has been shown that nitrogen  laser irradiation can
inhibit growth of  tubercular bacilli,  particularly at
high intensities7.
In vitro experiments have also provided
some evidence as possible influence of
nitrogen laser irradiation on the immune
system, for example nitrogen laser irradiation
was seen to enhance the intra-cellular killing
of intra-circular bacteria in human
neutrophil.  Nitrogen laser irradiation  leads
to temporary inactivation of drug sensitive as
well as drug resistant clinical isolates of
mycobacterium tuberculosis8.
When we started giving intralesional laser
therapy  to these patients they showed response
to the therapy  in a short duration of time and
both the size of gland as well as the symptoms
improved.  In a series of 10 patients,  M. M. Puri
observed similar  results with He-Ne laser9.
Two patients of lymphadenopathy did not
respond because  lymphnodes were deep  seated .
Two patients of sinuses had recurrence  because of
multiple sinuses. All the patients  are still at our regular
follow-up.  No  recurrence of  lymph node or
discharge at the site of  laser given has been
observed.
ACKNOWLEDGEMENTS
We thank Mr. A.G. Bhujle, Head,
Instrumentation and Control Division, CAT and
members of his division, for providing the Nitrogen
Laser Instrument. This work was funded by Board
of Research in Nuclear Sciences (BRNC), Mumbai.
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1. Campbell IA, Dyson AJ, Lymphnode Tuberculosis :  a
comparison of  treatments 18 months after completion
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3. Siu KF, NgA , Warg J. AVST NZJ Surg 1983; Jun, 53 (3):
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4. Finsen  NR (1901).  The chemical  rays of light and
smallpox. In : Finsen NR (ed) Phototherapy. Arnold,
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5. Dreher W, Domanska B.  Bactericidal effect of ultraviolet
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7. Sachdeva R, Bhagwanani NS,  Chitnis DS.  Nitrogen laser
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LOW  LEVEL  NITROGEN  LASER  THERAPY 231


A study of low level nitrogen laser therapy in the treatment of non-responding tubercular lymphadenopathy and sinuses

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A study of low level nitrogen laser therapy in the treatment of non-responding tubercular lymphadenopathy and sinuses

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