A Granulomatous Puzzle: Tubercular Lymphadenitis Without AFB Clues

Tubercular lymphadenitis (TBL) is the most common form of extrapulmonary tuberculosis (EPTB), accounting for 20%-40% of EPTB cases. We present you a case of a 45-year-old male presented with gradually progressive swelling in the lower right side of the jaw for 2 months. At his initial consultation at another center, a diagnosis of carcinoma of the right lower alveolus was suggested. However, the histopathological examination (HPE) performed at the same center revealed a tubercular granulomatous lesion. As the patient's symptoms didn't seem to correlate with this diagnosis, he didn't initiate his treatment there and sought further evaluation at our institution. In course of further investigation, Fine Needle Aspiration Cytology (FNAC) suggested for TBL but Acid-Fast Bacilli (AFB) and Gene Xpert showed negative results for mycobacterium tuberculosis. After 2 months of antitubercular regimen, the patient responded well to drugs with significant reduction in swelling. This case highlights the diagnostic challenge of atypical presentations of TBL in the head and neck region, emphasizing the role of rapid and minimally invasive FNAC for the early diagnosis of TBL even with negative Gene Xpert and AFB stain.