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Nascer e Crescer
Print version ISSN 0872-0754On-line version ISSN 2183-9417
Nascer e Crescer vol.29 no.3 Porto Sept. 2020
https://doi.org/10.25753/BirthGrowthMJ.v29.i3.19354
WHAT IS YOUR DIAGNOSIS? | QUAL O SEU DIAGNÓSTICO?
Infectious disease clinical case
Caso clínico de doença infecciosa
Ana LachadoI, Alexandre FernandesI, Carla TeixeiraI, Tiago Milheiro SilvaII, Laura MarquesI
I. Pediatric Infectious Diseases and Immunodeficiencies Unit, Department of Pediatric, Centro Materno-Infantil do Norte, Centro Hospitalar Universitário do Porto. 4050-371 Porto, Portugal. analachado@hotmail.com; alexandrefernandes.pediatria@chporto.min-saude.pt; carlateixeira.pediatria@chporto.min-saude.pt; lauramarques.dia@chporto.min-saude.pt
II. Pediatric Infectious Diseases Unit, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central. 1169-050 Lisboa, Portugal. tiago.milheiro.silva@gmail.com
Endereço para correspondência | Dirección para correspondencia | Correspondence
A 16-year-old male born in Angola and living in Porto, Portugal, for nearly one year was observed in the Emergency Department of a Lisbon hospital due to right supraclavicular swelling that had been growing over the last months after a holiday in Angola. He had been treated with unspecified antibiotics six months earlier due to similar swelling in the right cervical region, which spontaneously drained a purulent content. Anorexia, hypersudoresis, and weight loss were reported, without fever, cough, or sputum. On examination, the patient presented a painless supraclavicular lymphadenopathy with 3x2 cm of larger diameter, with fluctuation and local inflammatory signs (Figure 1). Examination was otherwise unremarkable.
What is your diagnosis?
Diagnosis
Tuberculous lymphadenitis
Discussion
Needle aspiration was performed and Mycobacterium tuberculosis spp was identified. Chest radiograph was normal, and HIV 1/2 serology and mycobacteriologic respiratory secretion exam were negative. Treatment with isoniazid, rifampicin, ethambutol, and pyrazinamide was started, with a significant swelling decrease over the next two weeks (Figure 2).
Tuberculous lymphadenitis (TL) is one of the most common forms of extrapulmonary disease in children, but it is not the first diagnostic hypothesis in supraclavicular lymphadenopathy cases.1,2 In the present case, patient’s origin from a high tuberculosis prevalence country as Angola favored this diagnosis. TL can be the manifestation of tuberculosis primary infection or reactivation.2
Needle aspiration enabled material collection for microbiological examination to confirm diagnosis and excluded oncological disease. When lymph nodes are affected, the condition is termed scrofula and may also be caused by nontuberculous mycobacteria. As in this case, most TL cases in developed countries occur in immigrants from high tuberculosis incidence countries. Pulmonary involvement was excluded, as it may be associated with LT, as well as HIV infection.
Usually, LT presents as a chronic lymphadenopathy with few or no systemic symptoms.3 In this case, systemic symptoms were present. Scrofula can be complicated with ulceration, fistula, or abscess.4 Other entities that should be considered in the differential diagnosis include malignant illnesses, as lymphoma, or other infections, as bacterial adenitis, cat-scratch disease, or tularemia.
REFERENCES
1. Lamb GS, Starke JR. Tuberculosis in infants and children. Microbiol Spectrum. 2017; 5:TNMI7-0037-2016. [ Links ]
2. Raut AA, Naphade PS, Ramakantan R. Imaging Spectrum of Extrathoracic Tuberculosis. Radiologic Clinics of North America. 2017; 54:475-501. [ Links ]
3. Fontanilla JM, Barnes A, von Reyn CF. Current diagnosis and management of peripheral tuberculous lymphadenitis. Clin Infect Dis. 2011; 53:555-62. [ Links ]
4. van Loenhout-Rooyackers JH, Laheij RJ, Richter C, Verbeek AL. Shortening the duration of treatment for cervical tuberculous lymphadenitis. Eur Respir J. 2000; 15:192-5. [ Links ]
Endereço para correspondência | Dirección para correspondencia | Correspondence
Ana Lachado
Pediatric Infectious Diseases and Immunodeficiencies Unit
Department of Pediatric
Centro Materno-Infantil do Norte
Centro Hospitalar Universitário do Porto
Largo da Maternidade
4050-371 Porto
Email: analachado@hotmail.com
Received for publication: 29.01.2020. Accepted in revised form: 03.04.2020