SPR unknown #28 Final

Lydia Kuhn BS, MSIV

Arie Franco MD, PhD

Medical College of Georgia/Children’s Medical Center

Abstract

15 year old with two week history of right sided neck mass, decreased energy and cough.

Keywords

SPR unknown 28 scrofula tuberculosis TB lymphadenitis mycobacterium


Publication Date: 2010-04-20

History

15 year old with two week history of right sided neck mass, decreased energy and cough.

Findings

Chest x-ray (images 1 & 2): right upper lung opacities, bilateral diffuse interstitial opacities and questionable hilar lymphadenopathy

Ultrasound (images 3-4): within the right neck there is a mixed cystic and solid fluid collection without increased peripheral flow. This measures 8.0 X 2.0 X 4.7 cm. There are multiple fluid collections adjacent to the larger fluid collection that are mixed in echogenicity without increased peripheral flow.

CT (images 5-7): There is a cluster of necrotic mass/lymphadenopathy in the right supraclavicular space. One of the largest discrete lymph nodes that appears to have a hypodense component, measures approximately 26 X 21 mm in dimension. There are also multiple nodules in the upper lobes of the lungs

Diagnosis

Scrofula (Mycobacterium tuberculosis lymphadenitis)

DDx

Mycobacterium tuberculosis lymphadenitis, non-tuberculous mycobacterium, malignancy (Hodgkin lymphoma and non-Hodgkin lymphoma), cat scratch disease, fungal infection, bacterial adenitis, Kikuchi’s disease

Discussion

Tuberculous lymphadenitis which was known centuries ago as the King's evil and is termed scrofula when occurring in the cervical region,continues to be a common cause of extrapulmonary tuberculosis (TB). TB is responsible for up to 43 percent of all of peripheral lymphadenopathy in the developing world [1], but this manifestation is also seen in developed countries. In the United States, about 20 percent of TB is extrapulmonary, and about 30 percent of these cases present with lymphadenitis [2,3].

Tuberculous cervical adenitis may be acquired either by ingestion of infected milk (bovine tuberculosis) or by lymphohematogenous spread of infection from an initial pulmonary focus [4]. In the United States, mycobacterial cervical lymphadenitis (scrofula) is four or five times more frequently due to atypical mycobacteria, commonly Mycobacterium scrofulaceum in children, than to M. tuberculosis [4].

M. tuberculosis cervical lymphadenitis is frequent in the HIV-infected population and there are several aspects of the infection that may differ from its manifestation in HIV-negative patients: higher frequency of fever, often negative results on PPD skin testing (anergy), and higher frequency of positive smears for acid-fast bacilli as well as greater number of organisms on fine-needle aspirates of involved lymph nodes [4].

The onset of scrofula is insidious. The most common presentation is an isolated, chronic, non-tender lymphadenopathy in a young adult patient without systemic symptoms. The mass may be present for up to 12 months before diagnosis is made [5,6]. Physical examination reveals a firm, discrete mass or matted nodes fixed to surrounding structures, sometimes accompanied by overlying skin induration [7]. This unilateral mass most frequently appears in the anterior or posterior cervical triangles though submandibular and supraclavicular lymph node involvement also occurs. Axillary, inguinal, mesenteric and mediastinal lymphadenopathy is less common [8].

The definitive diagnosis of TB lymphadenitis is made by histology and culture of lymph node material, although supportive data, such as a positive PPD, can be helpful in certain patient populations. Diagnosis via fine needle aspiration appears to be equivalent to excisional lymph node biopsy in HIV-infected patients. The type of mycobacterial species involved is very important. The atypical mycobacteria are frequently resistant to conventional antituberculous chemotherapy, and surgical excision of the involved nodes is therefore indicated [4].

References

  1. Dandapat, MC, Mishra, BM, Dash, SP, Kar, PK. Peripheral lymph node tuberculosis: a review of 80 cases. Br J Surg 1990; 77:911
  2. Centers for Disease Control. Reported Tuberculosis in the United States, 2006. Atlanta, Ga: U.S. Department of Health and Human Services, CDC, September 2007.
  3. Rieder, HL, Snider, DE Jr, Cauthen, GM. Extrapulmonary tuberculosis in the United States. Am Rev Respir Dis 1990; 141:347.
  4. Mandell, Gerald L, Bennett, John E, Raphael, Dolin. Principles and Practice of Infectious Diseases. Philadelphia: Elsevier Inc., 2005. 1206-07.
  5. Artenstein, AW, Kim, JH, Williams, WJ, Chung, RC. Isolated peripheral tuberculous lymphadenitis in adults: current clinical and diagnostic issues. Clin Infect Dis 1995; 20:876.
  6. Shikhani, AH, Hadi, UM, Mufarrij, AA, Zaytoun, GM. Mycobacterial cervical lymphadenitis. Ear Nose Throat J 1989; 68:660.
  7. Alvarez, S, McCabe, WR. Extrapulmonary tuberculosis revisited: a review of experience at Boston City and other hospitals. Medicine (Baltimore) 1984; 63:25
  8. Shafer, RW, Kim, DS, Weiss, JP, Quale, JM. Extrapulmonary tuberculosis in patients with human immunodeficiency virus infection. Medicine 1991; 70:384.

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