Unmasking tuberculous lymphadenitis in a middle-aged male with Hashimoto’s thyroiditis: a case report
Highlight box
Key findings
• Tuberculous lymphadenitis can present atypically in middle-aged males with underlying autoimmune disorders such as Hashimoto’s thyroiditis.
• Classical tuberculosis symptoms, including cough, night sweats, weight loss, and fever, may be entirely absent in such presentations, delaying diagnosis.
What is known and what is new?
• Tuberculous lymphadenitis typically affects younger patients, predominantly females, and usually manifests with characteristic symptoms. Autoimmune diseases, including Hashimoto’s thyroiditis, may increase susceptibility to opportunistic infections due to immune dysregulation.
• This manuscript highlights a unique case of atypical presentation of tuberculous lymphadenitis in a middle-aged male with Hashimoto’s thyroiditis, contributing novel insights into the complex interplay between autoimmune disorders and tuberculosis.
What is the implication, and what should change now?
• Primary care clinicians must maintain a high index of suspicion for tuberculosis in patients with persistent cervical lymphadenopathy, even without classic tuberculosis symptoms, especially in those with underlying autoimmune conditions.
• Early investigation and timely escalation using advanced diagnostics, such as ultrasound imaging, QuantiFERON-TB testing, and fine-needle aspiration cytology, are crucial to prevent delayed diagnosis and initiation of treatment.
• Awareness and vigilance regarding extrapulmonary tuberculosis presentations in non-endemic settings should be increased through targeted clinical education in primary care, focusing on recognising and managing atypical presentations, particularly in patients with immune-modulating disorders.
Introduction
Background
Tuberculosis (TB), a persistent infectious condition caused by the bacterium Mycobacterium tuberculosis (M. tuberculosis), remains a significant global health challenge. M. tuberculosis is a slender, rod-shaped, non-motile bacterium. It is an acid-fast bacillus (AFB), which means it retains certain stains even after being treated with acidic decolourising agents, a characteristic that is crucial for its identification in laboratory settings (1). The slow replication rate of M. tuberculosis, typically dividing every 15 to 20 hours, further complicates its treatment, as many antibiotics target fast-growing cells (1,2). Despite advancements in medical science, TB prevails as one of the most prevalent infectious diseases worldwide.
TB manifestations are bifurcated into pulmonary and extrapulmonary forms, with extrapulmonary TB contributing to 15–20% of total TB cases (2,3). Clinical symptoms are generally constitutional, including malaise, fever, weight loss, sweats, and anorexia. Pulmonary signs are usually absent in extrapulmonary TB, although some patients may show mild respiratory symptoms if concomitant pulmonary involvement is present. If the brain is involved, neurological symptoms may include headache, reduced consciousness, and cranial nerve palsies (2,4). A notable manifestation of extrapulmonary TB is tuberculous lymphadenitis (TBL), colloquially referred to as lymph node TB or scrofula, which accounts for roughly 35% of extrapulmonary TB cases.
TBL predominantly affects individuals between the ages of 10 and 30 years and exhibits a higher incidence rate in females (5). The most frequent symptom is the enlargement of lymph nodes, primarily in the cervical region and occasionally in the axillary region. Multiple lymph nodes are often involved bilaterally, and lymph nodes in immunocompetent patients histologically show well-formed granulomas composed of epithelioid histiocytes and Langhans-type giant cells (2,3).
Rationale and knowledge gap
The global incidence of TBL continues to pose diagnostic and management challenges, particularly in primary care settings and among patients with underlying autoimmune disorders. The interplay between autoimmune conditions and TB is complex, as autoimmune patients may have increased susceptibility to TB due to immune dysregulation and the immunosuppressive effects of some treatments, consequently increasing the risk of opportunistic infections (3). This report primarily focuses on the relationship between Hashimoto’s thyroiditis and extrapulmonary TB. Thyroid hormones modulate various immune system functions, including chemotaxis, phagocytosis, reactive oxygen species production, and cytokine release. The combination of autoimmune and hypothyroid features presents an interesting opportunity to explore the interplay between TB and Hashimoto’s thyroiditis. Literature addressing the interaction between these conditions remains limited, highlighting a crucial knowledge gap.
Objective
This case report aims to highlight the diagnostic complexity and clinical interplay between Hashimoto’s thyroiditis and TBL in a patient with Hashimoto’s thyroiditis who developed TBL, contributing to the growing body of literature on the association between autoimmune disorders and TB. It seeks to raise awareness of atypical TB presentations and underline the importance of vigilance in primary care practice, ensuring timely diagnosis and intervention. We present this case in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-102/rc).
Case presentation
A 40-year-old Caucasian male with a history of Hashimoto’s thyroiditis initially presented to his general practitioner with flu-like symptoms. The patient undertook a coronavirus disease 2019 (COVID-19) lateral flow test, which was negative. He confirmed that he had not travelled overseas in the previous 24 months. His medication history included levothyroxine 75 mcg daily only. The patient was diagnosed with a viral upper respiratory tract infection and reassured. He was advised to take paracetamol 1 g four times daily as needed for fever and aches, ibuprofen 400 mg three times daily as needed for inflammation and pain relief, and to continue his regular dose of levothyroxine 75 mcg daily for Hashimoto’s thyroiditis. All medications were taken during the acute phase of his viral upper respiratory tract infection, and the patient’s flu-like symptoms resolved within 10 days. During the initial assessment, it was also noted that the patient had a palpable lymph node in the right upper neck.
Two weeks following the resolution of his symptoms, the patient sought medical advice for the persistent, painless lymph node in his neck. On review by the general practitioner, the lymph node measured 3 cm in diameter, was soft, mobile, and non-tender, and the overlying skin was intact. The patient reported no symptoms. On direct questioning, he denied symptoms of chest pain, cough, dyspnoea, nocturnal sweats, fever, weight loss, or other constitutional complaints. While such symptoms are common in pulmonary TB, they are often absent in extrapulmonary forms such as lymphadenitis. Given the patient’s recent viral infection, a provisional diagnosis of viral lymphadenitis was considered.
Lymphoma was also considered, particularly given the node’s painless nature and absence of typical infection-related symptoms such as fever. However, the lack of systemic “B” symptoms such as fever, night sweats, and weight loss reduced the likelihood of lymphoma. Sarcoidosis, a granulomatous disease typically associated with pulmonary symptoms, and cat-scratch disease, usually involving animal exposure and tender lymphadenopathy, were also considered but deemed less likely due to the absence of characteristic clinical signs and symptoms.
During a telephone follow-up four weeks later, the patient reported a perceived decrease in the size of the lump and opted out of a face-to-face consultation and any investigations.
Approximately three months after the initial presentation, the patient contacted the GP again, concerned that the lump persisted and appeared to be enlarging. A thorough examination revealed a now 4 cm diameter lymph node in the right upper neck, which was less defined, mobile, firm, and painless. The GP promptly arranged blood tests and an urgent ultrasound of the neck. Laboratory investigations revealed elevated inflammatory markers, including C-reactive protein (CRP) at 75 mg/L (normal <10 mg/L), slightly low lymphocyte count [1.2×109/L, normal (1.0–3.0)×109/L], mildly elevated thyroid-stimulating hormone (TSH) at 5.6 mIU/L (normal 0.4–4.0 mIU/L), and significantly elevated anti-thyroid peroxidase antibody (anti-TPO) levels at 300 IU/mL (normal <35 IU/mL), consistent with Hashimoto’s thyroiditis. Liver enzymes were also mildly elevated, with ALT at 45 U/L (normal, 7–56 U/L) and AST at 50 U/L (normal, 5–40 U/L). Kidney function and thyroid hormone levels [triiodothyronine (T3) and thyroxine (T4)] were within normal ranges. HIV testing was performed and confirmed that the patient was HIV-negative (Table 1).
Table 1
| Test | Result | Normal range | Interpretation |
|---|---|---|---|
| CRP | 75 mg/L | <10 mg/L | Elevated, indicating inflammation |
| Lymphocyte count | 1.2×109/L | (1.0–3.0)×109/L | Slightly low, possibly due to chronic infection |
| T3 | 4.2 pmol/L | 3.1–6.8 pmol/L | Within normal range |
| T4 | 12.5 pmol/L | 12–22 pmol/L | Within normal range |
| TSH | 5.6 mIU/L | 0.4–4.0 mIU/L | Slightly elevated, consistent with Hashimoto’s |
| Anti-TPO | 300 IU/mL | <35 IU/mL | Elevated, confirming Hashimoto’s thyroiditis |
| ALT | 45 U/L | 7–56 U/L | Slightly elevated, indicating mild liver involvement |
| AST | 50 U/L | 5–40 U/L | Elevated, indicating liver involvement |
| Creatinine | 85 µmol/L | 60–110 µmol/L | Within normal range |
ALT, alanine aminotransferase; anti-TPO, thyroid peroxidase antibody; AST, aspartate aminotransferase; CRP, C-reactive protein; T3, triiodothyronine; T4, thyroxine; TSH, thyroid-stimulating hormone.
Further blood tests showed an elevated white blood cell count (17.5×109/L), neutrophil count (15.8×109/L), platelet count (380×109/L), and erythrocyte sedimentation rate (ESR) of 78 mm/h, suggestive of an inflammatory or infectious process. The neck ultrasound identified a 4 cm × 2 cm caseating lymph node at the site of clinical concern, with additional enlarged lymph nodes in the anterior triangle of the neck, raising suspicion for TB (Figure 1). Despite these findings, the chest X-ray appeared normal.
A QuantiFERON-TB test confirmed TB with a significantly elevated TB antigen response (3.67 IU/mL). Fine-needle aspiration cytology of the node showed necrotic epithelioid granuloma with giant cells, confirming a diagnosis of TBL.
The patient was referred to a specialised TB unit and underwent a 6-month anti-TB treatment regimen comprising an intensive phase of isoniazid (300 mg daily), rifampicin (600 mg daily), pyrazinamide (1.5 g daily), and ethambutol (15 mg/kg daily) for the first 2 months, followed by a continuation phase of isoniazid (300 mg daily) and rifampicin (600 mg daily) for the subsequent 4 months. The patient made a full clinical recovery without complications or adverse events.
The patient was followed up at 2-month intervals following treatment completion, over a further 6 months. He remained clinically well, with no recurrence of lymphadenopathy or development of systemic symptoms. Thyroid function remained stable, and he continues routine follow-up in primary care for Hashimoto’s thyroiditis.
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.
Discussion
Key findings
This case highlights a diagnostically challenging presentation of TBL in a 40-year-old male, diverging from the typical demographic predominantly comprising females and individuals in their 20s to 30s. The case is consistent with the findings discussed by Algarni et al. (4), highlighting inconsistencies in how TBL is described epidemiologically in conventional literature. Females were more likely to be diagnosed with TBL than men in the USA, France, UK, Taiwan, Zambia, and India, but males were more likely in data collected from Qatar and Denmark (2). This notion is reflected in this case.
TBL frequently affects patients aged 30–40 years, particularly in immigrant populations within the UK and other developed nations. While specific epidemiological data are limited, in most regions, TBL is more common among women (53% of affected population female in the UK) than among men (composite ratio, 1.4:1)—a different pattern than for pulmonary TB, which is more frequently seen among men. Its most common manifestation is cervical lymphadenopathy, accounting for 63–77% of all cases, varying by region (2). Though it represents 15–20% of extrapulmonary TB cases globally, residual lymphadenopathy persists in up to 20% of patients after six months of treatment, often necessitating extended therapy.
Complications include paradoxical lymph node enlargement during treatment, alongside general constitutional symptoms, which can prolong recovery. Median lymph node size is 3 cm, but nodes may be up to 8–10 cm in diameter. Patients do not generally report significant pain at presentation, and node tenderness during examination is noted in only 10–35% of cases. Globally, mortality rates for treated TBL are low (1–5%) (5,6), but untreated cases can lead to severe outcomes. In developed regions like the UK, morbidity is tied to delayed diagnosis and persistent symptoms.
Notably, this patient had no recent history of travel to TB-endemic regions, and the initial presentation was misleadingly indicative of a viral illness, further complicating the diagnostic process. The absence of systemic or pulmonary symptoms, which are common in pulmonary TB but frequently absent in lymph node TB, may have contributed to diagnostic uncertainty in this case.
Strengths and limitations
This report’s strengths lie in its comprehensive timeline, clear clinical documentation, and robust diagnostic follow-up, highlighting the clinical challenges and delayed recognition of atypical extrapulmonary TB presentations (Figure 2). However, limitations include its single-case nature, which restricts the generalisability of findings, and reliance on clinical investigations and treatment managed through specialist referral, resources not universally accessible in primary care.
Comparison with similar research
This case aligns with existing literature on atypical presentations of TBL, specifically in populations not traditionally considered high-risk for TB. Algarni et al. (4) have reported demographic variations internationally. Additionally, Cheng et al. (7) highlighted an increased risk of TB in patients with hypothyroidism, further supporting the relationship between autoimmune thyroid disorders and susceptibility to TB infection, as illustrated in this case.
Although TBL is well documented in global literature, this case is noteworthy for its occurrence in a non-endemic setting, in an immunocompetent patient without HIV or travel exposure. It illustrates the diagnostic uncertainty faced in primary care when extrapulmonary TB presents atypically in the presence of autoimmune comorbidity.
Explanations of findings
The patient’s underlying Hashimoto’s thyroiditis, a common cause of primary hypothyroidism, may have influenced the clinical course through the interplay of immune dysregulation and thyroid dysfunction. Thyroid hormone signalling plays a vital role in optimal immune responses during TB infection (6), potentially increasing susceptibility to infections like TB. In TBL, systemic symptoms such as fever, weight loss, or night sweats are frequently absent, and the disease may present solely with isolated, painless cervical lymphadenopathy. As such, the lack of pulmonary symptoms in this patient was consistent with known clinical patterns but may have delayed suspicion in primary care.
While HIV is a recognised risk factor for extrapulmonary TB, this patient tested negative, underscoring the significance of autoimmune thyroid disease as a potential contributor to immune dysregulation in this context. Moreover, immunomodulatory treatments for autoimmune diseases can further predispose patients to opportunistic infections. A nationwide, longitudinal study by Cheng et al. (7) supports this theory, finding patients with hypothyroidism 2.91 times more likely to develop TB compared to those without, underscoring the need for a vigilant approach to infectious symptoms in this patient cohort.
The absence of pulmonary symptoms and normal chest X-ray findings in this case highlights the deceptive nature of extrapulmonary TB, which can manifest without clear respiratory involvement. This reinforces the importance of considering TB in the differential diagnosis for unexplained lymphadenopathy, particularly in patients with underlying conditions that may mask or mimic infectious symptoms (Figure 3).
The initial reassurance and delayed escalation of care reflect a broader challenge in primary care: balancing the risk of over-investigation against the potential for overlooking serious conditions. This case advocates for a more dynamic approach to follow-up and investigation protocols, especially for persistent or atypical presentations (Table 2).
Table 2
| Challenge | Description | Impact on diagnosis | Management strategy |
|---|---|---|---|
| Initial presentation | Presented with flu-like symptoms and a palpable lymph node during a viral outbreak | Viral symptoms overshadowed possibility of TB, leading to initial misattribution | Increased awareness and consideration of underlying serious conditions even with common presentations |
| Underlying autoimmune condition | Patient with Hashimoto’s thyroiditis, an autoimmune thyroid disorder | Autoimmune conditions can mask or mimic TB symptoms, complicating the diagnostic process | Consideration of the entire clinical picture, including past medical history and potential interactions between autoimmune disorders and infectious diseases |
| Absence of classic TB symptoms | Lack of cough, fever, night sweats, or significant weight loss typically associated with TB | Decreased suspicion for TB, leading to potential diagnostic delay | Maintaining a broad differential diagnosis for lymphadenopathy, including TB, regardless of the presence of classic symptoms |
| Normal CXR | CXR did not show signs of pulmonary TB | Extrapulmonary TB, particularly lymphadenitis, may not present with pulmonary findings, leading to false reassurance | Understanding that normal pulmonary imaging does not rule out extrapulmonary TB |
| Delay in escalation | Initial reassurance followed by delayed further investigation | Potential delay in diagnosis and treatment initiation, increasing the risk of disease progression and transmission | Implementing a more proactive follow-up and investigation protocol for persistent or atypical lymphadenopathies |
| Diagnostic tools | Reliance on advanced diagnostic tests such as QuantiFERON-TB test and fine-needle aspiration cytology not readily available in primary care | Dependence on specialist referral for definitive diagnosis may introduce delays | Establishing clear pathways for expedited referral and investigation for suspected cases of TB in primary care settings |
CXR, chest X-ray; TB, tuberculosis.
Implications and actions needed
Diagnosing TB in primary care settings has significant public health implications, given the infectious nature of the disease. Early identification and management of TB cases are critical to preventing transmission and controlling the spread of TB, especially in low-prevalence regions where clinical vigilance for TB may be lower.
Primary care providers should adopt heightened clinical suspicion for extrapulmonary TB presentations, particularly among patients with underlying autoimmune conditions. It is essential to implement clear and proactive investigation protocols for persistent lymphadenopathy. Establishing direct and expedited pathways to specialist referrals and advanced diagnostic tests, such as ultrasound imaging, QuantiFERON-TB testing, and fine-needle aspiration cytology, should become standard practice to minimise diagnostic delays and ensure timely initiation of appropriate treatment.
Conclusions
This case report illustrates the complexities involved in diagnosing extrapulmonary TB, particularly TBL, in patients with atypical presentations and underlying autoimmune disorders such as Hashimoto’s thyroiditis. This case highlights the importance of maintaining clinical vigilance and a systematic diagnostic approach to persistent lymphadenopathy in primary care settings. The absence of classical TB symptoms and normal pulmonary imaging should not deter clinicians from considering extrapulmonary TB in the differential diagnosis. Early consideration and timely escalation of diagnostic investigations, including ultrasound, QuantiFERON-TB testing, and fine-needle aspiration cytology, are essential to avoid diagnostic delays, reduce morbidity, and prevent further disease transmission. At 6-month follow-up post-treatment, the patient showed complete clinical resolution with no recurrence.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-102/rc
Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-102/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-102/coif). W.J. serves as an unpaid editorial board member of AME Case Reports from July 2024 to June 2026. The other authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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Cite this article as: Ramkumar P, Yaqub Y, Jerjes W. Unmasking tuberculous lymphadenitis in a middle-aged male with Hashimoto’s thyroiditis: a case report. AME Case Rep 2025;9:128.
