KM is a 21 year old female from Bangladesh who immigrated to the United States seven months earlier with no previous significant past medical history presented to the Emergency department with complains remitting and relapsing cervical and axillary masses for past 2 years associated with low grade fever, weight loss and dry cough. The masses first appeared two year ago which were resolved after spontaneous drainage of serosanguinous and purulent material. Subsequently she noticed new masses a year ago which has since progressed in size and now became painful for past 2 weeks prompting her to visit emergency room. She reported 15 pounds weight loss in past 7 months. There was no sputum production, night sweats, anorexia, joint pains, muscle aches or history of cat bites. Review of systems was unremarkable except enlarging cervical and axillary masses. Social and family history was unremarkable except treated pulmonary tuberculosis in sister two years ago.
Physical examination revealed blood pressure 119/70 mm Hg, heart rate 79 beats/min, respiratory rate 16/min, and temperature 97.8F and oxyhemoglobin saturation 99% on Room Air. Pertinent positive findings on exam are as follows; well-developed well-nourished female of average height and built, appears comfortable with palpable 2x3 cm submandibular and posterior cervical lymph nodes, 4x3 cm mobile, tender, soft lymph node at right supra clavicular region and 5x4 cm mobile, nontender, soft lymph node at right axilla.
The basic investigation including complete blood count, basic metabolic profile, liver function studies, coagulation profile, thyroid stimulating hormone, urinalysis were all within normal limits. Patient was admitted to medical floor in negative pressure room with respiratory isolation in view of high suspicion of contagious tuberculosis. HIV test was negative. Three sputum samples for AFB smears were negative. PPD was 15 mm induration. CT scan of neck and chest revealed multiple enlarged calcified Lymph nodes predominantly along the lateral margin of right sternocleidomastoid muscle measuring 3.3x2 cm in dimension with central low attenuation, a 4x2 cm right axillary lymph node and a sub centimeter right sub pectoral lymph node. Multiple small calcified lymph nodes are also seen at mediastinal, bilateral hilar, subcarinal, gastrohepatic and porta hepatic region. In addition combination of calcified and non-calcified sub centimeter scattered pulmonary nodules were visualized as well.
Subsequently patient underwent FNA cytology of right neck mass which revealed inflammatory exudates and necrotic debris with no viable cells present. Smear and cultures were negative for bacteria, acid fast bacillus and fungi. On the basis of strong clinical and radiologic suspicion of tuberculous lymphadenitis with above cytologic examination, patient was started RIPE treatment and followed up in pulmonary clinic. Her clinical symptoms and lymphadenopathy improved and patient gained ten pounds.
Three months into RIPE treatment she developed enlarging painful right cervical lymphadenopathy despite initial improvement. Those enlarged cervical lymph nodes were noticed to be recurrently draining purulent material with spontaneous healing. After ensuring medication adherence, repeat CT scans neck and chest revealed significant decrease in size of previously enlarged cervical and right axillary lymph node but preexisting medial right axillary and right sub pectoral lymph nodes were markedly increased in size. Excision biopsy of right neck lymph node revealed soft tissue with necrotizing and non-necrotizing granulomatous inflammation. Notably AFB and fungal stains and cultures were negative. Patient was then initiated on 60 mg of daily prednisone with subsequent improvement in pain and size of right axillary and sub pectoral lymphadenopathy (Figures 1 and 2).