A 15-year-old, previously healthy, Syrian-born girl, who had immigrated from Turkey 3 months previously, presented to the emergency department with a 6-month history of cervical swelling, weight loss and intermittent fevers; a 1-month history of cough; and acute onset of night sweats.
On examination, the patient appeared well (50th percentile of body mass index), with bilateral cervical lymphadenopathy (Figure 1) and without other lymph node involvement. Chest radiography showed patchy bilateral interstitial and airspace opacities, nodules and a calcified granuloma in the right upper lobe. An intravenous contrast-enhanced computed tomography scan of her neck showed necrotic lymphadenopathy (Figure 2). Sputum was positive for acid-fast-bacilli, and polymerase chain reaction (PCR) was positive for Mycobacterium tuberculosis complex.
Bilateral cervical lymphadenitis in a 15-year-old girl with Mycobacterium bovis infection involving submental and submandibular nodes (bilateral level IA, right-sided level IB).
Sagittal reconstruction from an intravenous contrast-enhanced computed tomography scan of the neck of a 15-year-old girl with Mycobacterium bovis infection, showing submental and submandibular cervical lymphadenopathy with low central attenuation.
We prescribed rifampin, isoniazid, pyrazinamide and ethambutol for presumed disseminated M. tuberculosis infection. The patient underwent neck dissection and node excision given increasing lymphadenopathy despite 1 month of medical therapy. Biopsy tissue tested positive for acid-fast bacilli, with granulomatous inflammation present microscopically. Sputum and stool samples were culture-positive for a pyrazinamide-resistant and rifampin-, isoniazid-and ethambutol-susceptible organism, which was later identified as Mycobacterium bovis subspecies bovis. Further history-taking revealed she had regularly consumed unpasteurized milk while in Turkey.
The patient remains on rifampin and isoniazid, with slowly resolving lymphadenopathy. Close household contacts screened negative for tuberculosis with interferon-γ release assays, chosen over tuberculin skin tests, given their history of bacille Calmette–Guérin immunization.
The cause of bovine tuberculosis, M. bovis is part of the M. tuberculosis complex.1 Transmission typically occurs through ingestion of unpasteurized milk and soft cheeses.1,2 The global burden has greatly decreased through milk pasteurization and cattle testing, with almost complete elimination in Canada.2 Human-to-human airborne transmission is uncommon.
Extrapulmonary manifestations, mainly gastrointestinal disease, result from the primarily oral acquisition of M. bovis infection. 1 Cervical lymph node involvement is common.
The M. tuberculosis complex includes 12 species; in Ontario, more than 96% of isolates are M. tuberculosis.3 M. bovis is intrinsically resistant to pyrazinamide, a diagnostic clue that prompted specialized testing in this patient.2 A minimum treatment duration of 9 months is suggested given this resistance to pyrazinamide; recurrence is possible.4
Clinical images are chosen because they are particularly intriguing, classic or dramatic. Submissions of clear, appropriately labelled high-resolution images must be accompanied by a figure caption. A brief explanation (300 words maximum) of the educational importance of the images with minimal references is required. The patient’s written consent for publication must be obtained before submission.
Acknowledgements
The authors are grateful to David Manson for assisting with the selection, annotation and captioning of the computed tomography and radiography images. They are also grateful to Melissa Greenblatt for detailing the public health testing process for Mycobacterium tuberculosis complex.
Footnotes
Competing interests: None declared.
This article has been peer reviewed.
The authors have obtained patient consent.
This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/
In this issue
Article extras
Article tools
Jump to section
Related Articles
Cited By...
- No citing articles found.
More in this TOC Section
Similar Articles
Collections
