What is the management approach for a patient with a cervical abscess suspected to be secondary to Tuberculosis (TB) versus scrofula?

Management of Cervical Abscess Secondary to TB (Scrofula)

For cervical abscess caused by Mycobacterium tuberculosis, initiate standard four-drug anti-TB chemotherapy (isoniazid, rifampin, pyrazinamide, and ethambutol) immediately, combined with total surgical excision of the abscess and involved lymph nodes as the definitive treatment approach. 1

Diagnostic Confirmation

Obtain tissue diagnosis before or concurrent with treatment initiation:

• Perform fine-needle aspiration or excisional biopsy of the cervical mass to obtain specimens for acid-fast bacilli (AFB) smears, mycobacterial cultures, and histopathological examination 2, 1
• Send at least three specimens for AFB smears and mycobacterial cultures to confirm M. tuberculosis and assess drug susceptibility 3
• Test all patients for HIV infection given the strong association between tuberculous cervical lymphadenitis and HIV, particularly in immunosuppressed individuals 4, 2
• Obtain chest radiograph to evaluate for concurrent pulmonary tuberculosis, as extrapulmonary TB may coexist with pulmonary disease 4

Medical Management

Standard four-drug regimen for initial phase (2 months):

• Isoniazid 5 mg/kg (maximum 300 mg) daily 5
• Rifampin 10 mg/kg (maximum 600 mg) daily 3
• Pyrazinamide 15-30 mg/kg daily 3
• Ethambutol 15 mg/kg daily 6

Continuation phase (minimum 4 months):

• Isoniazid and rifampin only for at least 4 additional months 3, 5
• Total treatment duration of 6-9 months is typically sufficient for extrapulmonary TB, though some cases may require up to 12 months depending on clinical response 5

Critical medication considerations:

• Administer pyridoxine (vitamin B6) supplementation with isoniazid to prevent peripheral neuropathy, especially in malnourished patients, alcoholics, and diabetics 5
• Monitor for drug resistance by repeating cultures throughout therapy; if resistance emerges, modify the regimen accordingly 3
• For HIV-coinfected patients, coordinate antiretroviral therapy with TB treatment, noting significant drug interactions between rifampin and protease inhibitors/NNRTIs 4

Surgical Management

Total excision is superior to simple drainage:

• Primary total excision of the abscess and involved lymph nodes achieves 94% success rate with no local complications 1
• Simple incision and drainage alone results in 77% failure rate, requiring second operations for persistent sinus discharge, recurrent abscesses, or enlarging lymphadenopathy 1
• Perform surgery in conjunction with chemotherapy, not as monotherapy 1, 7

Alternative approach for deep or complex abscesses:

• Fine-needle aspiration through the pharynx can be both diagnostic and therapeutic for retropharyngeal tuberculous abscesses associated with spinal TB 8
• This minimally invasive approach combined with anti-TB chemotherapy can achieve resolution without open surgery in selected cases 8

Distinguishing TB from Nontuberculous Mycobacteria (NTM)

This distinction is critical because treatment differs fundamentally:

• M. tuberculosis (true scrofula) responds to anti-TB chemotherapy and may require adjunctive surgery 7
• M. scrofulaceum and other NTM cervical lymphadenitis often require surgical excision as primary treatment, as medical therapy alone is frequently inadequate 4, 7
• M. scrofulaceum has largely disappeared from clinical practice, replaced by MAC as the most common cause of childhood cervical lymphadenitis 4
• Molecular methodology (DNA probes or 16S rRNA gene sequencing) may be necessary to definitively distinguish M. tuberculosis from NTM species 4

Monitoring and Follow-up

Assess treatment response systematically:

• Monitor clinical improvement including resolution of fever, night sweats, and reduction in lymph node size 4
• Repeat cultures at 2 months to document bacteriologic response 4
• Small painless residual lymph nodes may persist for up to 2 years after successful treatment completion and do not indicate treatment failure 1
• Perform HIV testing and provide cotrimoxazole prophylaxis for HIV-positive patients 4

Common Pitfalls to Avoid

Do not perform simple incision and drainage as definitive treatment - this approach has a 77% failure rate requiring reoperation 1

Do not delay treatment initiation while awaiting culture results in patients with high clinical suspicion for TB, as early diagnosis improves prognosis and prevents transmission 2

Do not use single-drug therapy or add single drugs to failing regimens, as this rapidly leads to drug resistance 3

Do not assume all cervical mycobacterial lymphadenitis is M. tuberculosis - NTM species require different management approaches, often surgical rather than medical 4, 7