Case #18:

Clinical Presentation:
A 36 year-old Ecuadorian male presents with two months of progressive left neck swelling (Case 18 Image 1). He came to the USA five years previously. He denies fever, chills, night sweats or cough. He admits to a 6-pound weight loss despite a good appetite. The mass did not respond to a 10-day trial of Penicillin.

Clinical Diagnoses:
Bacterial Neck Abscess
Actinomycosis
Head and Neck Carcinoma
Cervical Tuberculosis (Scrofula)

Case 18 Image 2: exudate from the mass demonstrating a red-staining (acid-fast) beaded bacilli surrounded by polymorphonuclear leukocytes counter-stained green for contrast. Case 18 Image 3: culture of exudate on Lowenstein-Jensen medium showing yellow to buff colored , dry colonies. Case 18 Image 4: acid-fast smear of colonies showing massive inter-cellular adherence of bacilli forming long, serpentine, "cords."

Discussion:
Microbiologic Diagnosis:
Tuberculous Cervical Adenitis (Scrofula) due to Mycobacterium tuberculosis
This mycobacterial infection can occur in hosts with and without a normal immune system. In a patient from areas of high prevalence of Tuberculosis who presents with a large, matted adenopathy is suspicious for extrapulmonary Tuberculosis. Aerosols containing M. Tuberculosis from a patient with active pulmonary disease transmitted the primary infection.