Case Presentation: A 34-year-old woman with a reported history of sarcoid pericarditis presented from an otolaryngology (ENT) clinic for a progressively enlarging, painful left supraclavicular lymph node. She had three prior ER visits, including a brief admission one month ago for a core biopsy, and was discharged with antibiotics. The lesion worsened with purulent drainage and was associated with chills and weight loss. CT imaging revealed a large multiloculated and peripherally enhancing necrotic mass of the left supraclavicular fossa, a necrotic mediastinal lymph node, and multiple small pulmonary nodules. She was admitted for supraclavicular lymphadenopathy with superimposed cellulitis. A multidisciplinary workup was initiated with ENT, Hematology and Oncology, Infectious Diseases, and Rheumatology. Concern for malignancy and high suspicion for extrapulmonary tuberculosis (TB) or atypical mycobacterial disease prompted an excisional biopsy of the mass. However, initial diagnostics including sputum MTB PCR, biopsy cultures and stains, and pathology were unrevealing for infection and hematologic malignancy. The patient was discharged with oral antibiotics and outpatient follow up. One month later, the state Department of Health was alerted that the biopsy culture was positive for Mycobacterium tuberculosis and initiated treatment. The final speciation and drug susceptibility for M. tuberculosis complex were finalized two months after discharge.
Discussion: This patient was evaluated for several months until the diagnosis of cervical tuberculosis lymphadenitis, also known as scrofula, was confirmed. The delay in diagnosis can be attributable to the low prevalence extrapulmonary TB in the United States, provider unfamiliarity with the disease, and the inherent challenges in obtaining a diagnosis through mycobacterial cultures. A hospitalist needs to approach necrotizing lymphadenitis with high clinical suspicion of TB and inquire about risk factors. The patient is U.S. born with no travel history but had an occupational risk as a custodian for a correctional facility. A multidisciplinary approach was essential given the morbidity of the patient’s condition, and that definitive diagnostic testing for TB requires weeks to finalize. The differential diagnoses included atypical mycobacterial infection, fungal infection, hematologic malignancies, sarcoidosis, and IgG4-related disease, and Kikuchi-Fujimoto disease. Despite being the diagnostic gold standard, biopsy cultures have variable sensitivity and are prone to false-negative results. Excisional biopsy has the highest sensitivity and, in this case, was crucial for diagnosis and drug susceptibility testing.
Conclusions: This case highlights the challenges of diagnosing tuberculous lymphadenitis in low prevalence regions. Hospitalists should maintain a high index of suspicion with a low threshold for a comprehensive work up, including biopsy, to prevent delays in diagnosis. An excisional biopsy may be necessary for diagnosis and treatment when less invasive testing is unrevealing. Increased awareness of extrapulmonary presentations of TB is essential, especially for institutions serving internationally diverse or high-risk populations.