- A 21-year-old Filipino female student presented with a one-year history of left neck swellings. Physical examination revealed two firm, mobile masses on the left side of her neck and a smaller mass on the right side. - Investigations including blood tests, chest x-ray, ultrasound and biopsy of the lymph nodes were performed. The biopsy showed necrotizing granulomatous lymphadenitis suspicious for tuberculosis, though AFB staining was negative. - The patient was admitted and an excisional biopsy of the left lymph nodes was performed. She was started on anti-tuberculosis treatment and discharged with follow up appointments in the infectious disease clinic.

1. Case presentation
B/L Neck swellings
ID Unit - Medicine Dept. - KKUH
Thursday 23rd January 2014
Khalaf Alghamdi, MBBS

2. History
• N. A. Cairoden
• 21 YO
• Filipino, female
• Student in PNU
• Not known to have any chronic medical illnesses
• Presented to the clinic in 27th Nov. 2013 with 1
year Hx of left neck swellings
• History taken from the patient through translator

3. History of PC
• Norain was in her usual health state till 1 year
back when she, incidentally, noted a swelling in
the Lt. side of her neck, when she was in Philipin
• Initially, it was only one, small in
size, painless, then another swelling developed
below the old one within few days.
• They got increased gradually in size (like a big
olive) and still constant
• Some times can be felt warm, and occasionally
painful

4. Contd..
• Seen by doctor in private care center in
Philipin
• Augmentin only was prescribed for her
• Taken for one month
• No relieve

5. Contd..
• There was NO hx of
– Fever
– Cough
– SOB
– Difficulty in swallowing
– Night sweat
– Rash
– General malaise
– Weight loss
– Joint pain
– Dental infection
– URTIs
– Nausea or vomiting

6. Contd..
• No hx of previous same complaint
• ,, ,, of same illness in her family members
• ,, ,, of contact with animals
• ,, ,, of sexual relationships
• ,, ,, of using herbal medications
• ,, ,, of travelling before onset of complaint

7. Contd..
• No past hx of hospital admissions
• No past hx of surgical operations
• No past hx of blood transfusion
• She is not known to has any allergy for
drugs, foods or chemicals
• BCG and HepB virus vaccines taken at
childhood

8. Contd..
• She is single
• Living with her family in a rented apartment in
Riyadh
• Average economic status

9. Physical Ex.
• She was looking well, fit
• Oriented to T, P, P
• VS:
• BP=130/80
• HR= 80
• Temp=36.6
• O2 Sat=97% on RA
• Pain score=0
• Tall= 155 cm
• Weight= 50 kg

10. Physical Ex.
• Neck ex.: There were two visible & palpable masses on
the left side of her neck beside each other, one is
submental (1x2 cm) and the other is lower and smaller
• There is palpable mass on the right side of the neck
less than 1X2 cm
• They were firm, mobile, not fluctuating, not tender, no
sinus or discharge, skin is intact and normal in color
• No other swellings in the neck
• Lymphatic system: no enlarged tonsiles, posterior
cervical, occipital, axillary or inguinal lymph nodes

11. Physical Ex.
• There was no clubbing
• No signs of dehydration, normal skin color
• Chest: normal and equal breath sounds with
no added sounds
• CVS: normal heart sounds, no added sounds
• Abdomen: soft and lax. No tenderness. No
organomegaly

12. Investigations
• She was seen previously by occupational
health care and referred to ID clinic
• Labs requested: CBC with
ESR, U&E, HIV, Hep, Preg, VDRL, blood
group, MSU, True cut specimen for AFB and
biopsy
• Chest X-Ray
• Ultrasound

13. Investigations (CBC & ESR)

14. Investigations (U&E)

15. Investigations (HIV & Hep)

16. Investigations (Preg)

17. Investigations (VDRL)

18. Investigations (MSU)

19. Investigations (True cut AFB)
Biopsy Official Report:
Site of specimen: Lt. cervical lymph node
Type: True cut biopsy
Showed Necrotizing granulomatous lymphadenitis.
Comment: special stain for AFB and GMS are negative. Although
the AFB is negative, the histopathological picture is highly
suspicious for tuberculosis. Clinicopathological correlation is
recommended.

20. Investigations (Chest X-ray)
Report:
- No focal
parenchymal lung
lesion
-Clear CP angels
- Cardiothoracic
ratio within
normal range

21. Investigations (US)

22. Investigations (US)
US Official Report:
Findings: There are multiple bilateral enlarged hypoechoic cervical lymph nodes.
The largest lymph node on the right side measures 0.7 x 0.9 cm and the largest
lymph node on the left side measures 1.8 x 1.0 cm.
Conclusion:
-bilateral cervical lymphadenopathy
-FNA correlation is suggested

23. Admission
• She was admitted electively under ID team (after
seen in OPD) on Sunday 19th Jan. 2014 for
excisional biopsy
• CBC:
» WBC = 5.4
» HGB = 12
» PLT = 307
» ESR = 51
• MSU = absolutely normal
• U & E = absolutely normal
• Coagulation profile = absolutely normal

24. Treatment
• On Tuesday 22nd Jan. 2014 Excisional biopsy
done under GA for the left enlarged lymph
nodes only
• Patient has been started on oral ATT as a
guideline of pulmonary TB treatment
• Patient discharged
• Appointment x2/52 for ID OPD for follow up
and LFT & ESR