Q: I am a 54 years old male who had neck swelling 10 months back. ATT was taken for six months, after that discontinued for two and a half months. I restarted ATT one month back and still continuing but there is no sign of reduction in swelling. What are the possibilities of fungal infection of lymph node? FNAC impression is tuberculous lymphadenitis, non-reactive changes of lymph node and granulomatous lymphadenitis in three different reports. What tests do I need to undergo for fungal infection of lymph nodes?

A:The possibility of fungal infection can be easily done by lymph node biopsy and sending the specimens to pathology and microbiology department. Pathologist usually detects it by H&E (hematoxylin and eosin stain), PAS (Periodic acid-Schiff) and GMS (Gömöri methenamine silver stain) staining. Microbiologist observes it after KOH treatment and culture of the specimen. Both the departments should again look for Mycobacterium tuberculosis infection.

In this case there is a strong possibility of tubercular infection as supported by FNAC finding. Tubercular lymph node enlarges after one month of treatment which happened in this case. It is also possible that the same thing happened in the first six month of the treatment and patient had stopped taking antitubercular treatment (ATT) and presented again with the same complaints.

Hence my suggestion is first enquire with the patient about the compliance of the ATT. Get a thorough clinical examination especially look for other group of lymph node which might be enlarged and it will change the overall diagnosis. Then lymph node biopsy can be done and sent for pathological and microbiological examination. They can investigate it not only for tuberculosis but also for fungal infection or for metastatic deposition of cancer. Supraclavicular lymphadenopathy has the highest risk of malignancy, estimated as 90 percent in patients older than 40 years.