Cervical lymphadenopathy in a patient receiving anti-TNF a treatment: glandular tuberculosis or oropharyngeal tularemia?

Abstract

BACKGROUND: Tularemia is a global anthroponotic disease that is endemic in some regions of Turkey, and it is carried by small rodents (hares) and arthropods (ticks, horseflies). Tularemia is caused by the Francisella tularensis bacteria, which is a facultatively intracellular Gram-negative bacillus. CASE PRESENTATION: Herein, we present a case of oropharyngeal tularemia living in an endemic region of Turkey. The patient was 64 years old, had rheumatoid arthritis, and had been taking anti-TNF (adalimumab) in combination with methotrexate for about a year. She had swelling in her neck. She also had a sore throat and recurrent mouth ulcers. Her vital signs showed no abnormality; she had no fever, and physical examination only revealed hyperemia in the left cervical region and an enlarged painful lymph node. Significant tularemia serological titers supported the diagnosis, with contaminated water consumption being the most likely transmission route. Streptomycin (15 mg/kg/day, intramuscular) was given for 10 days. The patient healed completely without any complications. Six months later, there had been no recurrence. CONCLUSIONS: Particularly in endemic regions, tularemia should be considered in the differential diagnosis of lymphadenopathy with necrotic granuloma in patients receiving anti-TNF α treatment.

Keywords

• francisella tularensis
• granulomatous lymphadenitis
• lymphadenitis
• oropharyngeal tularemia