Figure 1
Axial post-contrast cervical CT scan
Enlarged cervical lymph nodes with low-density centre (sign of necrosis) and peripheral rim of enhancement.
Scrofula
SectionChest imaging
Case TypeClinical Cases
Authors
Koutsokosta E, Terzis I, Pitta X, Voultsinou D, Anastasiadou K, Palladas P.
CT and MRI Department, General Hospital ‘G.Papanikolaou’, Thessaloniki, Greece.
Connected authors
27 years, female
Clinical History
A 27-year-old female was referred to the radiology department for evaluation of right cervical and axillary painless mass.
Imaging Findings
A 27-year-old female was referred to the radiology department for evaluation of a painless right neck mass and a right axilla mass. She has a known history of rheumatoid arthritis. She has received a TNF (tumour necrosis factor) therapy.
A pre and post-contrast cervical and chest CT examination were performed. Cervical CT examination revealed: bilateral enlarged cervical lymph nodes, especially at the right side, with low-density centre (necrosis) and peripheral rim of enhancement (Fig. 1). Also supraclavicular enlarged lymph nodes were observed, at the right cervical area with the same characteristics (Fig. 2).
Chest CT examination revealed: enlarged right axillary lymph nodes with low density centre and a rim of enhancement (Fig. 3), a bilateral pleural effusion (Fig. 4), airspace opacities at the right upper and left lower lobe and bilateral fibrotic disease at the lower lobes (Fig. 5).
A right cervical node aspirate was positive for pansensitive Mycobacterium tuberculosis.
A pre and post-contrast cervical and chest CT examination were performed. Cervical CT examination revealed: bilateral enlarged cervical lymph nodes, especially at the right side, with low-density centre (necrosis) and peripheral rim of enhancement (Fig. 1). Also supraclavicular enlarged lymph nodes were observed, at the right cervical area with the same characteristics (Fig. 2).
Chest CT examination revealed: enlarged right axillary lymph nodes with low density centre and a rim of enhancement (Fig. 3), a bilateral pleural effusion (Fig. 4), airspace opacities at the right upper and left lower lobe and bilateral fibrotic disease at the lower lobes (Fig. 5).
A right cervical node aspirate was positive for pansensitive Mycobacterium tuberculosis.
Discussion
Tuberculosis is an airborne communicable disease caused by Mycobacterium tuberculosis, which is an obligate, aerobic, nonspore-forming rod. Patient-to-patient transmission typically occurs via inhalation of small aerosols and, in most cases, the disease is confined to the respiratory system. Although the thorax is most frequently involved, tuberculosis may involve any of a number
of organ systems, especially in immunocompromised patients, like respiratory, cardiac, central nervous, musculoskeletal, gastrointestinal and genitourinary systems. Immunocompromised patients (as the patients who were having TNF therapy) have a significantly higher prevalence of extrapulmonary tuberculosis than the general population.
Cervical tuberculous adenitis is a manifestation of a systemic disease process. It represents about 15% of cases of extrapulmonary tuberculosis.
About one half of these have a history of previous tuberculosis or chest radiographic evidence of past disease. This condition is most prevalent in the 20 to 30 year age group, but can occur at any age. The most common location is within neck nodes, often manifesting as bilateral painless cervical lymphadenitis, also known as scrofula. Four CT patterns of nodal disease have been observed:
1. Multichambered nodal mass with ring –like areas of enhancement both within and around the mass. The enhanced walls of these multichambered masses are thicker than those usually defined as rim enhancement of necrotic nodes secondary to metastatic carcinomatous disease.
2. A large, low density mass with a thick sometimes corrugated rim of enhancement about the periphery. This CT pattern is encountered when the walls of individual lymph nodes have been totally destroyed and the nodes coalesce to form a single large necrotic mass. This is commonly referred as a “cold abscess”.
3. A homogenous soft-tissue mass in a lymph-node-bearing area with or without enhancement. Normal fascial planes are preserved adjacent to the mass.
4. A soft-tissue mass in a lymph-node-bearing area with a thin rim of enhancement and normal fascial planes. This appearance by itself is not distinctive for tuberculosis and mimics neoplastic nodal disease.
Nodal calcification often develops late in tuberculosis, which helps differentiate tuberculous nodes from malignancy. Metastatic disease from head and neck squamous cell carcinomas, treated lymphoma, and non-nodal lesions (such as an infected branchial cleft cyst) should be considered for the differential diagnosis.
Fine-needle aspiration with CT guidance or, most often, ultrasonographic guidance is usually the first diagnostic investigation performed, with a reported sensitivity of 77% and a specificity of 93%. Biopsies are not usually recommended, as they may result in spread of the disease and sinus formation.
With proper treatment, patient recovery is usually complete. Antibiotic regimens used for treating pulmonary infection are also applied to tuberculous lymphadenitis. Just as the disease is slow to develop, it is also slow to respond to medical therapy. Antibiotics must be taken for at least a 6-month period, although a longer course may be necessary.
In conclusion, we should include cervical tuberculous adenitis in the differential diagnosis of an asymptomatic neck mass.
of organ systems, especially in immunocompromised patients, like respiratory, cardiac, central nervous, musculoskeletal, gastrointestinal and genitourinary systems. Immunocompromised patients (as the patients who were having TNF therapy) have a significantly higher prevalence of extrapulmonary tuberculosis than the general population.
Cervical tuberculous adenitis is a manifestation of a systemic disease process. It represents about 15% of cases of extrapulmonary tuberculosis.
About one half of these have a history of previous tuberculosis or chest radiographic evidence of past disease. This condition is most prevalent in the 20 to 30 year age group, but can occur at any age. The most common location is within neck nodes, often manifesting as bilateral painless cervical lymphadenitis, also known as scrofula. Four CT patterns of nodal disease have been observed:
1. Multichambered nodal mass with ring –like areas of enhancement both within and around the mass. The enhanced walls of these multichambered masses are thicker than those usually defined as rim enhancement of necrotic nodes secondary to metastatic carcinomatous disease.
2. A large, low density mass with a thick sometimes corrugated rim of enhancement about the periphery. This CT pattern is encountered when the walls of individual lymph nodes have been totally destroyed and the nodes coalesce to form a single large necrotic mass. This is commonly referred as a “cold abscess”.
3. A homogenous soft-tissue mass in a lymph-node-bearing area with or without enhancement. Normal fascial planes are preserved adjacent to the mass.
4. A soft-tissue mass in a lymph-node-bearing area with a thin rim of enhancement and normal fascial planes. This appearance by itself is not distinctive for tuberculosis and mimics neoplastic nodal disease.
Nodal calcification often develops late in tuberculosis, which helps differentiate tuberculous nodes from malignancy. Metastatic disease from head and neck squamous cell carcinomas, treated lymphoma, and non-nodal lesions (such as an infected branchial cleft cyst) should be considered for the differential diagnosis.
Fine-needle aspiration with CT guidance or, most often, ultrasonographic guidance is usually the first diagnostic investigation performed, with a reported sensitivity of 77% and a specificity of 93%. Biopsies are not usually recommended, as they may result in spread of the disease and sinus formation.
With proper treatment, patient recovery is usually complete. Antibiotic regimens used for treating pulmonary infection are also applied to tuberculous lymphadenitis. Just as the disease is slow to develop, it is also slow to respond to medical therapy. Antibiotics must be taken for at least a 6-month period, although a longer course may be necessary.
In conclusion, we should include cervical tuberculous adenitis in the differential diagnosis of an asymptomatic neck mass.
Differential Diagnosis List
Scrofula (Tuberculous lymphadenitis).
Final Diagnosis
Scrofula (Tuberculous lymphadenitis).
Case information
| URL: | https://eurorad.org/case/7982 |
| DOI: | 10.1594/EURORAD/CASE.7982 |
| ISSN: | 1563-4086 |
Figure 2
Axial post-contrast cervical CT scan
Enlarged right supraclavicular lymph nodes with the same characteristics as Figure 1.
Figure 3
Axial post-contrast cervical CT scan
Enlarged axillary lymph nodes with low density centre and peripheral rim enhancement
Figure 4
Axial chest CT scan
Bilateral pleural effusion.
Figure 5
Axial chest CT scan
Airspace opacities at the right upper lobe.
Figure 6
Axial chest CT scan
Airspace opacities left lower lobe.
Figure 7
Axial chest CT scan
Bilateral fibrotic disease at the lower lobes.
Axial post-contrast cervical CT scan
Enlarged cervical lymph nodes with low-density centre (sign of necrosis) and peripheral rim of enhancement.
Axial post-contrast cervical CT scan
Enlarged right supraclavicular lymph nodes with the same characteristics as Figure 1.
Axial post-contrast cervical CT scan
Enlarged axillary lymph nodes with low density centre and peripheral rim enhancement
Axial chest CT scan
Bilateral pleural effusion.
Axial chest CT scan
Airspace opacities at the right upper lobe.
Axial chest CT scan
Airspace opacities left lower lobe.
Axial chest CT scan
Bilateral fibrotic disease at the lower lobes.