Abstract
Tuberculosis remains the major cause of morbidity and mortality by a single infectious agent, particularly in developing countries. In recent years, we have witnessed the emergence of uncommon radiographic patterns of chest tuberculosis. Lymphadenitis is the most common extrapulmonary tuberculosis (TB) manifestation which, in developed countries, occurs more frequently in childhood, but also among adult immigrants from endemic countries and in HIV-infected people. Isolated and asymptomatic mediastinal lymphadenitis is uncommon in immunocompetent adults. We report a case of a young adult man from Senegal affected by sovraclavear and mediastinal TB lymphadenitis, which contains some uncommon elements: no compromised immunity, especially no HIV-infection, no lung lesions, no symptoms of infection or of mediastinum involvement, and rapid response to therapy in terms of mass size reduction. Examination of extra-thoracic lymph nodes and the patient's characteristics guided our diagnostic process to suspect TB. Surgical biopsy and subsequent histopathological and microbiological examinations of lymph material, first by Lowestein-Jensen and BACTEC cultures that remain the gold standard of diagnosis, confirmed the diagnosis. Chest X-ray was inconclusive; however, CT played an important role in the diagnostic course and in the management of the patient, particularly in determining disease activity, offering mediastinum and parenchymal details, as well as in identifying typical features of tuberculous lymph nodes and also of active/non active disease. Six months of antimycobacterial regimen is the recommended treatment in TB lymphadenitis of HIV-negative adults.
Highlights
The incidence rate of tuberculosis (TB) is almost stably high in people with human immunodeficiency virus (HIV) infection and among people from countries characterized by high TB endemicity [1,2,3]
We have witnessed the emergence of uncommon radiographic patterns of chest tuberculosis in adults, probably due to the progress in radiological supports such as computerized tomography (CT) and high resolution computerized tomography (HRCT) scans, with particular reference to isolated hilar or mediastinal lymphadenopathies, multiple cavities, basilar infiltrates, centrilobular nodules, tree in bud appearance, bilateral patchy infiltration, ground glass attenuation, miliary tuberculosis, and isolated pleural effusion [4,5]
While TB lymphadenitis is more frequently a clinical sign of disseminated diseases or of latent TB reactivation [2,18], in this rare case the sovraclavear and mediastinal TB lymphadenitis was not associated with other areas in the body, and, not to lung lesions which is more commonly seen in HIV-positive patients [13]
Summary
The incidence rate of tuberculosis (TB) is almost stably high in people with human immunodeficiency virus (HIV) infection and among people from countries characterized by high TB endemicity [1,2,3]. We have witnessed the emergence of uncommon radiographic patterns of chest tuberculosis in adults, probably due to the progress in radiological supports such as computerized tomography (CT) and high resolution computerized tomography (HRCT) scans, with particular reference to isolated hilar or mediastinal lymphadenopathies, multiple cavities, basilar infiltrates, centrilobular nodules, tree in bud appearance, bilateral patchy infiltration, ground glass attenuation, miliary tuberculosis, and isolated pleural effusion [4,5] These radiologic features were typically associated with defects in cell-mediated immunity; some were seen almost exclusive of interstitial lung diseases [6] and they were rarely seen in people indigenous from low-TB incidence areas, if we exclude the HIV-positive hosts. Giant cells; B: necrosis surrounded by histiocytic granulomatous reaction areas, as well as another lymph package of 63 by 19 millimeters with the same radiologic features, situated below the carina (Figure 2) These nodal finds were not associated with lung lesions but they were compatible with other characteristic signs of active TB such as nodal enlargement and conglomeration, involvement of multiple and typical sites, inhomogeneous enhancement. We prescribed an antimycobacterial therapy: two months of rifampicin 600 mg/day, isoniazid 300 mg/day, pyrazinamide 1500 mg/day and ethambutol 1200 mg/die, followed by four months of
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