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A 39-year-old Zambian man who was visiting the United States presented with a three-week history of a draining neck mass and a three-month history of swelling on the left side of his neck. He reported a weight loss of 4.5 kg (10 lb), night sweats, and a low-grade fever. Examination revealed an ulcer measuring 1 by 2 cm on the left side of his neck (Panel A), with an underlying mass measuring 2 by 2 cm. The chest x-ray film was normal. Computed tomography revealed multiple enlarged lymph nodes on both sides of the neck with central necrosis (Panel B, asterisks). A tuberculin skin test with purified protein derivative showed 15 mm of induration. Examination of fluid obtained by fine-needle aspiration of the mass on the side of his neck revealed abundant acid-fast bacilli, and a culture of the aspirate grew Mycobacterium tuberculosis, which was susceptible to all antituberculosis agents. Three sputum samples were negative for acid-fast bacilli. A test for human immunodeficiency virus type 1 (HIV-1) was positive. The CD4 count was 104 cells per cubic millimeter, and the viral load was 72,100 copies of HIV RNA per milliliter. The patient was treated with ethambutol, isoniazid, pyrazinamide, and rifampin for six months, with an excellent clinical response. Trimethoprim–sulfamethoxazole was begun for prophylaxis against Pneumocystis carinii pneumonia. He has since returned to Zambia and has not begun antiretroviral therapy. Scrofula (tuberculous lymphadenitis in the cervical region) presents as chronic, nontender lymphadenopathy, which may fistulize and drain cutaneously.
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