This Sudanese patient in her 30s presented with constitutional symptoms (fevers, night sweats, and loss of weight) over a period of months. On examination she was found to have prominent nodes in the neck and supraclavicular region.

CT scan demonstrated widespread centrally necrotic nodes, extending into the mediastinum. Given the patient’s demographic tuberculosis was thought most likely, which was confirmed on histology and microbiology.

Scrofula, is also known by a variety of combinations of tuberculosis, cervical and lymphadenitis, and comes from the Latin for ‘brood sow‘ – exactly why is unclear to me. It is also known as King’s evil as in the Middle Ages it was believed that “royal touch”, the touch of the sovereign of England or France, could cure the disease. It is unlikely that this was the case.

Extrapulmonary TB is a very frequent cause of peripheral lymphadenitis in the developing world, and is seeing a resurgence in the developed world among the immunocompromised population.

The aetiology is thought most likely to represent postprimary reactivation of ”Mycobacterium tuberculosis” spread haematogenously. It is also thought that it may be infection via the tonsils, in a similar fashion to gastrointestinal TB from infected milk.

Treatment is with antimycobacterial agents, as drainage, percutanous or surgical does not work well and is liable to create fistulas, which can also occur spontaneously.

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1. Dähnert W. Radiology Review Manual 5th edition. Lippincott, Williams & Wilkins 2003
2. UpToDate

Credit: Dr Frank Gaillard