Tuberculous cervical lymphadenitis

• Matted lymph nodes in the posterior triangle or deep upper cervical region with minimal surrounding inflammatory changes
• Central low-density/cystic caseation within enlarged nodes, often with muscle-equivalent attenuation initially
• Unilateral cervical lymphadenopathy with preserved hilar vascularity on Doppler ultrasound
• Lack of significant chest radiograph abnormalities despite neck pathology

• Ultrasound: Nodes show nodal matting with surrounding soft tissue edema that is less marked than expected for the size of collections, helping distinguish from bacterial suppurative lymphadenitis.
• Doppler ultrasound: Reactive nodes including tuberculous lymphadenitis demonstrate prominent vascularity confined predominantly to the hilum, contrasting with malignant nodes that show peripheral/capsular vascularity.
• CT/MRI: Initial appearance shows enlarged nodes with attenuation similar to muscle, progressing to central low-density areas as caseation develops, eventually becoming frankly cystic.
• Nodes are typically matted together with only minor surrounding inflammatory changes, unlike bacterial infections which show marked edema and skin involvement.
• Cervical involvement is unilateral in the majority of cases with predilection for posterior triangle (51%) and deep upper cervical (48%) node groups.
• Pathologic finding of central caseation appears as creamy-to-chalky off-white regions characteristic of mycobacterial infection.
• Ultrasound combined with guided fine-needle aspiration cytology achieves 92% sensitivity and 97% specificity for distinguishing benign from malignant nodal disease.
• Less than 50% of patients demonstrate abnormalities on chest radiographs despite cervical involvement.

• Necrotic metastases: Distinguished by peripheral/capsular Doppler vascularity and associated primary malignancy; tuberculous nodes show hilar vascularity.
• Nasopharyngeal carcinoma: Common differential in Asian populations; clinical context and imaging of primary tumor help distinguish from tuberculous lymphadenitis.
• Lymphoma: Typically shows less central low density and usually only after treatment; clinical presentation and imaging pattern differ from tuberculous nodes.
• Suppurative bacterial lymphadenitis: Nodes tend to be tender with marked inflammatory skin changes; tuberculous nodes are non-tender with minimal skin involvement.
• Fungal infection: May show similar low-density nodes but clinical and epidemiologic context differs.
• Infectious mononucleosis: Typically shows reactive lymphadenopathy without central caseation or matting.

Describe matted cervical lymph nodes with central caseation (low-density or cystic centers) and preserved hilar vascularity on Doppler, emphasizing minimal surrounding soft tissue edema relative to nodal size; note unilateral distribution and predilection for posterior triangle or deep upper cervical chain; correlate with clinical context, immunocompromised status, and chest imaging to raise suspicion for tuberculous lymphadenitis rather than malignancy.

• Relying solely on imaging to exclude malignancy: central low density can be seen with metastatic disease; Doppler vascularity pattern and clinical context are crucial for distinction.
• Misinterpreting nodal enlargement during antimycobacterial therapy as treatment failure: transient enlargement is expected and does not indicate failed medical management.
• Performing percutaneous drainage prior to medical management, which can create fistulae and complicate treatment.
• Overlooking the diagnosis in non-endemic or industrialized nations: resurgence occurs in IVDU and HIV-immunocompromised populations and must be considered in appropriate clinical context.