Pleuropulmonary Tuberculosis Presenting With Ruptured, Fistulized Scrofula

Abstract

Introduction: Cervical lymphadenitis (scrofula) is an uncommon clinical presentation of active tuberculosis in the United States and may herald underlying extrapulmonary tuberculous infection. CASE PRESENTATION: A 20 year old Caribbean male presented to the emergency department for wound care of a neck abscess. Physical exam revealed a poorly circumscribed 3cm × 2cm draining supraclavicular erosion with exposed subcutaneous tissue (Image 1). Air entry was decreased over right mid to lower lung zones with dull percussion note. Chest x-ray revealed right pleural effusion with irregular margins tracking to the apex. CT with contrast revealed a moderate sized right loculated pleural effusion and volume loss of right hemithorax. There were several peripherally enhancing structures in the right supraclavicular fossa, representing necrotic lymph nodes. HIV testing was negative and PPD revealed necrotizing induration of 15mm. Patient was taken for VATS decortication. AFB smear of pleural tissue was negative. Suspicion for pleural based pulmonary tuberculosis was high and RIPE therapy started. Histopathological examination of lung parenchyma and attached pleura revealed extensive necrotizing granulomatous chronic inflammation and fibrosis, consistent with mycobacterium tuberculosis. Special stains for AFB and GMS were negative. Repeat CT revealed persistent large foci of pleural air in mid-inferior lateral right hemithorax with visceral pleural thickening, consistent with trapped lung (Image 2). Pleural fluid AFB cultures grew mycobacterium tuberculosis complex six weeks post thoracotomy. DISCUSSION: Tuberculous cervical lymphadenitis, referred to as Scrofula, occurs in young immunocompetent patients with pleural tuberculosis caused by primary infection (1), and is the most common extrapulmonary location for tuberculosis in HIV/AIDS patients. Owing to the rarity of scrofula presentation in developed nations, clinical suspicion for and knowledge of extrapulmonary TB is lacking (2). Oftentimes, differential diagnosis for cervical lymph node masses exclude lymph node tuberculosis leading to delays in isolation, diagnostic studies, and initiation of treatment. Pleural tuberculosis is associated with the development of a visceral pleura fibrous peel and the formation of trapped lung (3). Conclusions: Recognition of cervical lymphadenopathy as an extrapulmonary manifestation of tuberculosis and maintenance of a high index of suspicion for the disease is important, especially in young immunocompetent patients.