A 74-year-old male patient was referred to our clinic from the same Psychiatric Hospital as Case 3, which led us to the conclusion that a TB exposure is present in that institution. He presented with a 5 to 6 cm round, mobile, elastic, supraclavicular tumor on the left side that has been slowly growing for the last year. A complete medical history and TB exposure history was also impossible to obtain. The evaluation protocol included a complete ENT, chest X-ray and blood work showing minimal changes. The mass was excised under general anesthesia and sent for histopathological examination. It also had suppuration and was filled with creamy yellow puss. The histopathological examination revealed similar results as Case 3, with intensely modified lymph nodes by the presence of frequent granulomas of various shapes and sizes, necrosis, giant multinuclear cells, areas of ulceration and granulation. The post-operative course was in this case rather laborious due to the precarious healing of the wound (Figure 7) which had to be re-stitched several times until it completely healed. After complete recovery, the patient was referred to the Infectious Disease Department for further diagnosis and treatment. The final diagnosis of primary tuberculous adenotonsillitis was set by special cultures and AFB staining of the sputum and the classic WHO Category-3 regimen was employed. Follow-ups at 3, 6 and 12 months revealed no sign of recurrence or residual disease.
Case 1, 3 and 4 did not receive the positive diagnosis of tuberculosis in our surgical clinic, but after they were sent to the infectious diseases clinic. Thus being said, the four cases of extra-pulmonary tuberculosis had minimal, non-specific changes in regards to the laboratory and imaging studies, having had modified erythrocyte sedimentation rates (elevated ranges of approximately 3 to 4 times the normal values) and elevated fibrinogen values (above the normal range), revealing the active inflammatory state of the patients. At the same time, the X-rays of patients 1, 3 and 4 had minimal changes, with accentuated interstitial pattern, while in case 2, the X-rays revealed a more complex reticular pattern with micronodules and a condensing area located peripherally, in the right medial lung lobe. In case 2, at first the patient refused the surgical intervention on her abdomen (due to intense, diffuse pain both spontaneous and when palpating, with muscle defence and right pneumoperitoneum), having accepted only the biopsy from the tongue pseudo-tumor. A diagnosis of perforated bowel (or perforated stomach) accompanied by acute peritonitis was established and due to worsening of symptoms, the patient consented to being operated, with the aforementioned final development.