Cervical Scrofula Revealing Miliary Tuberculosis and Previously Undiagnosed Advanced HIV: A Case Report

Cervical tuberculous lymphadenitis, or scrofula, may be the first manifestation of previously undiagnosed advanced HIV, even when concurrent miliary pulmonary tuberculosis produces few or no respiratory symptoms.A 25-year-old male immigrant from Eastern Europe presented with one to two weeks of progressive right cervical and jaw swelling, fever, night sweats, fatigue, and anorexia, without cough, dyspnea, or chest pain.Neck and chest computed tomography demonstrated necrotic bilateral cervical lymphadenopathy, supraclavicular and paratracheal adenopathy, and diffuse miliary pulmonary nodularity.HIV testing revealed advanced untreated infection with a CD4 count of 174 cells/mm³ and HIV-1 RNA of 956,000 copies/mL; QuantiFERON-TB Gold (QIAGEN, Hilden, Germany) was positive.Cervical lymph node biopsy demonstrated necrotizing granulomatous inflammation with acid-fast bacilli.Because the patient could not produce sputum, bronchoscopy with bronchoalveolar lavage (BAL) was performed, and BAL Mycobacterium tuberculosis (MTB) polymerase chain reaction detected MTB complex with rifampin resistance not detected.He was started on rifampin, isoniazid, pyrazinamide, and ethambutol therapy with pyridoxine and Pneumocystis jirovecii pneumonia prophylaxis.Antiretroviral therapy (ART) with tenofovir disoproxil fumarate/emtricitabine and dolutegravir was initiated six weeks after antituberculous therapy.Two weeks after ART initiation, he developed recurrent neck swelling and fever with new contralateral cervical lymphadenopathy, while HIV-1 RNA had declined to 2,180 copies/mL and CD4 count had risen to 190 cells/mm³.After consideration of treatment failure, drug resistance, bacterial infection, other opportunistic infection, and malignancy, the presentation was felt to be most consistent with paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS).Symptoms improved with conservative management and close monitoring.He completed the 60-day intensive phase of antituberculous therapy, transitioned to rifampin and isoniazid continuation therapy, and remained on ART.This case highlights that cervical scrofula may reveal advanced, previously undiagnosed HIV with radiographically extensive but clinically silent miliary tuberculosis, and that recurrent lymphadenopathy after ART initiation should prompt consideration of paradoxical TB-IRIS while alternative diagnoses are evaluated.