A 27-year-old unmarried woman with insignificant medical history and without any family history of tuberculosis presented to surgical outpatient department with 2-week history of progressively increasing and painful swelling on the right side of the neck. The patient was given nonspecific antibiotics and analgesics for 1 week with pyogenic abscess as the possible diagnosis, but she returned with worsening pain and increase in size of swelling (Fig. 1). The patient had no fever or other constitutional symptoms. Systemic examination revealed 3 × 4-cm tender, fluctuant, mobile swelling with erythematous indurated overlying skin. Throat, tonsillar, and systemic examinations were normal as were the blood counts and chest x-ray. Computed tomographic scan of the chest and abdomen was normal. Erythrocyte sedimentation rate was 35 mm the first hour, and purified protein derivative (PPD) or Mantoux test was negative. Serology for HIV was negative. Magnetic resonance imaging of the neck was normal, other than 4 × 4-cm mass in right supraclavicular region with central necrosis. Ultrasound of the swelling revealed an abscess and edema of adjacent tissue.
What is your diagnosis?
Fine-needle aspiration cytology of the swelling was done, which revealed feature of cold abscess, that is, macrophages, epithelioid cells, necrotic material, and stained positive for acid fast bacillus. Thus, solitary swelling in the neck of 2-week duration was tubercular cold abscess with involvement of overlying skin-the scrofuloderma. In view of endemicity of tuberculosis in our part of the world, standard 4-drug antitubercular treatment was started. Two months later, swelling had regressed in size, and overlying skin was normal. Patient has completed maintenance phase of 2 drugs (isoniazid and rifampicin) and is doing well.
Tuberculosis of the skin is common in countries where tuberculosis is endemic and constitutes 0.14% of the extra pulmonary tuberculosis.1 Lupus vulgaris is the most common form of skin tuberculosis reported, although in Hong Kong, tuberculosis verrucosa is the most common form reported.2 The other forms of cutaneous tuberculosis are papulonecrotic tuberculid, miliary skin tuberculosis,3 erythema induratum, tuberculosis verrucosa, and scrofulderma.2
Cervical tuberculous lymph adenitis constitutes 66% to 77% of all cases of tuberculous lymphadenitis4 and is known from centuries as scrofula and tuberculous lymphadenitis and referred as King's evil. Scrofuloderma is the form of cutaneous tuberculosis in which skin is involved as an extension of underlying soft tissue, lymph node, or bone.4 Presentation may be as a swelling with skin induration, fluctuance, nodularity, or a draining sinus or erythema induratum.4 Most common sites are neck and groin because of the abundance of lymph nodes at these sites. Healing is very slow and may lead to the formation of hypertrophied scars. The swelling may be present for almost 1 year before attention is sought, and as such, course is indolent and may persist for years.2,5 Our case presented acutely with just 2-week history. Diagnosis is easy if the multiple sites are involved, but difficulties arise when single swelling is present with all the clinical features of a pygenic abscess. PPD test is usually positive, but negative test does not rule out tuberculosis.6 Chest x-ray is supportive with evidence of active disease, pleural thickening, or apical fibrosis in variable number of cases.7
Fine-needle aspiration cytology is especially helpful in HIV-positive cases.8 Different results have been obtained by fine-needle aspiration ranging from 77% to 93% in different studies.9-11 Yield is increased with the advent of polymerase chain reaction on cytology samples, and complications are minimal when 14- to 21-gauge needle is used.8 The cytological criteria for diagnosis of tuberculous lymphadenitis were defined as epithelioid cell clusters or single granulomas with or without multinucleate giant cells and caseation necrosis.12
Excisional biopsy is indicated when diagnosis is uncertain. Incisional biopsy is avoided because it might lead to sinus formation.13 Ultrasound has been found useful, and one study reported on sonographic differentiation between tuberculous cervical lymph nodes and nodal metastases from non-head and neck carcinomas.14 Some features help to separate these 2 diagnoses including size, echogenicity, appearance of surrounding soft tissue, and the presence of intranodal cystic necrosis. Computed tomography and magnetic resonance imaging are other diagnostic modalities, especially to rule out other structural involvement like vertebrae.15 However, all these imaging tests are costly and not available in all centers.
Thus, our case was unique in that presentation was dramatic; swelling was single; and there were no clues in history, examination, or investigations to suggest tuberculosis. Although we could stain for acid fast bacillus in aspirated sample, the other features were also characteristic as was ultrasound. Therefore, in situations like ours and in areas where tuberculosis is endemic but resources are scarce, it is appropriate to use noninvasive or less invasive procedures for diagnosis to avoid complications of sinus formation, ugly scarring, and protracted course and secondary infections.
The authors thank Director General Dr Khalid Zafar and Director of Health of Makkah Dr Khalid Somary for keeping antitubercular medication available in all accessible areas and for their concern on the problem of tuberculosis in Makkah Region.
1. Golden MP. Extra pulmonary tuberculosis: an overview. Am Fam Physician
2. Wong Ko, Lee KP, Chiu SF. Tubercolosis of the skin in Hong Kong. (A review of 160 cases). Br J Dermatol
3. High WA, Evans CC, Hoang MP. Cutaneous miliary tuberculosis in two patients with HIV infection. JAMA CAD Dermatol
4. Alvarez S, McCabe WR. Extra pulmonary tuberculosis revisited: a review of experience at Boston City and other hospitals. Medicine (Baltimore)
5. Nguyen H, Le C, Nguyen H. Mycobacterium tuberculosis
infection presenting with cutaneous abscess, calcaneal abscess and pulmonary nodules. A case report and review of literature. April 2007. Priory Lodge Education Ltd. Available at: http://www.lights.ca/publisher/db/3/4163.html
6. Shriner KA, Mathisen GE, Goetz MB. Comparison of mycobacterial lymphadenitis among persons infected with human immunodeficiency virus and seronegative controls. Clin Infect Dis
7. Thompson MM, Underwood MJ, Sayers AD, et al. Peripheral tuberculosis lymphadenopathy: a review of 67 cases. Br J Surg
8. Artenstein AW, Kim JH, Williams WJ, et al. Isolated peripheral tuberculous lymphadenitis in adults: current clinical and diagnostic issues. Clin Infect Dis
9. Lau SK, Wei WI, Hsu C, et al. Efficacy of fine needle aspiration cytology in the diagnosis of tuberculous cervical lymphadenopathy. J Laryngol Otol
10. Pithie AD, Chicksen B. Fine-needle extra thoracic lymph-node aspiration in HIV-associated sputum-negative tuberculosis. Lancet
11. Ellison E, Lapuerta P, Martin SE. Fine needle aspiration diagnosis of mycobacterial lymphadenitis. Sensitivity and predictive value in the United States. Acta Cytol
12. Sen R, Marwah N, Gupta KB, et al. Cytomorphological patterns in tuberculous lymphadenitis. Ind J Tuberc
13. Lee KC, Tami TA, Lalwani AK, et al. Contemporary management of cervical tuberculosis. Laryngoscope
14. Ying M, Ahuja AT, Evans R, et al. Cervical lymphadenopathy: sonographic differentiation between tuberculous nodes and nodal metastases from non-head and neck carcinomas. J Clin Ultrasound
15. King AD, Ahuja AT, Metreweli C. MRI of tuberculous cervical lymphadenopathy. J Comput Assist Tomogr