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+A seven-year-old girl born in Spain with no previous pathology was referred to the Paediatric Infectious Diseases Unit for painful left submandibular lymphadenopathy of one month's duration, with no response to treatment with amoxicillin-clavulanic acid and oral anti-inflammatory drugs.
+The patient had no fever, night sweats or weight loss. She was not vaccinated with BCG. For one month a year she visits Morocco, where she has contact with animals (sheep, lambs) and consumes unpasteurised dairy products.
+Physical examination revealed a left submandibular conglomerate of lymphadenopathies, painful on palpation, hard, non-rolling and non-adherent, the largest lymph node measuring 2 × 2 cm. The rest of the physical examination and anamnesis by apparatus showed no pathological findings.
+Given the lack of response to treatment and taking into account the epidemiological data, a tuberculin test was performed, which was positive, with a 10 mm induration with vesicular pattern at 72 hours. Chest X-ray and abdominal ultrasound were normal.
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+Brucella, Epstein-Barr virus (EBV) and cytomegalovirus (CMV) serologies were negative. CBC showed normal haemogram, erythrocyte sedimentation rate (ESR) of 47 mm/hour and interferon-gamma release assays (IGRA) (QuantiFERON(r)) was positive with a value of 10.15 (normal range: 0-0.35).
+A fine needle aspiration puncture (FNA) of the adenopathy showed a thick, whitish material. Culture and cytology revealed a pattern of necrotising granulomatous lymphadenitis.
+Given the limited involvement of the patient and the suspicion of tuberculous adenitis, initial home treatment with isoniazid, rifampicin and pyrazinamide was prescribed, pending culture of the sample obtained by FNA. The culture was positive for M. bovis, with an antibiogram showing resistance to pyrazinamide and sensitivity to streptomycin, ethambutol, isoniazid and rifampicin. For this reason, pyrazinamide was replaced by ethambutol for two months, followed by isoniazid and rifampicin until the end of six months. Mycobacterial cultures in gastric juice were negative. During this time, the patient attended regular check-ups at the Paediatric Infectious Diseases Department, which showed a good clinical evolution and complete resolution of the infectious process.
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