An 89-year-old male smoker patient presented at the emergency department of our hospital with left, deep purplish cervical swelling with draining sinuses. The patient reported that three months ago, painless erythematous nodular swellings appeared in the left lateral neck area. No respiratory symptoms, fever, or weight loss were reported except for occasional dry cough and mucous expectoration since he had been a lifelong smoker of 70 pack-years. The patient was a taxi and bus driver. His past medical history included surgery for benign prostate hypertrophy 15 years ago, as well as an unscheduled visit to the emergency department of our hospital, 6 months ago, due to an acute hypertensive episode associated with pulmonary edema, being treated by intravenous diuretics. Since then, he had been on valsartan-hydrochlorothiazide therapy (16 mg + 12.5 mg), once daily. On examination, the patient, a tall and thin man, (BMI = 19.6 Kg/m2), with normal skin color, had a normal physical appearance except for his left lateral neck lesion including draining tract sinuses with purulent material (Figure 1) and scarce low-pitched expiratory wheezes. The cardiovascular examination showed a mild systolic murmur in the right second intercostal space compatible with moderate aortic valve regurgitation. On admission, the blood pressure (BP) and heart rate (HR) were 145/70 mmHg and 86 beats per minute, respectively, while blood and biochemistry tests were as follows: Hct = 37.3%; Hb = 13.8 g/dL; MCV = 81.7 fL; MCH = 29.6 pg; PLT = 214 x 103/muL; WBC = 6.3 x 103/muL (leukocyte type: NEU% = 70%, LYM% = 20%, MON% = 7%, and EOS = 3%); INR = 1.22; serum glucose = 101 mg/dL; urea = 39 mg/dL; creatinine = 1.02 mg/dL; Na+ = 139 mmol/L; K+ = 4.2 mmol/L; and erythrocyte sedimentation rate (ESR) = 52 mm/1st hour. The Mantoux test showed 10 mm induration, and his chest X-ray had no significant findings. The computed tomography (CT scan) showed minimal fibrous bands in the upper zone area of the right upper lobe, while a small calcified nodule (3 mm diameter) was also found in the periphery of the apical-posterior segment of the left upper lobe (Figure 2). Fiberoptic bronchoscopy revealed a diffusely red and hyperemic bronchial mucosa, particularly intense in the segments of the right upper lobe, with the presence of some small anthracotic areas (Figure 3). Bronchoalveolar lavage fluid (BAL) obtained from the apical-posterior segment of the left upper lobe showed increased (>70%) lymphocytes, 15% neutrophils, few (<8%) macrophages, and scarcity of bronchial epithelial cells with no evidence of malignancy. Direct smear for acid-fast bacilli was also negative. The surgical biopsy and the microscopic examination of the cervical lymph node showed epithelial granuloma with central coagulative (caseous) necrosis and the presence of M. tuberculosis complex, respectively. In addition, the microscopic examination of the purulent content of draining sinuses in the patient's neck also revealed the presence of M. tuberculosis complex. Final diagnosis for TL was established by histopathologic examination (Figures 4(a) and 4(b)).
The patient was started on a four- (4-) drug antituberculous regimen. One month after the initiation of the antituberculous regimen, and after an initial remission regarding the magnitude of the patient's neck growth, he experienced an enlargement of his lymph nodes with reappearance of draining sinuses. It was then decided to add oral steroids (20 mg prednisolone daily). Four weeks after steroid administration, there was a spectacular, almost complete remission, of his neck growth. The antituberculous treatment was continued for 6 months, and the patient was free of disease after its completion.