A 68- year old female presented in a clinic with cervical lymphadenopathy with a suppurative fistula which she has had since April of 2023. She had a history of: hypertension, CAD, erythematous gastropathy, insulin-dependent diabetes, depression, and hypothyroidism.
The disease started in April 2023 when the patient observed enlargement of cervical lymph nodes.
Patient had the first hospitalization in June 2023 which was cervical lymphadenopathy. The potential diagnosis was cat scratch disease. Because of this the biopsy was done. In addition the patient had: slightly elevated inflammation indicators, anemia and elevated hepatic enzymes. The tests results from both patient’s hospitalizations are shown in the chart below. During hospitalization CT scan of thorax was done which showed densities in both lungs but especially in the left one. During this hospitalization the suppurative fistula was dressed. The material for bacteriological tests was taken. The outcome of it was growth of Pseudomonas aeruginosa susceptible to amikacin, meropenem, gentamicin and tobramycin. The test of carbapenemazes presence was negative. Also negative were tests for colonization of multi resistant bacteria, blood cultures, pus cultures (anaerobic and aerobic). Test for cat scratch disease was also negative so this diagnosis was ruled out. The suppurative fistula was observed. It was treated and the consultation in the Surgery Clinic was advised.
During her second hospitalization (11.02.2024) she presented with complaints of: neck’s pain radiating to the ear, pain in swallowing and weakness. During an examination before admitting to a clinic, the patient was in a good clinical condition. On the neck in a right area under the clavicle was a fistula with exudate. In addition, this area was also edematous and painful. The ultrasonography of the neck’s lymph nodes showed multiple enlarged lymph nodes suggesting metastases. Screening for neoplasm markers was negative. Actinomycosis and tularemia were ruled out as possible diagnoses. No oxygenic or anaerobic bacteria was grown in the samples drawn from the nodes. The PCR was positive for DNA of Mycobacterium tuberculosis but acid-fast mycobacteria didn’t grow in samples drawn from fistula. Although the QFT-Plus test was positive and pathomorphology test proved the existence of MTB.
Considering all information from anamnesis, physical examination and additional tests the diagnosis of MTB was established. After a consultation with a pulmonologist antituberculous drugs were implemented (rifampicin, ethambutol and pyrazinamide). The hypertension treatment was continued. The lab results tended to normalize. The toleration of the treatment was good. There was still a suppurative fistula but the edema was significantly smaller.
The patient was discharged with instructions to continue treatment (rifampicin, ethambutol, pyrazinamide for 6 months) in an ambulatory care unit. Currently the patient is under the control of Infectious Diseases Outpatients Clinic with no complaints.
Table 1
Results of laboratory tests.
| 10.06.2023 | 15.06.2023 | 18.06.2023 | 27.06.2023 | 11.10.2023 | 14.10.2023 | 16.10.2023 | 22.10.2023 |
ALT < 31 U/L | 35 | | | 128 | 23 | | 20 | 16 |
AST < 32 U/L | 38 | | | 135 | 32 | | | 22 |
CRP < 5 mg/dl | 43.79 | 43.79 | 27.69 | 18.54 | 11.49 | 14.58 | | 8.73 |
D-dimers < 500 mg/ml | 652 | 733 | 667 | | 528 | | 599 | 599 |
Fibrynogen 200–400 mg/dl | 620 | 573 | | | 390 | | 420 | 370 |
Creatinine 0,6 − 0,9 mg/dl | 0.64 | | | | 0.74 | | | |
WBC 4-10x10³ | 9.93 | 9.10 | 8.25 | 7.68 | 8.18 | 7.52 | 7.70 | 6.85 |
Neu 1,6–7,2x10³µL | 6.99 | 5.79 | 4.74 | 4.87 | 4.82 | 4.27 | 4.49 | 3.32 |
Lym 0,8 − 4,7x10³µL | 1.92 | 2.33 | 2.68 | 1.78 | 2.63 | 2.52 | 2.57 | 2.80 |
Mono 0,1-1x10³µL | 0.82 | 0.72 | 0.67 | 0.73 | 0.54 | 0.51 | 0.43 | 0.52 |
Eos 0,02 − 0,6x 10³µL | 0.13 | 0.15 | 0.15 | 0.21 | 0.12 | 0.16 | 0.13 | 0.15 |
RBC 4–5,5x10⁶ | 3.71 | 3.65 | 3.5 | 3.48 | 4.13 | 3.68 | 3.84 | 3.74 |
PLT 130–350 x10³ | 372 | 354 | 346 | 336 | 295 | 251 | 294 | 255 |
PCT 0,12 − 0,16% | 0.46 | 0.45 | 0.44 | 0.41 | 0.39 | 0.33 | 0.4 | 0.35 |
HGB 12–16 g/dl | 10.7 | 10.4 | 10.1 | 10.1 | 12.1 | 10.8 | 11.4 | 10.9 |
HCT 37–47% | 33.2 | 33.1 | 31 | 30.9 | 37.4 | 33 | 35.2 | 34.1 |
Table 2
Results of additional tests.
Bartonella henselae | Negative |
Hepatitis C virus | Negative |
Borrelia burgdorferi | Negative |
Pseudomonas aeruginosa | Negative |
Quantiferon-TB Gold Plus test | Positive |
Patomorfology | Mycobacterium tuberculosis present in sample |