Scrofula

A 16-year-old Asian American girl presented for evaluation of a cyst on the anterior neck that had become enlarged and inflamed over the past 9 months. She also had a productive cough for 1 month. There was no history of night sweats, weight loss, or fever.

History. Cultures of fluid aspirated from the cyst 9 months earlier by the patient's pediatrician were negative. The white blood cell count 1 month after the development of the cyst was 10,000/µL, with 65% neutrophils and 26% lymphocytes. An ultrasonogram had shown an oval-shaped heterogeneous cyst anterior to the lower third of the sternocleidomastoid muscle with a complex echogenic pattern and floating debris that suggested an inflammatory or hemorrhagic process. An endocrinologist had ruled out thyroid involvement. Another ultrasonogram performed 3 months later showed a 3.2 3 3.2-cm abscess with an irregular and thickened wall.

Five months after the cyst developed, the patient was evaluated by an otorhinolaryngology surgeon who noted a small healing granuloma; no purulent material was expressed. A CT scan of the neck revealed an 8 3 5-mm supraclavicular lymph node, lymphadenopathy in the chest, and an infiltrate in the apex of the lung. One of the lymph nodes in the chest had calcification within it.

Five years earlier, the patient's mother had been treated for active tuberculosis (TB) with a multidrug regimen that was supervised by the Department of Health. The organism was sensitive to all anti-TB medications. At that time, the patient was given a 9-month course of isoniazid because results of a PPD (purified protein derivative) tuberculin test were positive and a chest x-ray film was negative. It was not clear whether the patient complied with therapy.

Examination. The patient was well developed, afebrile, and in no acute distress. The cyst was about the size of a dime and tender on palpation; no drainage was noted. Chest examination revealed diffuse crackles and unilateral wheezing.

The diagnostic impression was cervical tuberculous lymphadenitis (scrofula) with active TB. A regimen of isoniazid, rifampin, pyrazinamide, and ethambutol was started. A sputum smear was 2+ positive for acid-fast bacillus, and culture subsequently grew Mycobacterium tuberculosis that was sensitive to all of the medications. The sedimentation rate was 38 mm/h, and results of the Quantiferon-TB Gold assay were positive. The patient was referred to the New York City Bureau of TB Control for directly observed therapy and contact notification. Her mother and sibling at home were asymptomatic and chest x-ray findings were normal; currently, anti-TB therapy has not been restarted.

A review of a chest x-ray film obtained at the time the cyst developed revealed a nodular infiltrate in the axillary segment of the right upper lobe and in the right middle lobe. This finding should have raised the possibility of TB.

The top 5 countries of origin of foreign-born persons with TB are Mexico, Philippines, Vietnam, India, and China. Currently, Hispanic persons make up the largest percentage of cases. This patient had never traveled to China, where her mother was born and likely acquired the infection.

In cities with large immigrant populations, such as New York, we continue to see cases of TB in immigrants from many areas of the world. The index of suspicion for TB must be high in any child who has immigrated to the United States, traveled to a country with an increased incidence of TB, or lived with a family member who is an immigrant. In 2006, more than 13,000 TB cases were reported.¹ California, New York, Texas, and Florida accounted for 48% of the national case load. *

1. Centers for Disease Control and Prevention. Trends in tuberculosis incidence-- United States, 2006. MMWR. 2007;56(RR-11):245-250.

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