Paradoxical Reaction in the Treatment of Scrofula List of authors
A 66-year-old man presented to the outpatient clinic with a 1-month history of a progressively enlarging mass on the lower right side of the neck (Panel A). He otherwise felt well. His temperature was 37.0ยฐC, and he did not appear to be cachectic. On examination, the neck mass was soft and nontender, and it measured 5.5 cm at the largest dimension. A chest radiograph showed no lung lesions. Findings on a computed tomographic scan of the neck and chest showed multiple, enlarged lymph nodes with peripheral enhancement extending from the lower right side of the neck to the mediastinum. Fine-needle aspiration of the neck mass was performed. Acid-fast bacilli were observed on microscopic examination, and culture grew Mycobacterium tuberculosis, which was sensitive to first-line antituberculous treatment. Test results for the human immunodeficiency virus were negative. A diagnosis of mycobacterial cervical lymphadenitis, or scrofula, was made. Treatment with rifampin, isoniazid, pyrazinamide, and ethambutol was initiated. The neck mass showed a paradoxical reaction, with drainage, during the first 3 months of treatment (Panel B, day 84 of treatment), but with wound care the neck mass gradually resolved over 5 months (Panel C, day 156 of treatment). The patient completed a 9-month course of treatment, and at follow-up 3 months after treatment was completed, he was well, without disease recurrence.