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Case of the Month - April 2014

Moherndran Archary, UKZN. SASPID

An eight year old, HIV seronegative girl presented to an outpatients unit with a 3 month history of left sided neck swelling and intermittent fever. She had no TB contacts nor had been treated for previously TB. Her past medical history revealed 2 previous hospital admissions; the first, at 12 months of age was for an uncomplicated febrile convulsion, the second for a swelling on neck which was biopsied and treated with a short course of antibiotics. No further details were available and the swelling resolved completely within a few days, according to her parents.

On examination she was afebrile, there was significant unilateral cervical lymphadenopathy. She had multiple, non- matted, non- tender nodes in left anterior triangle of the neck, the largest of which was 1.5 x 1.5 cm. There was mass measuring 3 x 3 cm in the left submandibular region, which was mobile and non-tender, with a healed sinus.

She had no lymph nodes palpable elsewhere. Her ENT examination was normal and she had no signs to suggest an upper respiratory tract infection. The respiratory, cardiac and abdominal system examination was normal.

Blood investigations, including an ESR were normal. Chest X-rays showed no radiological evidence to suggest Mycobacterium tuberculosis. The auramine stain was negative, but the TB culture from a fine needle aspirate of the submandibular mass was positive after 72 hours.

A PCR/Line probe Assay confirmed Mycobacterium fortuitum.

An excisional lymph node biopsy was done by the surgical team. The histology showed features of necrotising and non-necrotising granulomatous inflammation.

She was commenced on combination therapy of ciprofloxacin and clarithromycin for a minimum of 6 months duration.

On follow up she was well, with minimum scarring noted at the biopsy site.

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