A 41-year-old Indonesian lady, non-diabetic, immune-competent, presented with complaints of painless swelling at the lower end of the neck, increasing in size for the past two months. There was history of cough with scanty expectoration for the past one year with insignificant loss of appetite and weight. Local examination showed a 4.5 cm × 6 cm fluctuating non-tender swelling with erythematous overlying skin but no draining point (Panel). On general examination there is no clubbing or lymphadenopathy. Respiratory examination revealed few crepitations over the right infra-clavicular area. Rest of the systemic examination is unremarkable. Her blood investigations showed elevated erythrocyte sedimentation rate (ESR) of 46 mm/hr. Full blood count, liver profiles and renal functions were all normal. A chest radiography was taken. Q: What is the diagnosis? Answer: refer to page 113

(Refer to page 99) Answer: Tubercular cold abscess The patient’s chest radiography is shown in panel showing right upper zone consolidation. Sputum examination were all negative. Bronchoscopy showed a mass partially obstructing the anterior segment of right upper lobe bronchus. Biopsy revealed multiple multinucleated granulomas and Langhans giant cells with areas of caseation and Acid Fast Bacilli (AFB) on Zeil-Neelsen staining. The patient responded to anti-tubercular treatment (ATT).