“Away from the lungs”: A case report of extrapulmonary tuberculosis

“Away from the lungs”: A case report of extrapulmonary tuberculosis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report “Away from the lungs”: A case report of extrapulmonary tuberculosis Julia Piekarska, Patrycja Niewrzał, Piotr Czupryna, Justyna Adamczuk, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4468421/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: To report a case of primary extrapulmonary tuberculosis in immunocompetent. Method : Retrospective observational case report. Results: A 68- year old female presented in a clinic with cervical lymphadenopathy with a suppurative fistula which she has had since April of 2023. During an examination before admission to a clinic on the neck in the right area under the clavicle was a fistula from which sipped a little secretion. In addition, this area was also edematous and painful. In differential diagnosis cat scratch disease has been ruled out. The lab tests showed slightly elevated inflammatory parameters and anemia. The ultrasonography of the neck’s lymph nodes showed multiple lymph nodes which looked like Mts. Indicators of a tumor were negative. Actinomycosis and tularemia were excluded. 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. Patient was treated with antituberculosis drugs with clinical improvement. Conclusion : Extrapulmonary tuberculosis still occurs in society. It can be difficult to diagnose if there isn’t any source of infection in the lungs. Extrapulmonary tuberculosis lymphadenopathy suppurative fistula MTB TB Mycobacterium tuberculosis Introduction Tuberculosis (TB) is an airborne infectious disease caused by mycobacteria of the Mycobacterium tuberculosis complex group [ 1 ]. There are three types of mycobacteria - M. tuberculosis, M. bovis and M. africanum . Most often it occupies the lungs, but it can attack any other organ, in which case we speak of extrapulmonary tuberculosis [ 2 ]. Structures such as the pleura, lymph nodes, bones, genitourinary system, spine, pericardium and central nervous system can be involved. Extrapulmonary tuberculosis in its course can mimic other chronic diseases, making its diagnosis difficult [ 3 ]. If the spread of mycobacteria through the bloodstream occurs, then we are dealing with miliary tuberculosis, which, if untreated, leads to death [ 4 ]. Factors that increase the risk of tuberculosis are age over 40, HIV co-infection, history of liver disease [ 5 ], smoking, alcoholism, diabetes and malnutrition [ 6 ]. According to the WHO, there were 7.5 million new TB cases and 1.3 million deaths from the disease in 2022 [ 7 ]. In Poland, 3787 new TB cases were diagnosed in the same year [ 8 ]. It is estimated that extrapulmonary tuberculosis accounts for 7–8% of all tuberculosis cases, and miliary tuberculosis accounts for 1–2%. In 2022, 55% of TB patients were men, 33% were women, while children accounted for 12% (from 0 to 14 years of age) [ 9 ]. The BCG vaccine remains the only existing licensed vaccine for tuberculosis. It prevents the development of childhood TB, but does not protect against TB in adults [ 10 ]. Our patient had predisposing factors for developing extrapulmonary tuberculosis. She is over 40 years old and has insulin-dependent diabetes. Furthermore, some publications say that women are more likely to suffer from extrapulmonary TB [ 11 ]. Case report 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 Discussion Our case demonstrates extrapulmonary localisation of tuberculosis and aims to increase the awareness of this etiology in the differential process of skin changes, which are hard to treat with standard antibiotics. It is extremely important in this era, where anti-vaccination movements are so active and more and more people refrain from vaccinations. Extrapulmonary tuberculosis develops through the spread of M. tuberculosis bacilli via blood and lymphatic routes. Due to the action of the immune system, a protective mechanism against M.tuberculosis bacilli develops which results in the formation of an abscess containing live tubercle bacilli [ 12 ]. The cervical lymph nodes are the most common site for the development of tuberculosis of the lymph nodes. The main symptoms that may be present in tuberculosis of the lymph nodes are fever, fatigue, weight loss, night sweats [ 13 ] and painful swelling of the lymph nodes [ 14 ]. Knowing our patient's symptoms and state of well-being, we can conclude that she did not present most of the symptoms mentioned above, so this is one of the reasons for the difficulty in diagnosing the disease. The smear taken from our patient's fistula did not show the presence of acid-fast mycobacteria, so the best diagnostic test to confirm or exclude the disease is the pathomorphological examination, which confirmed the presence of mycobacterial DNA. In case of lymph nodes enlargement with no accompanying symptoms cat scratch disease is usually the primary diagnosis, but in this case, this assumption has been rejected. In differential diagnosis tularemia and actinomycosis should be also considered. The treatment implemented for our patient's extrapulmonary tuberculosis is the standard anti-tuberculosis treatment also used for pulmonary tuberculosis. In addition, surgical intervention was decided and the abscess was drained. The patient reported no complaints during treatment and laboratory tests began to normalize. The patient is currently under treatment. Conclusions Diagnosing TB of the lymph nodes remains a challenge due to the lack of specific disease symptoms and the need for multiple tests, including invasive tests [ 15 ]. The response of patients with extrapulmonary TB to treatment is slow, in addition, the healing of fistulas in extrapulmonary TB is decelerated, so patients require frequent follow-up visits with specialists to control the disease and fully heal. Knowledge about extra-pulmonary localisation of TB is important, especially in the situation of anti-vaccine movement activation. . Our patient's case of extrapulmonary tuberculosis was difficult to diagnose. Tests performed to diagnose the disease included lymph node biopsy, ultrasound, basic laboratory tests, neoplasm markers, PCR test for the presence of M.tuberculosi s DNA, swab for the culture of aerobic and anaerobic bacteria from fistula, QFT-plus test and histopathological examination. The QFT-plus test and histopathological examination confirmed ongoing tuberculosis infection in our patient's organism. It is essential that in the future, methods will be developed to enable faster and more accurate diagnosis of extrapulmonary tuberculosis, as well as methods that will enable differentiation with other diseases. Declarations The authors declare that there is no conflict of interest. Written consent was obtained for anonymized patient information to be published in this article. Author Contribution J.P and P.N wrote the main manuscript text. PC., J.A and J.Z reviewed the text. A.M.M. made adjustments to the text. References Solovic I, Jonsson J, Korzeniewska-Koseła M, et al. Challenges in diagnosing extrapulmonary tuberculosis in the European Union, 2011. Euro Surveill. 2013;18(12):20432. Published 2013 Mar 21. Strausz J. Tuberkulózis 2006 [Tuberculosis 2006]. Orv Hetil. 2007;148(18):829–31. 10.1556/OH.2007.28057 . Rymkiewicz E, Milaniuk S, Rękas-Wójcik A, Dzida G, Mosiewicz J. Extrapulmonary tuberculosis-a multidisciplinary problem. Forum Family Med (Vol. 2016;10(1):34–41. Sharma SK, Mohan A. Miliary Tuberculosis Microbiol Spectr. 2017;5(2). 10.1128/microbiolspec . TNMI7-0013-2016. Sanches I, Carvalho A, Duarte R. Who are the patients with extrapulmonary tuberculosis? Rev Port Pneumol (2006). 2015;21(2):90–3. 10.1016/j.rppnen.2014.06.010 . Lönnroth K, Jaramillo E, Williams BG, Dye C, Raviglione M. Drivers of tuberculosis epidemics: the role of risk factors and social determinants. Soc Sci Med. 2009;68(12):2240–6. 10.1016/j.soc sci med.2009.03.041 . The WHO Global. Tuberculosis Report 2023 assessed on 11.04.2024. Korzeniewska-Koseła M. Tuberculosis and respiratory diseases in Poland in 2012. Warsaw: Institute of Tuberculosis and Lung Diseases; 2013. pp. 25–33. The WHO Global. Tuberculosis Report 2023 assessed on 11.04.2024. Fatima S, Kumari A, Das G, Dwivedi VP. Tuberculosis vaccine: A journey from BCG to present. Life Sci. 2020;252:117594. 10.1016/j.lfs.2020.117594 . Mazza-Stalder J, Nicod L, Janssens JP. La tuberculose extrapulmonaire [Extrapulmonary tuberculosis]. Rev Mal Respir. 2012;29(4):566–78. 10.1016/j.rmr.2011.05.021 . Ramirez-Lapausa M, Menendez-Saldana A, Noguerado-Asensio A. Extrapulmonary tuberculosis: an overview. Rev Esp Sanid Penit. 2015;17(1):3–11. Khusro A, Aarti C. Extrapulmonary tuberculosis: an overview on infection beyond lungs. World News of Natural Sciences; 2020. p. 28. Benjelloun A, Darouassi Y, Zakaria Y, Bouchentouf R, Errami N. Lymph nodes tuberculosis: a retrospective study on clinical and therapeutic features. Pan Afr Med J. 2015;20:65. 10.11604/pamj.2015.20.65.5782 . Published 2015 Jan 23. Qian X, Albers AE, Nguyen DTM, et al. Head and neck tuberculosis: Literature review and meta-analysis. Tuberculosis (Edinb). 2019;116S:S78–88. 10.1016/j.tube.2019.04.014 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4468421","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":306570151,"identity":"c92a723c-f3c1-4c0d-abb7-932506274790","order_by":0,"name":"Julia Piekarska","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYBACxgYQBDIkGBibH3wAMtjYidfCfMxwBkgLM1E2gbWwJUjzgLiEtDDPbm58OKPmnr1k+xkDY5tf2+T5mBkYP3zMwWPDnIPNhhuOFSfO5skxeJzbd9uwjZmBWXLmNjxaZiS2ST5gS0iQY8gxMM7tuc0I1MLGzItfS/vPB/8S7OX43xhIW/bctidGSxvjxrYExtkSaQnSDD9uJxLWAvSL5My+hMSZMx4fM+xtuJ3cxszYjNcvhrPbH37s+ZZgL3E+sfnBjz+3bee3Nx/88BGflhkodraByQbc6oFAXgKF+wev4lEwCkbBKBihAACzb1WQqoyj/QAAAABJRU5ErkJggg==","orcid":"","institution":"Medical University of Białystok","correspondingAuthor":true,"prefix":"","firstName":"Julia","middleName":"","lastName":"Piekarska","suffix":""},{"id":306570152,"identity":"94d7c2d0-a950-4a20-9652-e1a0760f29b4","order_by":1,"name":"Patrycja Niewrzał","email":"","orcid":"","institution":"Medical University of Białystok","correspondingAuthor":false,"prefix":"","firstName":"Patrycja","middleName":"","lastName":"Niewrzał","suffix":""},{"id":306570153,"identity":"c8a16b6d-01e7-4c97-8300-fb6627a98561","order_by":2,"name":"Piotr Czupryna","email":"","orcid":"","institution":"Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok","correspondingAuthor":false,"prefix":"","firstName":"Piotr","middleName":"","lastName":"Czupryna","suffix":""},{"id":306570154,"identity":"748b61c9-874d-47dc-aca0-0f5a1f094ca7","order_by":3,"name":"Justyna Adamczuk","email":"","orcid":"","institution":"Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok","correspondingAuthor":false,"prefix":"","firstName":"Justyna","middleName":"","lastName":"Adamczuk","suffix":""},{"id":306570155,"identity":"ea8610f2-cfef-41b6-830a-325fe8e37a1e","order_by":4,"name":"Joanna Zajkowska","email":"","orcid":"","institution":"Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok","correspondingAuthor":false,"prefix":"","firstName":"Joanna","middleName":"","lastName":"Zajkowska","suffix":""},{"id":306570156,"identity":"62302cac-1163-4b4b-9569-a0b1355edd86","order_by":5,"name":"Anna Moniuszko-Malinowska","email":"","orcid":"","institution":"Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok","correspondingAuthor":false,"prefix":"","firstName":"Anna","middleName":"","lastName":"Moniuszko-Malinowska","suffix":""}],"badges":[],"createdAt":"2024-05-23 17:29:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4468421/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4468421/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57332824,"identity":"d2a4fff3-61bc-4f38-90d4-6464b9602cb7","added_by":"auto","created_at":"2024-05-29 08:50:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":393727,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4468421/v1/f2bf4082-57b8-4472-b6e5-30e80ec858c2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"“Away from the lungs”: A case report of extrapulmonary tuberculosis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTuberculosis (TB) is an airborne infectious disease caused by mycobacteria of the \u003cem\u003eMycobacterium tuberculosis complex\u003c/em\u003e group [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. There are three types of mycobacteria - \u003cem\u003eM. tuberculosis, M. bovis and M. africanum\u003c/em\u003e. Most often it occupies the lungs, but it can attack any other organ, in which case we speak of extrapulmonary tuberculosis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Structures such as the pleura, lymph nodes, bones, genitourinary system, spine, pericardium and central nervous system can be involved. Extrapulmonary tuberculosis in its course can mimic other chronic diseases, making its diagnosis difficult [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. If the spread of mycobacteria through the bloodstream occurs, then we are dealing with miliary tuberculosis, which, if untreated, leads to death [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Factors that increase the risk of tuberculosis are age over 40, HIV co-infection, history of liver disease [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], smoking, alcoholism, diabetes and malnutrition [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to the WHO, there were 7.5\u0026nbsp;million new TB cases and 1.3\u0026nbsp;million deaths from the disease in 2022 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In Poland, 3787 new TB cases were diagnosed in the same year [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. It is estimated that extrapulmonary tuberculosis accounts for 7\u0026ndash;8% of all tuberculosis cases, and miliary tuberculosis accounts for 1\u0026ndash;2%. In 2022, 55% of TB patients were men, 33% were women, while children accounted for 12% (from 0 to 14 years of age) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The BCG vaccine remains the only existing licensed vaccine for tuberculosis. It prevents the development of childhood TB, but does not protect against TB in adults [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur patient had predisposing factors for developing extrapulmonary tuberculosis. She is over 40 years old and has insulin-dependent diabetes. Furthermore, some publications say that women are more likely to suffer from extrapulmonary TB [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e"},{"header":"Case report","content":"\u003cp\u003eA 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.\u003c/p\u003e \u003cp\u003eThe disease started in April 2023 when the patient observed enlargement of cervical lymph nodes.\u003c/p\u003e \u003cp\u003ePatient 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\u0026rsquo;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 \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e 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.\u003c/p\u003e \u003cp\u003eDuring her second hospitalization (11.02.2024) she presented with complaints of: neck\u0026rsquo;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\u0026rsquo;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 \u003cem\u003eMycobacterium tuberculosis\u003c/em\u003e but acid-fast mycobacteria didn\u0026rsquo;t grow in samples drawn from fistula. Although the QFT-Plus test was positive and pathomorphology test proved the existence of MTB.\u003c/p\u003e \u003cp\u003eConsidering 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.\u003c/p\u003e \u003cp\u003eThe 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.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of laboratory tests.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.06.2023\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.06.2023\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.06.2023\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.06.2023\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.10.2023\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14.10.2023\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e16.10.2023\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e22.10.2023\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eALT\u0026thinsp;\u0026lt;\u0026thinsp;31 U/L\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e35\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e128\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAST\u0026thinsp;\u0026lt;\u0026thinsp;32 U/L\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e38\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e135\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCRP\u0026thinsp;\u0026lt;\u0026thinsp;5 mg/dl\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e43.79\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e43.79\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e27.69\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e18.54\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e11.49\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e14.58\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e8.73\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eD-dimers\u0026thinsp;\u0026lt;\u0026thinsp;500 mg/ml\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e652\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e733\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e667\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e528\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e599\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e599\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFibrynogen 200\u0026ndash;400 mg/dl\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e620\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e573\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e390\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e420\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e370\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCreatinine 0,6\u0026thinsp;\u0026minus;\u0026thinsp;0,9 mg/dl\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eWBC 4-10x10\u0026sup3;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6.85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNeu 1,6\u0026ndash;7,2x10\u0026sup3;\u0026micro;L\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLym 0,8\u0026thinsp;\u0026minus;\u0026thinsp;4,7x10\u0026sup3;\u0026micro;L\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMono 0,1-1x10\u0026sup3;\u0026micro;L\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEos 0,02\u0026thinsp;\u0026minus;\u0026thinsp;0,6x\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e10\u0026sup3;\u0026micro;L\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eRBC 4\u0026ndash;5,5x10⁶\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3.71\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e3.65\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e3.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e3.48\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e4.13\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e3.68\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e3.84\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e3.74\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePLT 130\u0026ndash;350\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003ex10\u0026sup3;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e372\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e354\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e346\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e336\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e295\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e251\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e294\u003c/p\u003e \u003c/td\u003e \u003ctd 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align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e37.4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e33\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e35.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e34.1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of additional tests.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBartonella henselae\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatitis C virus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBorrelia burgdorferi\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuantiferon-TB Gold Plus test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePositive\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatomorfology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMycobacterium tuberculosis\u003c/b\u003e \u003cb\u003epresent in sample\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur case demonstrates extrapulmonary localisation of tuberculosis and aims to increase the awareness of this etiology in the differential process of skin changes, which are hard to treat with standard antibiotics. It is extremely important in this era, where anti-vaccination movements are so active and more and more people refrain from vaccinations.\u003c/p\u003e \u003cp\u003eExtrapulmonary tuberculosis develops through the spread of \u003cem\u003eM. tuberculosis bacilli\u003c/em\u003e via blood and lymphatic routes. Due to the action of the immune system, a protective mechanism against \u003cem\u003eM.tuberculosis bacilli\u003c/em\u003e develops which results in the formation of an abscess containing live tubercle bacilli [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The cervical lymph nodes are the most common site for the development of tuberculosis of the lymph nodes. The main symptoms that may be present in tuberculosis of the lymph nodes are fever, fatigue, weight loss, night sweats [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and painful swelling of the lymph nodes [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eKnowing our patient's symptoms and state of well-being, we can conclude that she did not present most of the symptoms mentioned above, so this is one of the reasons for the difficulty in diagnosing the disease. The smear taken from our patient's fistula did not show the presence of acid-fast mycobacteria, so the best diagnostic test to confirm or exclude the disease is the pathomorphological examination, which confirmed the presence of mycobacterial DNA.\u003c/p\u003e \u003cp\u003eIn case of lymph nodes enlargement with no accompanying symptoms cat scratch disease is usually the primary diagnosis, but in this case, this assumption has been rejected. In differential diagnosis tularemia and actinomycosis should be also considered.\u003c/p\u003e \u003cp\u003eThe treatment implemented for our patient's extrapulmonary tuberculosis is the standard anti-tuberculosis treatment also used for pulmonary tuberculosis. In addition, surgical intervention was decided and the abscess was drained. The patient reported no complaints during treatment and laboratory tests began to normalize. The patient is currently under treatment.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eDiagnosing TB of the lymph nodes remains a challenge due to the lack of specific disease symptoms and the need for multiple tests, including invasive tests [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The response of patients with extrapulmonary TB to treatment is slow, in addition, the healing of fistulas in extrapulmonary TB is decelerated, so patients require frequent follow-up visits with specialists to control the disease and fully heal. Knowledge about extra-pulmonary localisation of TB is important, especially in the situation of anti-vaccine movement activation.\u003c/p\u003e \u003cp\u003e. Our patient's case of extrapulmonary tuberculosis was difficult to diagnose. Tests performed to diagnose the disease included lymph node biopsy, ultrasound, basic laboratory tests, neoplasm markers, PCR test for the presence of \u003cem\u003eM.tuberculosi\u003c/em\u003es DNA, swab for the culture of aerobic and anaerobic bacteria from fistula, QFT-plus test and histopathological examination. The QFT-plus test and histopathological examination confirmed ongoing tuberculosis infection in our patient's organism.\u003c/p\u003e \u003cp\u003eIt is essential that in the future, methods will be developed to enable faster and more accurate diagnosis of extrapulmonary tuberculosis, as well as methods that will enable differentiation with other diseases.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors declare that there is no conflict of interest. Written consent was obtained for anonymized patient information to be published in this article.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJ.P and P.N wrote the main manuscript text. PC., J.A and J.Z reviewed the text. A.M.M. made adjustments to the text.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSolovic I, Jonsson J, Korzeniewska-Koseła M, et al. Challenges in diagnosing extrapulmonary tuberculosis in the European Union, 2011. Euro Surveill. 2013;18(12):20432. Published 2013 Mar 21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStrausz J. Tuberkul\u0026oacute;zis 2006 [Tuberculosis 2006]. 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Rev Esp Sanid Penit. 2015;17(1):3\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhusro A, Aarti C. Extrapulmonary tuberculosis: an overview on infection beyond lungs. World News of Natural Sciences; 2020. p. 28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenjelloun A, Darouassi Y, Zakaria Y, Bouchentouf R, Errami N. Lymph nodes tuberculosis: a retrospective study on clinical and therapeutic features. Pan Afr Med J. 2015;20:65. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.11604/pamj.2015.20.65.5782\u003c/span\u003e\u003cspan address=\"10.11604/pamj.2015.20.65.5782\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Published 2015 Jan 23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQian X, Albers AE, Nguyen DTM, et al. Head and neck tuberculosis: Literature review and meta-analysis. Tuberculosis (Edinb). 2019;116S:S78\u0026ndash;88. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.tube.2019.04.014\u003c/span\u003e\u003cspan address=\"10.1016/j.tube.2019.04.014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Extrapulmonary tuberculosis, lymphadenopathy, suppurative fistula, MTB, TB, Mycobacterium tuberculosis","lastPublishedDoi":"10.21203/rs.3.rs-4468421/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4468421/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e To report a case of primary extrapulmonary tuberculosis in immunocompetent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e: Retrospective observational case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e A 68- year old female presented in a clinic with cervical lymphadenopathy with a suppurative fistula which she has had since April of 2023.\u003c/p\u003e\n\u003cp\u003eDuring an examination before admission to a clinic on the neck in the right area under the clavicle was a fistula from which sipped a little secretion. In addition, this area was also edematous and painful. In differential diagnosis cat scratch disease has been ruled out. The lab tests showed slightly elevated inflammatory parameters and anemia. The ultrasonography of the neck’s lymph nodes showed multiple lymph nodes which looked like Mts. Indicators of a tumor were negative. Actinomycosis and tularemia were excluded. No oxygenic or anaerobic bacteria was grown in the samples drawn from the nodes. The PCR was positive for DNA of \u003cem\u003eMycobacterium tuberculosis\u003c/em\u003e 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. Patient was treated with antituberculosis drugs with clinical improvement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Extrapulmonary tuberculosis still occurs in society. It can be difficult to diagnose if there isn’t any source of infection in the lungs.\u003c/p\u003e","manuscriptTitle":"“Away from the lungs”: A case report of extrapulmonary tuberculosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-29 08:42:00","doi":"10.21203/rs.3.rs-4468421/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b1c75683-c0bb-4ba2-9c92-a122b32a8546","owner":[],"postedDate":"May 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-29T08:42:00+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-29 08:42:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4468421","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4468421","identity":"rs-4468421","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}