An atypical manifestation of lymph node tuberculosis

Tuberculosis is a chronic granulomatous infection caused by Mycobacterium tuberculosis. Since the 80’s, new cases have been increasing especially in developed countries because of spreading of HIVinfection, immunodeficiency and immigration phenomenon. Cervical lymphadenitis is the most frequent localization of extrapulmonary tuberculosis. Clinical manifestations consist in a slow growth and painless swelling of a single or multiple neck nodes, generally unilateral, with rare manifestations of fistulization and of systemic symptoms. Diagnosis is performed by fine-needle aspiration cytology (FNAC) or excisional biopsy integrated by Ziehl-Neelsen stain and Mycobacteria culture. A 57-year-old male patient affected by a right-side large laterocervical swelling. The patient referred that almost one month before he noted the onset of the lesion sizing about 1 cm, so he treated it with antibiotic association of amoxicillin and clavulanate acid without any improvement. The lesion quickly doubled its size, became painful and hyperemic the skin above it. Because of the clinical worsening, the patient undergone to neck ultrasonography that showed a neck mass sizing about 50×25 mm. He began a new antibiotic therapy with Ceftriaxone intra muscle, with no modifications of the lesion. Few days later his clinical conditions drastically got worse - increasing pain and skin fistulization. So he practiced a magnetic resonance imaging of the neck that showed a massive suppurated lesion of the neck. The patient was hospitalized in our Otolaryngology Unit where he began a diagnostic iter in order to clarify the nature of the lesion and differentiate between neoplastic/lymphoproliferative lesion and an infective one. After a biopsy of the lesion, the hysthopatologic examination reported the presence of dense mononuclear cell infiltrate surrounding a set of Langerhans cells, so our diagnostic suspect was addressed to extrapulmonary tuberculosis. The authors report a case of a healthy man without risk factors for tuberculosis infection, come to our attention with a large and aggressive unilateral tubercular cervical lymphadenitis, skin fistulization and no systemic symptoms. To make diagnosis of tubercular lymphadenitis, we sustain that biopsy is still the gold standard if FNAC is in doubt.