Tuberculous Cervical Lymphadenitis (Scrofula) Associated with Massive Pleural Effusion in an Immunocompetent Adult: A Rare Presentation of Extrapulmonary Tuberculosis Confirmed by GeneXpert MTB/RIF.

Abstract

Background: Tuberculous cervical lymphadenitis (scrofula) is the most common form of extrapulmonary tuberculosis, although its coexistence with massive pleural effusion is uncommon and may delay diagnosis because of its nonspecific clinical presentation. We report the case of a 47-year-old man presenting with a large right-sided pleural effusion associated with a suppurative cervical lymphadenitis, in whom rapid molecular testing established the diagnosis of disseminated extrapulmonary tuberculosis. Case Presentation: A 47-year-old male presented with progressive right-sided chest pain, exertional dyspnea, intermittent fever, night sweats, weight loss, and a progressively enlarging left laterocervical mass. Physical examination revealed multiple enlarged, fluctuant cervical lymph nodes and clinical signs of a massive right pleural effusion. Thoracic computed tomography demonstrated a large right pleural effusion with compressive atelectasis and enlarged cervical and mediastinal lymph nodes. Ultrasound-guided cervical lymph node drainage and tube thoracostomy were performed, followed by repeated pleural fluid evacuations through the chest tube. Purulent material obtained from the cervical abscess and pleural fluid were subjected to microbiological, cytological, and molecular investigations, including Xpert MTB/RIF (GeneXpert MTB/RIF). GeneXpert MTB/RIF detected Mycobacterium tuberculosis complex in both the drained cervical purulent material and pleural fluid, with no evidence of rifampicin resistance. Conventional bacterial cultures remained negative, while mycobacterial cultures were subsequently positive for M. tuberculosis. Pleural fluid analysis was consistent with an exudative lymphocytic effusion with elevated adenosine deaminase levels. Histopathological examination of the cervical tissue demonstrated necrotizing granulomatous inflammation with central caseous necrosis, epithelioid histiocytes, and Langhans-type multinucleated giant cells, supporting the diagnosis of tuberculous lymphadenitis. HIV serology was negative, and no additional immunodeficiency was identified. Standard first-line antituberculous therapy (isoniazid, rifampicin, pyrazinamide, and ethambutol) was initiated promptly following microbiological confirmation, leading to progressive regression of the cervical lesions, complete resolution of the pleural effusion, and favorable clinical evolution during follow-up. Conclusions: The simultaneous occurrence of tuberculous cervical lymphadenitis and massive pleural tuberculosis represents an uncommon presentation of extrapulmonary tuberculosis that requires a high index of clinical suspicion. The combination of histopathological examination and rapid molecular testing of extrapulmonary specimens allowed definitive and timely confirmation of tuberculosis and facilitated prompt initiation of appropriate therapy. Clinicians should consider tuberculosis in patients presenting with cervical suppurative lymphadenitis and unexplained pleural effusion, even in the absence of microbiologically confirmed pulmonary disease, to avoid diagnostic delay and improve clinical outcomes.