Tuberculous adenitis is a common cause of lymphadenopathy, especially in areas where tuberculosis is endemic. Tuberculosis (TB) lymphadenitis in cervical, axillary, and inguinal areas can present as nontender swelling without significant systemic symptoms in immunocompetent young adults. we report a case of TB adenitis in a 26-year-old male from India, who was admitted with 1-month history of painless swellings in the lower neck on both sides. Fine-needle aspiration of the right lesion of this patient showed the presence of stainable acid-fast bacilli and cultured organisms on aspirate. His HIV serology was negative. Four drugs antituberculous regimen treatment was started with good response.
Keywords: King′s evil, scrofula, tuberculous adenitis.
Tuberculous lymphadenitis, known centuries ago as the King’s evil and as scrofula when occurring in the cervical region, continues to be a common cause of extrapulmonary tuberculosis (TB). TB adenitis is responsible for up to 43% of all of peripheral lymphadenopathy in the developing world. TB lymphadenitis sometimes breaks leading to sinus formation. They respond to anti-TB medications.
A 26-year-old male from India, with no history of any disease before, presented with 1-month history of painless swellings in the lower neck on both sides. The left mass drained spontaneously few days ago. No history of fever, cough, or other symptoms. He denied any swellings at other sites of his body. Examination revealed an afebrile, healthy-looking young male. There are two swelling at the root of the neck; the right side one covered by a plaster (i.e., may be a recent procedure like fine needle aspiration was done). And a left one which opened up (i.e., sinus). Both around 3 cm in diameter, firm consistency, nontender, mobile, and not attached to skin. There is no axillary or inguinal lymphadenopathy. Other systems examination was unremarkable [Figure 1].
The most likely diagnosis is tuberculous lymphadenitis (scrofula). The differential diagnoses include, lymphomas, thyroid cancers, neck cysts, and malignant nasopharyngeal tumors.
His blood tests showed normal WBC, Hb, and platelets, ESR – 76 mm and normal urea and electrolytes. Chest X-ray reported normal. PPD skin test 25 mm with central necrosis. Fine-needle aspiration of the right lesion of this patient confirmed the presence of stainable acid-fast bacilli and cultured organisms on aspirate. His HIV serology was negative. Four drug regimen antituberculous treatment for 2 months followed by two drugs, total of 6 months was given. On follow-up patient showed an excellent response with no complications.
Tuberculous adenitis is a common cause of lymphadenopathy in areas where tuberculosis is endemic. The incidence of extrapulmonary tuberculosis is 5.4% in the United States. TB lymphadenitis comprises 30-50% of these cases. The most common site is cervical lymphadenitis. This is referred to as scrofula. Twenty-one percent of extrapulmonary tuberculosis cases were associated with HIV infection. , Tuberculous lymphadenitis can also occur in association with pulmonary and/or miliary disease. Our patient is from India, HIV negative, healthy young adult.
Clinical presentation depends on the lymph nodes involved. TB lymphadenitis in cervical, axillary, and inguinal areas can present as nontender swelling without significant systemic symptoms in immunocompetent young adults. Cervical node involvement occurs in over two-thirds of TB adenitis.  It can be unilateral involving one or more nodes of the anterior and posterior cervical chain. The affected nodes may also erode into adjacent organs resulting in draining sinuses, , this patient developed a sinus from one of the lymph nodes. Constitutional symptoms are often present in HIV co-infection, whereas non-HIV patients may be asymptomatic. ,, Our patient showed high positive PPD test with central necrosis, over 90% of patients with non-HIV tuberculous adenitis will have positive tuberculin skin tests. Needle aspiration of the nodes is often sufficient to make the diagnosis. Excision biopsy is rarely used.  Jha et al . confirmed diagnosis of tuberculous adenitis by needle aspirate in 93% of TB adenitis.  TB lymphadenitis frequently responds to medical management.
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