Case Presentation: A 54 year old man with no known past medical history who presented with complaints of shortness of breath and a new axillary mass for the last three weeks. He previously moved from Kenya 6 years prior with no recent travel. As his mass grew, he began to experience increasing fatigue and shortness of breath. On admission, he was found to have hypotension, tachycardia, subjective fevers and bandemia. He was cachect with mild ascites with a large nonfluctuant left axillary mass. The mass was tender to palpation with no drainage or sinus tracts. CT showed a 9.1×9.4×15.1cm complex cystic mass that encased the left axillary artery, innumerable hypodense lesions in spleen, kidney and lungs, and cirrhotic liver with ascites. He tested HIV-1+ with a CD4 count of 2cell/mcL and a viral load of 1,540,000 copies/mL. FNA aspiration of his axillary mass showed 10mL of pus, thick brown fluid and AFB+ for Mycobacterium tuberculosis. He was AFB+ on bronchiolar lavage and determined to have milliary tuberculosis(MTB) with both pulmonary and extrapulmonary dissemination and an axillary tuberculous abscess. He was treated with RIPE(rifampin, isoniazid, pyrazinamide, and ethambutol) therapy for six months, emtricitabine/tenofovir, fluconazole and entecavir. His abscess continued to drain after aspiration and receded with anti-tuberculosis therapy.

Discussion: Tuberculosis(TB) is one of the oldest and deadliest diseases known to man, with traces of the disease being found in mummified remains from as early as 9,000 years ago. Over time TB has been found to present in a variety of manners, posing a unique diagnostic challenge even in areas of advanced medical technology.One such rare manifestation of the disease is known as MTB. There is limited data on the incidence of this disease, but is generally estimated to be <2% of all TB cases and has a higher incidence in the immunocompromised. Extrapulmonary TB can be transmitted one of three ways, exogenously as the primary nidus, endogenously, and hematogenously. MTB often involves hematogenous spread to lymph nodes and the most common cause of tuberculous lymphadenitis is localized in the superficial cervical nodes, known as scrofula. The lymphadenitis can progress to abcess development and can ultimately ulcerate through the skin. The axillary lymph nodes are an uncommon location for tuberculous lymphadenitis, representing only 8% of cases with a median size of 3cm. This abscess measured 15.1cm in the coronal plane on CT scan, making it especially large for a tuberculosis-related abscess. It was also unusually tender, a noteworthy finding as tuberculosis typically causes cold abscesses, an infection by certain bacteria which causes with limited inflammation.

Conclusions: Tuberculosis often presents as a diagnostic dilemma due to its ability to mimic other disease processes. We present a case of an unusual scrofula-like presentation of MTB to the axillary lymph nodes resulting in the development of a large complex abscessed mass. Given that tuberculosis remains one of the top 10 causes of death worldwide, recognition of atypical presentations continues to be of high importance.