Journal of Medical Ultrasound (2014) 22, 158e163

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CASE REPORT

Ultrasonographic Features of Tuberculous

Cervical Lymphadenitis
Chen-Han Chou 1,2, Tsung-Lin Yang 1,3, Cheng-Ping Wang 1*

1
Department of Otolaryngology, National Taiwan University Hospital, Taipei, 2 Department of
Otolaryngology, National Taiwan University Hospital Yunlin Branch, Yunlin County, and 3 Research
Center for Development Biology and Regenerative Medicine, National Taiwan University, Taipei,
Taiwan

Received 14 May 2014; accepted 26 June 2014

Available online 16 September 2014

KEY WORDS Making an accurate diagnosis of tuberculous cervical lymphadenitis (TCL) has been a problem
cervical to clinicians because it is a versatile masquerader and is often confused with lymphomas or
lymphadenitis, cervical metastases. Ultrasound (US) has advantages over other examination modalities in that
tuberculosis, it is noninvasive, inexpensive, time-saving, and able to guide procedures such as fine-needle
ultrasound aspiration and core-needle biopsy. It is increasingly being recognized as a primary tool for
the evaluation of cervical lymph nodes. In this article, we present six cases with microscopi-
cally and/or pathologically confirmed TCL and illustrate the US features. A literature review
was also conducted. The key US features of TCL include hypoechogenecity, strong internal
echoes, echogenic thin layers, nodal matting, soft tissue changes, and displaced hilar vascu-
larity. US is a reliable and effective tool in assessing cervical lymphadenopathies. When TCL
is suspected under US, US-guided procedures such as fine-needle aspiration or core-needle bi-
opsy can be conducted concomitantly to obtain the microscopic or pathological proof.
ª 2014, Elsevier Taiwan LLC and the Chinese Taipei Society of Ultrasound in Medicine.
Open access under CC BY-NC-ND license.

Introduction

Cervical lymph nodes can be involved via various patho-

Conflicts of interest: The authors have no conflicts of interest
relevant to this article to disclose.
* Correspondence to: Dr Cheng-Ping Wang, Department of
Otolaryngology, National Taiwan University Hospital, 1 Chang-Te
Street, Taipei, Taiwan.
E-mail address: wangcp@ntu.edu.tw (C.-P. Wang).
logical processes, including inflammatory diseases, lym-
phomas, and even metastases. It is crucial to determine the
etiology of an enlarged cervical node before proper treat-
ment modalities can be chosen. When encountered with
inflammatory cervical nodes, clinicians should be alert to
the possibility of tuberculous cervical lymphadenitis (TCL),

http://dx.doi.org/10.1016/j.jmu.2014.06.007
0929-6441/ª 2014, Elsevier Taiwan LLC and the Chinese Taipei Society of Ultrasound in Medicine. Open access under CC BY-NC-ND license.
Ultrasonographic Features of TCL 159

one of the most common extrapulmonary tuberculoses. Case 1

Although tuberculosis has been considered an issue in un-
developed countries or specific ethnic groups, the emerging
number of human immunodeficiency virus (HIV)-infected
population heralds the awakening of tuberculosis in West-
ern countries in recent decades. Making a correct diagnosis
of TCL has been a problem to clinicians because it is a
versatile masquerader and is often confused with lym-
phomas or cervical metastases. Ultrasound (US) has ad-
vantages over other examination modalities in that it is
noninvasive, inexpensive, time-saving, and able to guide
procedures such as fine-needle aspiration (FNA) and core-
needle biopsy (CNB). It is increasingly being recognized as a
primary tool for the evaluation of cervical lymph nodes.
Some authors have depicted different US characteristics of
TCL, yet few could provide a worthwhile picture. Accord-
ingly, we present six cases of patients with TCL and sum-
marize the common US features in this study.
Case Reports
All patients were identified in the National Taiwan Univer-
sity Hospital Yunlin Branch, Yunlin County, Taiwan from
October 2013 to April 2014. An ultrasound machine (HD15
Ultrasound System; Koninklijke Philips N.V., Eindhoven, The
Netherlands) with a 5e12-MHz linear array transducer (L12-
5) was used. FNA was performed with 22-gauge needles,
whereas CNB was done with 18-gauge biopsy needles
(Temno Evolution, TT186, CareFusion Corporation, San
Diego, CA, United States).
A 34-year-old female without major diseases presented to
our clinic with multiple tumors at the right side of her neck of
2 months’ duration. The tumors grew slowly and eventually
caused pressure pain. On examination, two 3-cm masses
were noted at the right level II, with fluctuation sensation
and erythematous change of the overlying skin. Because the
patient also reported a low-grade fever and a weight loss of
4 kg in 1 month, lymphoma was considered first. However,
her hemogram revealed a white count of 5500/mL
(segmented form Z 59.6%, lymphocyte Z 33.5), whereas
the lactate dehydrogenase level was 169 U/L. Computed
tomography (CT) with contrast medium showed multiple
small necrotic lymph nodes at the right level II and a rim-
enhanced lesion superficial to the right sternocleidomastoid
muscle (Fig. 1A). US revealed six hypoechoic lymph nodes
scattering along the right upper jugular chain with a matting
pattern. Most of them showed increased internal echo and
thin echogenic layers at periphery (Fig. 1B). The borders of
the involved lymph nodes became blurred because of adja-
cent tissue reaction, and an anechoic pocket extended su-
perficially to the subcutaneous region (Fig. 1C). TCL was
highly suspected based on these US features and prompted
US-guided FNA to the abscess and CNB to two involved nodes.
The cytology smear revealed polymorphic neutrophils only.
Nevertheless, the pathological report from CNB showed
caseating granulomatous inflammation, rimmed by an
aggregate of epithelioid cells, lymphocytes, and Langerhans
giant cells. Acid-fast bacilli were not identified in the

Fig. 1 In a 34-year-old woman with tuberculous cervical lymphadenitis (Case 1), CT demonstrates multiple necrotic nodes (A,
arrowheads) and a rim-enhanced lesion in the subcutaneous area (asterisk). Ultrasound shows that the involved nodes are hypo-
echoic with strong internal echoes and echogenic thin layers (B, arrow). An anechoic pocket is seen in the subcutaneous region as in
the CT, and fine-needle aspiration yielded pus positive for acid-fast stain (C, circled region). CT Z computed tomography.
160
specimen. However, the mycobacterial culture from subcu-
taneous abscess aspirates confirmed the extrapulmonary
infection of Mycobacterium tuberculosis, which was sensi-
tive to isoniazid (H), ethambutol (E), rifampicin (R), and
pyrazinamide (Z). The sputum culture yielded no mycobac-
teria, and she was started on a fixed-dose combination
chemotherapy with HERZ (isoniazid, ethambutol, rifampin,
and pyrazinamide). After 3 months of therapy, the neck tu-
mors are now clinically undetectable, and she is still
receiving HERZ.
Case 2
A 56-year-old female who has been in good health was
referred to our clinic for survey of neck masses. A rubbery
painless mass first appeared at the right supraclavicular
region 5 weeks prior to the US examination, and gradually
became painfully fluctuated. Another two with similar
presentations developed within the following 3 weeks. US
demonstrated hypoechoic lymph nodes with displaced hilar
vascularity and strong internal echoes (Fig. 2). Acid-fast
stain and mycobacterial culture of specimens from US-
guided FNA confirmed the diagnosis as TCL, and she has
been receiving HERZ therapy.
Cases 3e6
The major US findings of Cases 3e6 are summarized in
Table 1, and some examples are given in Figs. 3 and 4. In all
cases, TCL was diagnosed based on the mycobacterial cul-
tures from FNA and/or pathology from CNB).
Discussion
The history of TCL could be traced back to the time of
Hippocrates, when he described a common pediatric dis-
ease with a protracted course of scirrhous cervical mass of
“cold and mucous nature” [1]. Taking the form of scrofula
and “King’s Evil”, TCL has afflicted mankind for centuries
before pulmonary tuberculosis was recognized [2]. Being a
unique manifestation of M. tuberculosis infection, TCL
is the most common form of extrapulmonary tuberculosis
[3]. It usually involves the lymph nodes of the jugular
Fig. 2 In a hypoechoic tuberculous node of a 56-year-old woman (Case 2), the hilar vascularity is displaced (A), presumably by
the intranodal caseating necrosis (arrowheads). Another node in the same patient shows strong internal echoes and mild perinodal
edema (B). IJC Z internal jugular vein; SCA Z subclavian artery.
C.-H. Chou et al.
chain, posterior triangle, and supraclavicular fossa [4,5].
TCL is a common cause of lymphadenopathy in areas where
tuberculosis is endemic, such as Southern Asia, Eastern
Asia, and Africa [6,7]. In Western countries, it is relatively
uncommon and has been reported to preferentially affect
immigrants from Asia or Inuit [8e10]. However, its inci-
dence has started to rise worldwide in recent years, in
tandem with the growing number of HIV-infected popula-
tion [11,12]. Unlike pulmonary tuberculosis, whose course
and symptoms are indolent, tuberculous infection in the
cervical region is usually more apparent. However, it has
been notoriously known as a “dangerous masquerader”,
because it can resemble almost any kind of cervical infec-
tion or neoplasm and poses a diagnostic challenge to the
clinicians [13].
Conventionally, CT has been the primary imaging mo-
dality in diagnosing TCL [14]. However, the common CT
patterns of tuberculous lymphadenitis may also be seen in
other diseases such as lymphoma, metastatic lymphade-
nopathy, and inflammatory diseases [15]. Furthermore, CT
is more costly and time-consuming than US, aside from the
fact that it has additional risks such as radiation exposure
and contrast medium allergy. In recent decades, US has
been increasingly recognized as a noninvasive tool for the
evaluation of cervical lymph nodes. It is inexpensive, time-
saving, repeatable, and easily accessible. More impor-
tantly, US is superior to other imaging modalities in that
FNA or CNB can be performed simultaneously under its
guidance. The additional cytological or pathological infor-
mation greatly increases the diagnostic accuracy of US [16].
The histopathological development of tuberculous
lymphadenitis involves five stages, and is closely related to
the US features of tuberculous nodes [17,18]. Briefly, stage
I nodes have nonspecific reactive changes as in other
lymphadenitis. Stage II nodes are fixed to surrounding tis-
sues because of periadenitis changes. Cold abscess de-
velops later on (stage III) when mycobacterial infection
progresses, followed by the formation of collar-stud ab-
scess (stage IV) and eventually the sinus tract formation
(stage V). Initial inflammation is shown on US as simple
nodal enlargement or rounding, while caseation, necrosis,
and suppuration in later stage appear as a hypoechoic mass
with inhomogeneous texture and irregular borders. Finally,
the US pictures of nodal matting and extranodal spread into
Ultrasonographic Features of TCL 161

Table 1 Cases with tuberculous cervical lymphadenitis and the ultrasound findings.
Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 All, % (n/N )
Age (y) 34 56 28 24 43 31 d
Sex F F F F M M d
Laterality R R L R R L d
Location Levels II & III Level IV Levels IV & Vb Level II Levels III & IV Level II d
Node number (s) 6 3 11 2 3 4 29
Hypoechogenecity 6/6 3/3 11/11 2/2 3/3 4/4 100.0 (29/29)
Internal echoes 5/6 3/3 8/11 2/2 3/3 4/4 86.2 (25/29)
Echogenic thin layer 3/6 2/3 4/11 0/2 2/3 4/4 51.7 (15/29)
Calcification 0/6 1/3 0/11 0/2 1/3 0/4 6.9 (2/29)
Absent hilus 6/6 3/3 11/11 0/2 3/3 3/4 89.6 (26/29)
Round shape (S/L > 0.5) 5/6 3/3 11/11 2/2 3/3 3/4 93.1 (27/29)
Posterior enhancement 4/6 3/3 10/11 2/2 2/3 4/4 86.2 (25/29)
Nodal matting þ þ þ   þ 66.7 (4/6)
Surrounding tissues Edema/abscess d Edema d Edema Edema d

adjacent structures concur with the pathological changes in
stages IV or V as the disease progresses. Multiplicity of
nodes is a common finding in TCL [4,19]. Not surprisingly,
different US patterns can be apparent simultaneously in
one patient who has multiple tuberculous cervical lymph
nodes of different stages.
The common US features of TCL are summarized in
Table 2 [4,16,19,21,22,23] and discussed below. As in other
inflammatory diseases, nodal enlargement is the first US
sign at the early stage of tuberculous lymphadenitis. In
contrast to the usual oval shape of normal or reactive
lymph nodes, however, TCL commonly appears as round
lesions [20]. In their study including 315 tuberculous nodes,
Ying et al [21] reported that 79% had increased S/L ratio
(more than 1/2), although the percentage was less than
that of metastatic nodes (95%). As compared with its shape
or size, changes in the internal texture of a lymph node
provide more clues to the diagnosis of TCL. The presence of
central echogenic hilus within lymph nodes is usually
considered a sign of benignity because nodal malignancy
tends to disrupt the medullary lymphatic sinuses of normal
lymph nodes. However, an absent hilus is also frequently
reported in tuberculous nodes (76e86%) [21]. Tuberculous
nodes are predominantly hypoechoic largely because of the
high incidence of intranodal cystic necrosis [21]. For the
same reason, posterior acoustic enhancement is also
frequently reported [19,22]. By contrast, scattered calci-
fications within tuberculous nodes or hyalinosis in caseous
necrosis create strong internal echoes, which are thought
to be highly specific for tuberculous lymphadenitis. Under
US, they appear as single or multiple coarse, high-echo
spots located focally either in the central or the periph-
eral area within nodes. In a study reviewing cervical lymph
nodes in 192 patients, 84% of tuberculous nodes and 11% of
metastatic nodes contained strong internal echoes under
US, whereas none of the reactive nodes had internal echoes
[16]. In cases with advanced tuberculous infection, the
evolving pathological process leads to clustered calcifica-
tions in several foci and appear as hyperechoic spots with
evident posterior acoustic shadow under US. It is not as
common as strong internal echoes under US, yet still has
been reported in up to one-quarter of tubercular nodes
[19,23]. Another key US feature of tuberculous nodes is the
“echogenic thin layer”, which usually locates deep to the

Fig. 3 A 28-year-old woman (Case 3) presented with progressive left neck swelling of 5 weeks’ duration. Magnetic resonance
imaging reveals a confluent cervical mass at the left supraclavicular region, which enhanced markedly after gadolinium
enhancement on fat-suppressed T1-weighted series (A). Ultrasound further magnified the swelling as multiple round nodes with
matting pattern (B).
162 C.-H. Chou et al.

owing to the edema or active inflammation of the latter

Fig. 4 Tuberculous cervical lymphadenitis (TCL) in a 43-year-
old man (Case 5). This lymph node at right level III is hypo-
echoic with blurred border and posterior acoustic enhance-
ment. Note the echogenic thin layer (arrowheads) at deep
peripheral margin.
peripheral margin and measures 2e3 mm in thickness. It
can be detected in 86.7% of pathologically confirmed cases
and corresponds to the specific granulomatous tissue layer
surrounding the caseous necrosis with proliferation of
epithelioid cells, Langerhans giant cells, and capillaries
accompanied by infiltration of lymphocytes and plasma
cells [4,22]. In a study reviewing 73 cervical lymph nodes,
the concomitant presence of strong echoes and echogenic
thin layer has a sensitivity of 100% and a specificity of 100%
for tuberculosis [22].
The acoustic impedance difference between a tubercu-
lous node and its surrounding soft tissues usually decreases
(periadenitis). As a result, the borders of cervical tuber-
culous nodes are usually unsharp [20]. When left unat-
tended, the inflammation may progress beyond lymph
nodes and spread into subcutaneous tissues. The so-called
“collar stud” abscess or a fistula tract may be seen on US
in this stage [19]. The perionodal inflammatory reactions
also appear as soft tissue edema and nodal matting under
US [20]. It may also been seen in patients whose necks have
been irradiated [24]. However, in patients without previous
radiotherapy, the presence of soft tissue edema and nodal
matting is highly suggestive of tuberculosis.
On Doppler sonography, normal or reactive nodes tend
to hilar vascularity, whereas the presence of peripheral
vascularity is an ominous sign of nodal malignancy. The
vascular pattern of tuberculous nodes varies on Doppler
sonography, however, depending on the degree of intra-
nodal necrosis and the stages of the disease. An intranodal
cystic necrosis pushing the hilus away from its central po-
sition would cause displaced vascularity, a common US
feature (81%) of tuberculous nodes [20]. As cystic necrosis
aggravates, it eventually destroys the blood vessels of the
lymph nodes and results in apparent avascularity, a US
feature seen in 6e41% of tuberculous nodes [25,26]. Avas-
cularity may also reflect the healing process at later stages
of the disease, when fibrosis and hyalinization cause
compression and obliteration of intranodal vessels [27].
Although typical US features exist, none are pathogno-
monic and TCL cannot be diagnosed merely with US. For
example, the metastatic nodes from papillary thyroid car-
cinoma may mimic tuberculous nodes under US because of
the shared features of cystic necrosis. Moreover, it is
difficult to differentiate between sprinkled calcifications of
papillary thyroid carcinoma metastases and caseative ne-
crosis of tuberculous nodes when punctate echogenic foci
are seen on US. A confirmative diagnosis therefore depends
on ancillary tests, such as FNA, CNB, mycobacterial culture,
or polymerase chain reaction test for M. tuberculosis gene
[28]. The sensitivity of cultures performed on FNA

Table 2 Ultrasonographic features of tuberculous cervical lymphadenitis: review of the literature.

Gupta et al [23] Baatenburg de Khanna Suh Asai Ying et al [21]
Jong et al [19] et al [16] et al [4] et al [22]
Nation/Area India Netherlands India Korea Japan Hong Kong
Case number 27 12 62 101 15 47 (315 nodes)
Hypoechogenecity 100% 100% 77% 90.9% 100%
Internal echoes 91.7% 84% 33.3% 64%
Echogenic thin layer 86.7%
Calcification 29.6% 25% 1%
Cystic necrosis 60%
Absent hilus 26% 86%
Round shape (S/L > 0.5) 79%
Irregular margin 58.3% 66% 86.7%
Sharp border 29.6% 62%
Multiplicity 58.3% 79.2%
Nodal matting 37% 81% 73.3% 59%
Surrounding tissues Abnormal Subcutaneous Peripheral Abnormal (49%)
(85.2%) involvement (58.3%) halo (84%)
Posterior enhancement 22.2% 75% 93.3% 22%
Ultrasonographic Features of TCL
specimens was reported to reach 86%, whereas that of
microscopy and cytology from FNA specimen was 18% and
38%, respectively [29]. Surgical biopsy has long been
considered the primary measure to obtain specimens suf-
ficient to histopathologically determine the nature of cer-
vical nodes. However, such an invasive procedure is often
followed by fistula formation and poor wound healing in the
scenario of tuberculous lymphadenitis [30]. US-guided CNB,
whose role in diagnosing other cervical lymphadenopathies
has been reported [31], provides a favorable alternative in
treating TCL. It leaves a smaller scar and has lower chances
of complications as compared with surgical biopsies, while
offering a similar diagnostic accuracy [32]. In our cases,
CNB was performed under US guidance without complica-
tions, and provided specimens adequate for the final
diagnosis.
Conclusion
Clinicians should always be alert to the possibility of TCL
when patients present with neck masses, especially those
who live in epidemic areas of tuberculosis. US serves as a
reliable and effective tool in making the differential diag-
nosis. The key US features of TCL include hypo-
echogenecity, strong internal echoes, echogenic thin
layers, nodal matting, soft tissue changes, and displaced
hilar vascularity. When TCL is suspected under US, US-
guided procedures such FNA or CNB can be conducted
concomitantly to obtain the microscopic or pathological
proof.
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