A 20‐year‐old woman from Honduras presented with a 4 × 3‐cm mass on her left neck that had been gradually enlarging over the past 3 years. The mass was well defined, mobile, and nonerythematous. She had mild tenderness at the site but was otherwise without complaints. She had no history of fevers, chills, night sweats, cough, or lymphadenopathy. She denied any known sick contacts or other risk factors for M. tuberculosis. She had been treated with oral antibiotics on multiple occasions but had no improvement in her symptoms. Chest x‐ray revealed no cavitary lesions or evidence of intrapulmonary processes, and her HIV test was negative. However, a 14‐mm induration developed after a PPD was placed, and a subsequent fine needle aspiration sample revealed caseating granulomatous tissue that was later identified as Mycobacterium tuberculosis. She was placed in respiratory isolation, and multiple sputum smears were negative for acid‐fast bacilli.
Scrofula is an extrapulmonary manifestation of Mycobacterium infection in the subcutaneous tissue that most often affects the submandibular, parotid, or supraclavicular lymph nodes. It has a bimodal distribution, with an incidence that is highest among adolescents and the elderly. Lymphadenitis is the primary manifestation of tuberculosis in 5% of the population, and the cervical lymph nodes are the site of infection in two thirds of these cases. In the immunocompromised population, cervical lymphadenitis represents up to one third of the total presentations. It typically presents as a firm, well‐defined, mobile nodule that is otherwise asymptomatic. The term cold abscess has been used to describe the mass because of the lack of color or temperature changes that are usually found with a bacterial abscess. As the mass enlarges, it may become soft due to liquefaction and can eventually form an ulcer. Surgical resection of these masses is associated with a high rate of recurrence and can lead to seeding and distant spread of the disease. Therefore, oral antituberculosis therapy is the preferred method of treatment and should be initiated promptly. It is important for the hospitalist to recognize the extrapulmonary manifestations of Mycobacterium tuberculosis and initiate the appropriate treatment because over the last 20 years a rise in the incidence of scrofulous tuberculosis has been noted in the United States. This is primarily a result of a rise in immigration from endemic countries, the rising population of those infected with HIV, worsening urban social conditions, and the abandonment of rigid TB control programs.
The patient was ultimately diagnosed with scrofulous tuberculosis and started on multiple‐drug antituberculosis therapy with outpatient monitoring at a tuberculosis clinic.
S. Whelton, none; A. Carhill, none.