| Author | Affiliation |
|---|---|
| Jacob Lawing, MD | University of Alabama at Birmingham, Department of Emergency Medicine, Birmingham, Alabama |
| Jeremy Towns, MD | University of Alabama at Birmingham, Department of Emergency Medicine, Birmingham, Alabama |
| Matthew A. Heimann, MD | University of Alabama at Birmingham, Department of Emergency Medicine, Birmingham, Alabama |
ABSTRACT
Case Presentation
A 32-year-old male who recently immigrated from Kenya presented to the emergency department (ED) with a painful, enlarging, right-sided neck mass for eight weeks duration. Point-of-care ultrasound was used to reveal a large cystic mass with internal septations and numerous hypoechoic round lesions. Initial tuberculosis blood test ordered in the ED was positive with cultures ultimately growing Mycobaceterium tuberculosis.
Discussion
Scrofula should be considered in the differential in patients presenting with enlarging neck masses who have epidemiological risk factors for tuberculosis.
CASE PRESENTATION
A 32-year-old male presented to the emergency department (ED) due to a painful, enlarging, right-sided neck mass for eight weeks. Notably, he had immigrated from Kenya approximately one year prior. He reported subjective fevers but denied weight loss, night sweats, or pulmonary symptoms. Physical exam revealed a moderate-sized area of focal swelling noted to right lateral neck associated with cervical lymphadenopathy (Image 1).
A T-SPOT.TB test (an interferon-gamma release assay) was ordered from the ED and returned positive. Empiric treatment with cefepime was started, and the patient was admitted to the hospital for ultrasound-guided lymph node biopsy. Limited point-of-care ultrasound (Image 2) and computed tomography of the neck with contrast (Image 3) were performed.
DISCUSSION
This diagnosis of scrofula was ultimately made through acid-fast bacillus culture, which grew Mycobacterium tuberculosis. Scrofula, or mycobacterial lymphadenitis, is a type of extrapulmonary tuberculosis (TB) caused by hematogenous or lymphatic dissemination of pulmonary TB or reactivation of latent TB. Common presentations include an enlarging mass with or without tenderness and erythema located within the cervical or supraclavicular lymph nodes.
1
Associated symptoms include fever, rigors, and night sweats.
2
Point-of-care ultrasound of tuberculous nodes will be hypoechoic and round, with intranodal cystic necrosis and adjacent soft-tissue edema. Diagnosis is made by histopathology along with a smear of acid-fast bacilli and culture of lymph nodes. Treatment includes rifampicin, isoniazid, pyrazinamide, and ethambutol. It is imperative to obtain appropriate imaging such as ultrasound or computed tomography in enlarging neck masses with epidemiologic risk factors of TB and ensure close follow-up.
Footnotes
Section Editor: Melanie Heniff, MD
Full text available through open access at http://escholarship.org/uc/uciem_cpcem
Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.
Address for Correspondence: Jacob Lawing, MD, University of Alabama at Birmingham, Department of Emergency Medicine, 521 19th St. South, Suite 203, Birmingham, AL 35233. Email: jglawing@uabmc.edu
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Submission history: Revision received January 7, 2024; Submitted April 15, 2024; Accepted April 24, 2024
The authors attest that their institution requires neither Institutional Review Board approval, nor patient consent for publication of this case report. Documentation on file.
REFERENCES
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