Presentation
Enlarging right sided neck lump for past 6 months associated with cough, weight loss & evening rise of temperatures.
Patient Data
Ultrasound scan showed ill-defined thick irregular walled collection on right side of neck with caudal retrosternal extension. Collection was clearly separate from thyroid gland and no significant size cervical lymphadenopathy noted on either side.
Contrast-enhanced CT confirmed irregular walled right cervicothoracic collection extending up to the level of carina. Superior mediastinal vessels are abutted and partially compressed by the collection. The right internal jugular vein has got segmental thrombosis. Few necrotic lymph nodes noted in right hilar- suprahilar region.
Case Discussion
CT clearly mapped the extent of collection & relationship with surrounding structures. No significant lymph nodes noted in neck on either side. Both lungs are clear and cervicodorsal spine was unaffected. No calcified mediastinal or hilar lymph nodes. The CT appearance on background of typical history of long standing neck swelling, cough, weight loss & evening rise of temperature for nearly six months favored diagnosis of tuberculosis in an asian origin of patient who had recently visited home country.
Patient underwent neck exploration and drainage of mediastinal abscess. Drained fluid culture showed acid fast bacilli positive and anti-TB triple therapy was started. IJV thrombosis was treated with therapeutic dose of tinzaparin for 3 months.
Other differentials on imaging could be non-tuberculous pyogenic abscess, but history was long standing and no spiking temperatures. Metastatic necrotic nodal mass could be a differential but less likely due to typical clinical history and absence of known primary neoplasm in neck and thorax.
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