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					Case presentation:

A 16 year old girl, previously healthy, presented with a 6 month history of a slowly
growing left neck mass. She had no dyspnea, dysphagia, weight loss, cough or
change in voice quality. The patient recalled a previous episode of low-grade
fever, during the time period in which the left neck mass was present, for which
she received a course of antibiotics. Although the fever subsided, the mass
persisted. As a result, she was referred to our medical center.

On physical examination she had a 10 x 6
cm left neck mass extending from the
angle of mandible to clavicle, firm, non
tender with no overlying skin changes
(Figure 1). Multiple bilateral small lymph
nodes were palpable. A CT scan was done
and revealed a 10x6x5 cm left
heterogeneous neck mass, with several
areas of cystic necrosis, compressing the
internal jugular with several small lymph
nodes (Figure 2).

                                                        Figure 1. Left neck mass
Findings of other investigations were as
follows: (a) CBC was benign, (b) ESR=
61, (c) serology for Toxoplasma and
Bartonella was negative, (d) PPD test was
positive, and (e) chest X-ray was clear.
FNA       revealed      histiocytes   and
multinucleated giant cells; no malignant
cells were present. A culture of the fluid
revealed no bacterial growth.

The patient was started on anti-
tuberculous treatment (4 drug) and then
underwent excision of the neck mass. She
developed dehiscence of the wound and
was treated with compressive dressing.

DIAGNOSIS: Mycobacterial cervical

                                              Figure 2. CT scan of the neck showing the
                                                        multiloculated left neck mass

Cervical lymphadenitis is the most common manifestation of mycobacterial
infections in the head and neck. The incidence of mycobacterial cervical
lymphadenitis has increased in parallel with the increase in the incidence of
mycobacterial infection worldwide [1]. It can be a manifestation of a systemic
disease or primary disease in the neck.

Mycobacterium species involved can be divided into two subtypes: the tuberculous
mycobacteria and nontuberculous mycobacteria (NTM) or atypical mycobacteria.
Ten percent of patients present with a fluctuant mass and 5% present with a
draining sinus [2,3]. The skin overlying the lesion may appear erythematous or
violaceous and may be tender to palpation [4]. Fistula is more common in
tuberculous lymphadenitis than those caused by atypical mycobacteria. Cervical
adenitis due to NTM is primarily a disease of childhood, and usually presents as a
unilateral mass or draining sinus [5,6]. Typically, primary infections mostly by
contamination through the respiratory tract; however, the oral mucosa or gingiva
may be the port entry for atypical strains.

The differentiation of tuberculous from NTM cervical lymphadenitis is important
because their treatment protocols are different (Table 1).

     Table 1. Clinical clues to differentiate between tuberculous and nontuberculous
              cervical adenitis [1].

Diagnosis of atypical mycobacteria is made after a high index of suspicion, a
thorough history and physical exam, a PPD test, staining for acid-fast bacilli,
radiologic examination, and fine-needle aspiration (FNA) [7,8]. Definite diagnosis
is made by culture, PCR and pathologic examination. The PPD test is the principal
diagnostic test, as it may be positive in 49.4% in mycobacterial cervical
lymphadenitis [9]. Positive results could be obtained in the majority of tuberculous
infections whereas the result is mostly negative or intermediate in nontuberculous
infections. FNA can detect cervical tuberculous lymphadenitis in 25–77% of
cases, and NTM in 52.9%. It is a sensitive, specific and cost effective method for
the diagnosis, especially in children [1]. The culture is diagnostic but a negative
culture does not exclude the diagnosis. Mycobacterial cervical lymphadenitis is
caused by tuberculous mycobacteria in 64% and nontuberculous mycobacteria in
36% of cases [9].

The radiological workup may include a chest X-ray, CT and MRI of the neck. The
chest X-ray may reveal findings of tuberculosis in cases due to tuberculous
infections, and it is usually clear in atypical infections. CT may reveal the presence
of conglomerated nodal masses with central lucency, a thick irregular rim of
contrast enhancement and inner nodularity with a varying degree of homogeneous
enhancement in smaller nodes, and a diffusely effaced fascial plane that may
suggest mycobacterial cervical lymphadenitis [10,11]. MRI may reveal discrete,
matted and confluent masses with necrotic foci that are more frequently peripheral
rather than central [12].

In terms of treatment, a tuberculous infection usually responds very well to
antituberculous chemotherapy, whereas a NTM infection may require a surgical
intervention [13,14]. Surgical intervention for tuberculous adenopathy is
considered when an excisional biopsy is needed for diagnostic purposes or when a
node remains enlarged after antimicrobial therapy. Surgery can be aspiration,
incision and drainage, curettage or complete excision. Excision of the overlying
skin should be performed when the skin is involved. Curettage is indicated in case
of proximity of the lesion to a nerve or severe involvement of the skin.

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