A 93-year-old Caucasian woman was referred to the Internal Medicine Consultation due to cervical adenopathies with 3 months duration. With respect to past medical history, 4 years earlier she had been diagnosed with cutaneous sarcomatoid carcinoma of the face and submitted to surgical excision. The patient denied having fever, asthenia, fatigue, weight loss or night sweats; furthermore, there were no respiratory symptoms. She denied having a previous history of tuberculosis (TB) and recent contact with people with known or suspected TB. There was no epidemiological context or contact with animals. On physical examination, an enlarged, mobile and painful right cervical lymph node was evident; the remainder of the examination was unremarkable.
Cervico-thoraco-abdominal-pelvic computed tomography (CT) showed a right cervical mass (Fig. 1) with multiple adenopathies and some fibrotic lesions in the upper right lobe; there were no other adenopathies nor evidence of neoplastic disease. Fine needle aspiration (FNA) biopsy of the cervical node was performed and yielded a noncaseous granulomatous process. There was no evidence of Reed-Sternberg cells or neoplastic cells; Ziehl-Neelsen staining was negative, as well as polymerase chain reaction (PCR) assessment for Mycobacterium tuberculosis (MT) and culture. The patient was kept under close surveillance. In the meantime, an IgG lambda monoclonal gammopathy was diagnosed; renal function and calcium metabolism were normal, there was no anaemia or elevated urinary free light chains and beta-2 microglobulin was normal. Peripheral blood immunophenotyping demonstrated a polyclonal B cell population. In addition, serology tests for syphilis, human immunodeficiency virus (HIV), hepatitis B virus and hepatitis C virus were negative, and QuantiFERON testing was positive. Two months later, the adenopathies had grown and there was cutaneous fistulization with suppurative lymphadenitis (Figs. 2A and 2B).
Microbiologic examination of a suppuration swab was positive for Staphylococcus aureus and the patient was treated with cefuroxime, displaying only slight improvement. An excisional biopsy was programmed and histological examination revealed granulomas with caseous necrosis and suppuration.
PCR assessment of the samples was negative for MT, Nocardia, Mycobacterium avium complex, Toxoplasma gondii, Aspergillus fumigatus, Bartonella spp., Treponema pallidum and Leishmania infantum. Considering the presence of persistent cervical lymphadenopathy with caseous granulomas, a positive QuantiFERON test, and the exclusion of other potential causes, the hypothesis of cervical tuberculous lymphadenitis was strongly suspected, even without a positive PCR test for MT. The patient started presumptive treatment with isoniazid, rifampicin, pyrazinamide and ethambutol. Afterwards, diagnostic confirmation was obtained by isolation of MT in one of the lymph node cultures. Antimicrobial susceptibility testing did not demonstrate resistances. The patient presented a favourable clinical outcome with gradual reduction in the size of the adenopathies and there were no side effects attributable to the antituberculous drugs.