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Case Presentation: Tuberculous Lymphadenitis (TB Lymph Node Swelling)

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📋 Presenting Complaint

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🗒️ History of Presenting Illness

• Painless neck swelling — gradual onset over weeks to months
• Located in the posterior cervical chain or supraclavicular fossa (most common); may be bilateral
• The swelling has been slowly increasing in size
• No acute pain over the swelling initially; skin overlying the node appears normal early on
• Later: node may become matted, firmer, with overlying skin becoming inflamed
• If advanced: fluctuance, abscess formation, or sinus tract discharging through the skin

Systemic (Constitutional) Symptoms

• Low-grade fever, often diurnal (worse in afternoons/evenings)
• Night sweats
• Weight loss / anorexia
• General malaise and weakness
• Systemic symptoms are often absent or mild in isolated lymphadenitis

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⛔ Negative History (Pertinent Negatives)

Pulmonary infection is present in only a minority of TB lymphadenitis cases — the negative respiratory history does NOT exclude TB. — Rosen's Emergency Medicine, p. 2711

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🔍 Past Medical & Social History

• BCG vaccination status (may reduce severity but does not prevent all forms)
• Travel to or origin from TB-endemic region (Sub-Saharan Africa, South/Southeast Asia)
• Living conditions: overcrowding, poor ventilation
• HIV status: HIV-negative in this case (or note if positive — HIV increases risk of generalized lymphadenopathy)
• No prior TB treatment
• No known contact with confirmed TB case (TB lymphadenitis can occur without known exposure)

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🩺 Physical Examination

General

• Appears well or mildly unwell; may be afebrile or have low-grade fever
• No acute distress

Head & Neck

• Solitary or multiple enlarged lymph nodes in the posterior cervical chain / supraclavicular region
• Early stage: discrete, rubbery, firm, freely mobile; overlying skin normal
• Later stage: nodes become matted (adherent to each other and underlying structures); skin becomes erythematous and warm
• Advanced: fluctuant mass (cold abscess); may have an open sinus tract draining caseous material
• No tenderness on palpation (key feature)

Respiratory

• Chest clear to auscultation bilaterally (absence of crackles, bronchial breathing)
• No signs of pleural effusion
• Percussion note normal

Abdomen

• No hepatosplenomegaly
• No abdominal lymphadenopathy palpable

Other

• No axillary or inguinal lymphadenopathy (in isolated cervical disease)
• No clubbing, no jaundice, no skin lesions

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🔬 Investigations

Bedside / Routine

• Tuberculin Skin Test (Mantoux): often positive (induration ≥10 mm)
• IGRA (Interferon-Gamma Release Assay): positive in TB infection
• Full Blood Count: mild normocytic anaemia, leukocytosis, thrombocytosis
• ESR / CRP: mildly elevated (non-specific)
• CXR: may be normal (pulmonary TB absent in majority) — no active parenchymal lesion, no hilar adenopathy in isolated disease

Diagnostic (Confirmatory)

• Fine-Needle Aspiration Cytology (FNAC) — first-line diagnostic procedure
  • AFB smear positive in ~20–50% of cases
  • Shows caseating granulomas (epithelioid histiocytes + Langhans giant cells + central necrosis) in nearly all immunocompetent patients
  • Sensitivity 77%, specificity 93% for TB
• Mycobacterial culture of aspirate — M. tuberculosis isolated in ~70% of confirmed cases; gold standard
• Xpert MTB/RIF assay (GeneXpert): rapid molecular diagnosis; sensitivity 81%, specificity 99%
• Excisional lymph node biopsy: if FNAC inconclusive

Caseating granulomas are seen in nearly all biopsy specimens from immunocompetent patients. In immunodeficiency states, granulomas may be poorly formed or absent. — Murray & Nadel's Textbook of Respiratory Medicine, p. 1198

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🩻 Clinical Image

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🧾 Differential Diagnosis

The differential diagnosis includes lymphoma, metastatic cancer, fungal disease, cat-scratch disease, sarcoid, toxoplasmosis, reactive adenitis, and bacterial adenitis. — Rosen's Emergency Medicine

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💊 Management

Anti-TB Chemotherapy (First-Line)

• 2RHZE / 4RH (2 months Rifampicin + Isoniazid + Pyrazinamide + Ethambutol, followed by 4 months Rifampicin + Isoniazid)
• A 6-month regimen is adequate for drug-susceptible TB lymphadenitis
• Responses may be slower than pulmonary TB
• Paradoxical upgrading reactions (nodes enlarge or new nodes appear during treatment) can occur — do not indicate treatment failure; represent immune reconstitution

Surgical

• Incision and drainage should NOT be performed — leads to permanent sinuses and prolonged drainage
• Surgical excision is reserved for: failure of medical therapy, diagnostic uncertainty
• FNAC preferred over excision biopsy as initial diagnostic step

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Key Teaching Points

1. TB lymphadenitis is the most common form of extrapulmonary TB worldwide (~35% of extrapulmonary cases)
2. It predominantly affects women, adolescents, and young adults; also common in children and HIV-positive individuals
3. The characteristic node is painless, non-tender, posterior cervical or supraclavicular
4. Pulmonary TB is absent in the majority — a negative chest examination and normal CXR do NOT rule it out
5. FNAC is the cornerstone of diagnosis; culture remains the gold standard
6. Nodes may mature, suppurate, and form sinus tracts if untreated
7. Treatment is medical, not surgical — incision and drainage is contraindicated

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Case Presentation: Tuberculous Lymphadenitis (Scrofula)

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Presenting Complaint

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History of Presenting Illness

• Painless, slowly progressive swelling in the right side of the neck for 8 weeks
• Initially a single small lump; now appears to have two or three lumps matting together
• No redness over the skin initially; recently the overlying skin has become slightly indurated
• No pus discharge or sinus tract at this stage
• Reports mild evening fever and night sweats over the past 3–4 weeks
• Weight loss of approximately 3–4 kg over 2 months
• Appetite reduced; general fatigue and malaise

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Negative History (Pertinent Negatives — Critically Important)

Respiratory Negatives

Pulmonary TB is absent in the majority of TB lymphadenitis cases — a negative respiratory history does NOT rule out TB lymphadenitis. — Goldman-Cecil Medicine

Local / Neck Negatives

Systemic / Other Negatives

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Past Medical History

• No prior TB or other chronic illness
• No previous surgeries or hospitalisations
• BCG vaccination in childhood (scar present)

Drug History

• No regular medications
• No known drug allergies

Family & Social History

• Lives in a densely populated household (4–5 people, 2-room dwelling)
• No known family member with TB (but may still be a source)
• Non-smoker, no alcohol

Review of Systems

• No haematuria, dysuria (rules out genitourinary TB as co-presentation)
• No back pain or limb weakness (rules out Pott's disease)
• No headache or neck stiffness (rules out TB meningitis)
• No abdominal distension (rules out TB peritonitis)

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Physical Examination

General Appearance

• Young woman, alert and oriented, looks mildly unwell
• No acute distress; not pale, not jaundiced, not cyanosed
• Low-grade fever: Temp 37.8°C | PR 88 bpm | BP 110/70 mmHg | RR 18/min | SpO₂ 98% on air

Head & Neck (Most Important)

• Right posterior cervical chain: 3 enlarged lymph nodes, largest ~3 × 2.5 cm
• Nodes are firm, non-tender, partially matted
• Overlying skin: slightly erythematous and thickened; no fluctuance yet; no sinus tract
• No transillumination
• Left cervical nodes: 1 mildly enlarged, soft, non-tender node (~1 cm)
• No supraclavicular, axillary, or inguinal lymphadenopathy

Respiratory System

• Chest expansion: equal bilaterally
• Percussion: resonant throughout; no dullness
• Auscultation: vesicular breath sounds, air entry equal bilaterally; no crackles, no wheeze, no bronchial breathing
• No signs of pleural effusion

Cardiovascular

• Heart sounds I and II heard; no murmurs
• No raised JVP, no ankle oedema

Abdomen

• Soft, non-tender
• No hepatomegaly, no splenomegaly
• No palpable abdominal masses

Musculoskeletal

• Normal spine — no gibbus deformity, no kyphosis (excludes Pott's disease)

Neurological

• No focal deficits; no neck stiffness

Skin

• BCG scar present (left deltoid)
• No skin lesions, erythema nodosum, or lupus vulgaris

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Clinical Image

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Summary / Clinical Impression

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Differential Diagnosis

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Investigations

Caseating granulomas are seen in nearly all biopsy specimens from immunocompetent patients. In immunodeficiency states, granulomas may be poorly formed or absent. — Murray & Nadel's Textbook of Respiratory Medicine

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Management

Anti-TB Chemotherapy

• Intensive phase (2 months): Rifampicin (R) + Isoniazid (H) + Pyrazinamide (Z) + Ethambutol (E) → 2RHZE
• Continuation phase (4 months): Rifampicin + Isoniazid → 4RH
• Total: 6 months — adequate for drug-susceptible TB lymphadenitis
• Responses may be slower than pulmonary TB
• Paradoxical reactions (nodes temporarily enlarge during treatment) can occur — indicate immune reconstitution, not treatment failure

Surgical

• Reserved for: failed medical therapy, diagnostic uncertainty
• Do NOT incise and drain — permanent sinuses result

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