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Neuroradiology Case of the Week

Case 404

May 2009

David Tuttle, MD

Clinical Presentation: A 27-year-old man presented with high fever and enlarged left suprclavicular lymph nodes on physical examination. He reported a recent travel history to India.

Imaging Findings: A selected post-contrast axial CT image demonstrates multiple enlarged left supraclavicular lymph nodes with central low attenuation and enhancing margins. There is slight compression on the adjacent superior vena cava.

Diagnosis: Tuberculus lymphadenitis

Discussion: Tuberculous (TB) lymphadenitis is the most frequent form of extrapulmonary tuberculosis and accounts for 5% of cases of tuberculosis in Western countries. In the United States it is more common in immigrants and racial minorities. In HIV negative persons, it is usually unilateral and cervical in location (scrofula), which is caused by hematogenous or lymphatic spread of the infection from the lung.
     Scrofula presents as a unilateral firm, red, nontender mass located along the upper border of the sternocleidomastoid muscle or in the supraclavicular area. It usually progresses indolently without systemic symptoms. Occasionally, compression of adjacent organs may lead to symptoms such as dysphagia, and affected nodes may rarely erode into adjacent organs resulting in draining sinuses, empyema, and esophageal perforation. Conversely, in individuals with AIDS, peripheral TB lymphadenitis is almost always multifocal and associated with major systemic symptoms such as fever, weight loss, and evidence of TB in the lungs.
     The tuberculin skin test is almost always positive. Fine needle aspiration shows cytologic evidence of granuloma, but smears and cultures are usually negative. Biopsy with culture is often required for diagnosis. Laboratory tests such as adenosine deaminase level or PCR may be helpful in establishing the diagnosis. TB lymphadenitis frequently responds to the standard 6 month medical therapy. Surgery may rarely be required in cases of persistent sinus drainage or poor response to medical management.

References:

1. Lazarus AA, Thilagar B. Tuberculous lymphadenitis. Dis Mon 2007 Jan;53:10-15. [MDConsult]
2. Cohen J, Powderly WG. Infectious Diseases, 2nd ed., Mosby, 2004. [MDConsult]
3. Mandell GL, Bennett JE, Dolin R. Mandell, Bennett, & Dolin: Principles and Practice of Infectious Disease. 6th ed., Churchill Livingstone, 2005. [MDConsult]