The disease mycobacterial cervical lymphadenitis, also known historically as scrofula and the king's evil, involves a lymphadenitis of the cervical (neck) lymph nodes associated with tuberculosis as well as nontuberculous (atypical) mycobacteria such as Mycobacterium marinum.
Disease Scrofula is the term used for lymphadenopathy of the neck, usually as a result of an infection in the lymph nodes known as lymphadenitis. It can be caused by tuberculous or nontuberculous mycobacteria. About 95% of the scrofula cases in adults are caused by Mycobacterium tuberculosis, most often in immunocompromised patients (about 50% of cervical tuberculous lymphadenopathy). In immunocompetent children, scrofula is often caused by atypical mycobacteria (Mycobacterium scrofulaceum) and other nontuberculous mycobacteria (NTM). Unlike the adult cases, only 8% of cases in children are tuberculous. With the stark decrease of tuberculosis in the second half of the 20th century, scrofula became a less common disease in adults, but remained common in children. With the appearance of HIV/AIDS, however, it has shown a resurgence, and can affect patients at all stages of the disease.
Signs and symptoms The most usual signs and symptoms are the appearance of a chronic, painless mass in the neck, which is persistent and usually grows with time. The mass is referred to as a "cold abscess", because there is no accompanying local color or warmth and the overlying skin acquires a violaceous (bluish-purple) color. NTM infections do not show other notable constitutional symptoms, but scrofula caused by tuberculosis is usually accompanied by other symptoms of the disease, such as fever, chills, malaise and weight loss in about 43% of the patients. As the lesion progresses, skin becomes adhered to the mass and may rupture, forming a sinus and an open wound. The fatal outcome some patients experienced in earlier times was due to a cheese-like presentation of the lungs and the King's Evil lesions. It was also associated with pulmonary tuberculosis. Cervical lymphadenitis is commonly caused by an infection of mycobacteria in the head region. This disease is very inconsistent; cases can have different laboratory findings. Sometimes the disease can occur due to tuberculosis disease. However it is vital that, on a case-by-case basis, it is determined whether the cause is tuberculous or nontuberculous mycobacteria, as treatment often differs between the two forms.
Diagnosis Diagnosis is usually performed by needle aspiration biopsy or excisional biopsy of the mass and the histological demonstration of stainable acid-fast bacteria in the case of infection by M. tuberculosis (Ziehl–Neelsen stain), or the culture of NTM using specific growth and staining techniques.
Pathology The classical histologic pattern of scrofula features caseating granulomas with central acellular necrosis (caseous necrosis) surrounded by granulomatous inflammation with multinucleated giant cells. Although tuberculous and non tuberculosis lymphadenitis are morphologically identical, the pattern is somewhat distinct from other causes of bacterial lymphadenitis.
Treatment
17th century King's Evil, as the disease was historically called, was known as a frequent disorder in the 17th century, and was believed to be caused by bad blood coagulating in spongy organs such as the thyroid and the lymph nodes. Physicians also believed the disease could be inherited and could result from parents' untreated venereal infections. The treatment for mycobacterial cervical lymphadenitis consisted primarily of small incisions to remove the surrounding soft tissue and/or the abnormal mass. Until the 18th century, many doctors thought the only way to cure the disease was to be touched by a member of a royal family. In both France and England, the kings, who were thought to have inherited a miraculous power to cure the illness, touched crowds of infected people. The 'touchings' began in France during the reign of King Philip I (1060–1108) and in England during the reign of King Henry I (1100–1135). This act of public healing by powerful kings and royal family members encouraged the nickname "King's Evil". After the touching, the sovereign presented the affected person with an angel on a gold-plated coin that was to be hung around the infected person by a ribbon. This was used as a way of warding off the disease. This coin could have weighed as much as 5 grams and was considered a touch piece of great value. At age three the English lexicographer Samuel Johnson, for example, was treated for scrofula in this way, touched by Queen Anne and presented with a piece of gold, unfortunately to no effect. The royal touch and surgical removal were not the only methods of healing employed: Scrophularia nodosa (common name: Figwort), which has nodular roots that resemble the swollen lymph nodes of the affected, was thought to be useful in treating the disease, according to the doctrine of signatures – the plant being hung around the neck of the affected. Figwort does, in fact, contain compounds that can help decrease inflammation, irritation and discomfort.
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