A previously healthy young man from Myanmar who works in the IT industry in Singapore. Presented with a left neck lump that increased gradually in size over the past 10 weeks, associated with a low-grade fever (up to 37.9 degrees Celsius) over the past month. No other systemic symptoms or such as cough or weight loss. One week prior to his medical appointment, a little pustule developed over the lump which discharged seropurulent (yellowish) fluid spontaneously.

Here are a couple of photos (including a close-up) of the neck lump:

Neck lump in a young man

Neck lump (close-up)

Question: What is the most likely diagnosis and what would be the investigation of choice?

[Updated 5th October 2014]

This young man had tuberculous cervical lymphadenitis, also known as scrofula. In the olden days, it was apparently also called the “king’s evil“, and could be healed by the touch of a royal hand. These days, anti-tuberculosis drugs are far more accessible to most people, and possibly more reliable. Surgery alone has a poor track record – there is frequently recurrence and/or development of fistula post-procedure. One further point of note is that drug-resistant tuberculosis is not rare in Myanmar – this should be taken into consideration during both the diagnostic work-up and therapy of such cases.