A 32-year-old woman presented to the Ear, Nose and Throat clinic with a tender lump on her right side of the upper neck that had appeared for 2 weeks. She had a mild fever initially but did not have a loss of appetite, weight loss or night sweats. She also did not experience any cough, chest pain, nasal obstruction or otologic symptoms. There was no recent contact history of tuberculosis. She was treated for cervical lymphadenitis with amoxicillin by a general practitioner before coming to us. However, her neck lump persisted. On examination, there was a firm 1.5 x 1 cm right upper neck lump which was mildly tender. We performed nasal endoscopy, which showed a nasopharyngeal mass almost obliterating the fossa of Rosenmuller on both sides (Figure 1).
The surface of the mass looked irregular with yellowish secretions on it. The rest of the ear, nose and throat examinations were unremarkable. Our working diagnosis was NPC with neck metastasis. We ordered an ultrasound scan of the neck and fine needle aspiration cytology (FNAC) of the neck lump. A biopsy of the nasopharyngeal mass was taken. The ultrasound scan reported multiple hypoechoic enlarged cervical nodes bilaterally with distortion of the fatty hilum. A computed tomography (CT) scan of the nasopharynx and neck was ordered to further evaluate the neck lump and nasopharyngeal mass.
The FNAC was reported as showing 2 foci of atypical cells arranged in a sheet, composed of enlarged hyperchromatic nuclei. The nuclear membranes were found to be irregular with moderate cytoplasm in the background of abundant polymorphous lymphoid cells and red blood cells. The Ziehl-Neelsen (ZN) stain of the FNAC was negative for acid-fast bacilli (AFB). Metastatic carcinoma of the neck node was suspected. The CT scan showed a heterogeneously enhancing soft tissue mass measuring 2 x 1.4 x 3.9 cm in the nasopharynx, obliterating the bilateral fossa of Rosenmuller and extending inferiorly to the upper part of the oropharynx (Figure 2). Multiple enlarged, homogenously enhancing cervical nodes were seen on both sides. The visualized apical lungs showed minimal consolidation and centrilobular nodules with tree-in-bud appearances.
The radiologist's impression from the CT scan finding was that of nasopharyngeal cancer with multiple cervical lymphadenopathy. Lesions in the lung apices were suspected of being active lung infections. Histopathological examination of the nasopharyngeal mass biopsy revealed necrotizing granulomatous inflammation with epithelioid histiocytes and multinucleated giant cells. No malignant cells were seen. Stains for AFB and Grocott methenamine silver (GMS) stain for fungal hyphae were negative.
A repeat biopsy of the nasopharyngeal mass was sent due to strong suspicion of nasopharyngeal cancer with neck metastasis. The repeat biopsy showed caseating granuloma with dense chronic inflammatory cells forming lymphoid follicles and the ZN stain demonstrated a few AFB (Figure 3(a)-(c)). Malignant cells were again not detected and GMS staining was negative for fungal hyphae.
The repeat biopsy was again negative for malignant cells and fungal hyphae. We ordered sputum smears for microscopy and a chest x-ray to exclude pulmonary tuberculosis. The chest x-ray was normal, but her sputum smears for AFB tested positive. Her white blood cell (WBC) count was 6.99 x 109/L, neutrophil count 70.4%, lymphocyte count 19%, Hb level was 12.2 g/dL, erythrocyte sedimentation rate was (ESR) 60 mm/h and anti HIV and HBsAg tests were negative. A diagnosis of nasopharyngeal tuberculosis secondary to pulmonary tuberculosis was made. We referred her to a pulmonologist colleague who put her on first-line anti-tubercular drugs. The patient was admitted to the tuberculosis ward for 2 weeks to be observed for any drug reactions and acute side-effects as per the protocol. The patient responded well to standard treatment of a 2 months intensive phase (isoniazid, rifampicin, pyrazinamide, ethambutol), and a 4 months continuation phase (isoniazid and rifampicin). Her neck node was not palpable after 2 months of treatment and the nasopharyngeal mass disappeared in 3 months. She remained asymptomatic at 6 months follow-up.