A 26 year-old Ecuadorian woman presented with 3 months of enlarging neck masses. A few years prior to presentation, she noticed small lumps on the right side of her neck, which were stable and asymptomatic until 3 months prior to arrival, when they began to grow in size and became painful. These symptoms were accompanied by an unintentional 20 lb weight loss notably without fevers, chills, or night sweats. She had firm, nontender, mobile lymph nodes in right anterior cervical chain, with the largest lymph node measuring 2×3 cm, with additional adenopathy in the supraclavicular area and left submandibular region. Extensive enlarged heterogeneous lymph nodes without necrosis within the right neck were visualized on CT. A fine needle aspiration (FNA) of a prominent node was significant for a heterogeneous population of lymphocytes in a background of necrosis, staining negative for acid fast bacilli (AFB). An excisional biopsy revealed a lymph node with multiple necrotizing caseating granulomas and giant cells, negative for AFB but overall consistent with tuberculous lymphadenitis.
Tuberculous lymphadenitis is a manifestation of Mycobacterium tuberculosis affecting the lymph nodes. While tuberculous lymphadenitis (or scrofula when located in the cervical region) is less commonly encountered in modern times as a result of effective treatments for tuberculosis, it has been recognized as a clinical entity since antiquity. In the middle ages it was believed that the touch of royalty could cure scrofula, with French and English monarchs applying the “royal touch” to tens of thousands of subjects a year.
The differential diagnosis for isolated cervical lymphadenopathy, while extensive, includes malignancy (particularly lymphoma), infections (including nontuberculous mycobacteria), and sarcoidosis. While nonspecific, factors which weigh in favor of tuberculous lymphadenitis include HIV co-infection, highly endemic country of origin, age of 20-40 years, and chronicity of lymphadenopathy.
Diagnosis is obtained through histopathologic examination through either FNA or excisional lymph node biopsy. FNA is preferred for initial evaluation as it is less invasive, but has less diagnostic yield when compared to excisional biopsy. Tuberculous lymphadenitis is suggested by the finding of caseating granulomas and confirmed by culture or nucleic acid amplification (NAA).
While the differential diagnosis for cervical lymphadenopathy is broad, providers should retain a high level of suspicion for tuberculous lymphadenitis in patients similar to ours: young adults with chronic lymphadenopathy from countries with a high incidence of tuberculosis. Diagnostic evaluation should include biopsy through either FNA or excision with culture or NAA to confirm the diagnosis. While providers may not have the privilege of invoking the Royal Touch, scrofula can be effectively treated with standard antimycobacterial agents.