Scrofula in 2025: Symptoms, Pictures & Treatment Costs Explained

Understanding Scrofula

Scrofula is a manifestation of tuberculosis bacteria causing symptoms beyond the lungs, primarily presenting as inflamed lymph nodes in the neck region. Medically, it is known as “cervical tuberculous lymphadenitis,” where:

• Cervical refers to the neck area.
• Lymphadenitis indicates inflammation of lymph nodes, key components of the immune system.

It remains the most prevalent form of extrapulmonary tuberculosis infection globally.

Historically dubbed the “king’s evil,” scrofula was once believed curable only by royal touch. Today, advances in medicine have transformed diagnosis and treatment approaches.

Visual Identification of Scrofula

Recognizing Symptoms

Typically, scrofula causes swelling and nodular lesions on one or both sides of the neck. These swollen lymph nodes often feel like small, firm lumps, usually painless and cool to the touch. Over weeks, these nodules may enlarge and potentially discharge pus or fluid.

Additional symptoms may include:

• Persistent fever
• General malaise or fatigue
• Night sweats
• Unexplained weight loss

While less frequent in developed countries where tuberculosis is controlled, scrofula accounts for around 10% of tuberculosis cases in the United States. It remains a significant health challenge in developing regions.

Causes Behind Scrofula

The bacterium Mycobacterium tuberculosis is the primary cause of scrofula in adults. In some cases, Mycobacterium avium intracellulare contributes to the infection.

Children are more commonly affected by non-tuberculous mycobacteria, often contracted through contact with contaminated objects.

Risk Factors

Individuals with weakened immune systems face higher risks. In the U.S., scrofula represents about one-third of tuberculosis cases among immunocompromised people. Conditions or medications that reduce T-cell counts diminish the body's ability to combat infections, increasing vulnerability.

People living with HIV on antiretroviral therapy may experience heightened inflammatory responses to tuberculosis bacteria.

Diagnostic Procedures

When tuberculosis is suspected as the cause of neck swelling, doctors commonly perform a purified protein derivative (PPD) skin test. This involves injecting a small amount of PPD under the skin to detect immune response. A raised, hardened area indicates exposure but is not definitive due to other bacteria potentially causing similar symptoms.

Definitive diagnosis usually requires a biopsy of the affected lymph nodes, often via fine-needle aspiration, carefully conducted to prevent bacterial spread.

Imaging studies, such as X-rays, help assess the extent of lymph node involvement and differentiate scrofula from other conditions like cancer.

Though no specific blood test exists for scrofula, doctors may order tests like cat-scratch disease titers or HIV screening to exclude other diagnoses.

Modern Treatment Strategies

Scrofula requires prolonged antibiotic treatment, often extending six months or more. Initial therapy typically includes multiple antibiotics such as:

• Isoniazid
• Rifampin
• Ethambutol

After the first two months, treatment usually continues with isoniazid and rifampin for an additional four months.

Patients may notice temporary worsening of lymph node swelling or new nodules during therapy, a phenomenon known as a “paradoxical upgrading reaction.” It is critical to continue treatment despite these changes.

In some cases, oral corticosteroids are prescribed to reduce inflammation. Surgical removal of persistent lymph node masses may be considered after completing antibiotic therapy to avoid complications such as fistula formation.

Potential Complications

Less than half of scrofula patients have concurrent pulmonary tuberculosis. The infection can spread beyond the neck, and chronic draining wounds may develop, increasing risk for secondary bacterial infections.

Prognosis and Follow-up

With appropriate antibiotic therapy, scrofula has an excellent cure rate between 89% and 94%. If you experience neck swelling or other related symptoms, seek medical evaluation promptly. Tuberculosis skin testing is widely available at public health clinics as a convenient and affordable diagnostic tool.

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