Tuberculous Cervical Lymphadenitis (Scrofula): A Comprehensive Clinical and Imaging Review

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 Tuberculous Cervical Lymphadenitis (Scrofula): A Comprehensive Clinical and Imaging Review

Introduction

Tuberculous cervical lymphadenitis (TCL), also known as scrofula, is the most common form of extrapulmonary tuberculosis (TB), representing a significant proportion of TB cases in endemic regions. This condition involves infection of the cervical lymph nodes by Mycobacterium tuberculosis and is frequently underdiagnosed or misdiagnosed, particularly in non-endemic countries where its incidence is low.
Recent immigration from TB-prevalent areas, increasing global travel, and the HIV pandemic have reintroduced this age-old disease into the diagnostic spectrum of physicians and radiologists worldwide.

Case Presentation

A 32-year-old woman presented with a painless supraclavicular mass persisting for three weeks. She had a history of successfully treated pulmonary tuberculosis one year prior, with multiple negative acid-fast bacilli (AFB) sputum cultures post-treatment.

Initial Ultrasound Findings

  • Figure 1–6: Ultrasonography of the supraclavicular mass revealed a heterogeneous, predominantly solid lesion up to 5 cm, lacking intense vascularity and without significant cystic degeneration.

  • Color Doppler studies demonstrated peripheral capsular vessels but no marked intranodal vascularity—consistent with granulomatous necrosis.

Figure 1: Ultrasound image of supraclavicular mass showing heterogeneous solid nature without intense vascularity.

Figure 2: Close-up sonographic view highlighting irregular echotexture.

Figure 3: Longitudinal ultrasound section showing heterogeneous internal architecture.

Figure 4: Transverse ultrasound section with hypoechoic areas suggesting necrosis.

Figure 5: Color Doppler view with capsular but not intranodal vascularity.

Figure 6: Doppler view confirming absent central vascularity due to necrotizing granulomatous changes.


CT Imaging

Several weeks later, a contrast-enhanced neck and chest CT was performed.

  • Figure 7: Axial neck CT (contrast-enhanced) showed a 7 cm partially cystic conglomerate mass in the left lower neck subcutaneous tissues adjacent to the sternocleidomastoid muscle.

  • Figure 8: Coronal chest CT (lung window) revealed multiple nodular opacities and pleural-based masses in the left lung apex, suggestive of incompletely treated pulmonary TB.

Figure 7: Axial contrast-enhanced CT of the neck showing a rim-enhancing, partially cystic conglomerate lymph node mass in the lower left neck.

Figure 8: Coronal contrast-enhanced chest CT revealing pleural-based nodules and parenchymal scarring in the left upper lobe.


Cause and Etiology

Tuberculous cervical lymphadenitis results from lymphatic spread of M. tuberculosis from a primary focus—usually pulmonary TB—via hematogenous or lymphatic routes.
Etiologic agents include:

  • Mycobacterium tuberculosis (most common)

  • Mycobacterium bovis (less common, often related to unpasteurized dairy consumption)

Risk factors:

  • Prior TB infection

  • HIV co-infection

  • Immunosuppressive therapy

  • Intravenous drug use

  • Recent immigration from TB-endemic regions

Pathophysiology

The pathogenesis follows granulomatous inflammation with caseous necrosis inside affected lymph nodes:

  1. Bacilli enter lymphoid tissue → trigger type IV hypersensitivity reaction.

  2. Macrophages transform into epithelioid cells, forming granulomas.

  3. Caseation necrosis develops, leading to central liquefaction and potential cystic transformation.

  4. Untreated, nodes may coalesce and form sinus tracts to the skin.

Epidemiology

  • Global burden: TCL accounts for up to 35% of extrapulmonary TB cases in endemic countries.

  • Demographics: More common in children and young adults, with a slight female predominance.

  • Geographic distribution: High incidence in Asia, Africa, and the Middle East; rising cases in Europe/North America due to migration.

Clinical Presentation

Typical features include:

  • Painless cervical or supraclavicular lymphadenopathy (often unilateral)

  • Firm, matted nodes that may later soften

  • Absence of systemic TB symptoms in many cases

  • Occasionally, low-grade fever, night sweats,and  weight loss

Delayed treatment can lead to fluctuance and spontaneous drainage.

Imaging Features

Ultrasound

  • Hypoechoic or heterogeneous masses

  • Loss of normal nodal hilum

  • Capsular vascularity on Doppler, absence of intranodal flow

  • Cystic degeneration due to necrosis

CT

  • Low-density lymph nodes with rim enhancement

  • Conglomerate masses with surrounding soft tissue edema

  • No calcification in the acute phase; calcifications in healed nodes

Treatment

  • First-line: Standard anti-tuberculous therapy (ATT) for 6–9 months:

    • Isoniazid, Rifampicin, Pyrazinamide, Ethambutol

  • Surgical intervention: Only for diagnostic biopsy or persistent abscess drainage.

  • Drug-resistant cases require regimen modification.

Prognosis

  • Excellent prognosis with early treatment.

  • Untreated disease may lead to sinus formation and chronic draining fistulas.

  • Drug resistance and HIV co-infection worsen outcomes.

Quiz

1. Which imaging feature is most typical of tuberculous cervical lymphadenitis on ultrasound?
A) Intense intranodal vascularity
B) Homogeneous hyperechoic nodes
C) Heterogeneous solid mass without intense vascularity
D) Well-circumscribed fatty mass

2. What is the most common causative organism of scrofula?
A) M. bovis
B) M. tuberculosis 
C) M. kansasii
D) M. avium

3. Which CT finding is more likely in previously treated TCL?
A) Rim enhancement
B) Calcification
C) Homogeneous soft-tissue mass
D) None of the above

4. Which patient group is most commonly affected by TCL?
A) Elderly males
B) Young adults with female predominance
C) Neonates
D) Middle-aged men with diabetes

5. What is the recommended initial management?
A) Surgical excision
B) Chemotherapy
C) Standard ATT regimen
D) Observation only

Answer and Explanation

1. Answer: C) Heterogeneous solid mass without intense vascularity. Explanation: Necrotizing granulomas reduce intranodal vascularity.

2. B) M. tuberculosis. Explanation: M. tuberculosis is the predominant pathogen worldwide.

3. B) Calcification. Explanation: Calcification is a sequela of healed TB lymphadenitis.

4. B) Young adults with female predominance. Explanation: Epidemiologic data show a higher prevalence in young females.

5. C) Standard ATT regimen. Explanation: ATT is the mainstay; surgery is reserved for complications.

References

[1] J. B. Bomanji, N. Gupta, P. Gulati, and C. J. Das, “Imaging in tuberculosis,” Cold Spring Harb Perspect Med, vol. 5, no. 6, p. a017814, 2015.
[2] B. C. Jha, A. Dass, N. M. Nagarkar, R. Gupta, and S. Singhal, “Cervical tuberculous lymphadenopathy: Changing clinical pattern and concepts in management,” Postgrad Med J, vol. 77, no. 905, pp. 185–187, 2001.
[3] J. H. Park and D. W. Kim, “Sonographic diagnosis of tuberculous lymphadenitis in the neck,” J Ultrasound Med, vol. 33, no. 9, pp. 1619–1626, 2014.
[4] J. Tran, O. Green, and L. Modahl, “Chest manifestations of mycobacterium tuberculosis complex – Clinical and imaging features,” Semin Roentgenol, vol. 57, no. 1, pp. 67–74, 2022.
[5] S. Fontanilla, A. Barnes, and M. von Reyn, “Current diagnosis and management of peripheral tuberculous lymphadenitis,” Clin Infect Dis, vol. 53, no. 6, pp. 555–562, 2011.
[6] R. C. Rock, W. J. O’Brien, and S. L. Jacobs, “Tuberculous lymphadenitis: Review of 86 cases,” Am J Med, vol. 69, no. 6, pp. 867–872, 1980.
[7] P. R. Das, “Extrapulmonary tuberculosis: Overview, manifestations, and imaging,” Radiol Clin North Am, vol. 59, no. 2, pp. 191–210, 2021.

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