Rapidly enlarging mediastinal mass in a middle-aged patient with fever

Abstract

A 47-year-old Indian female patient presented with lowgrade intermittent fever, anorexia and malaise of 4 months’ duration. She had a history of disseminated tuberculosis 2 years previously, for which she was successfully treated with first-line anti-tubercular drugs. On physical examination, she was found to have multiple matted cervical and axillary lymph nodes with mild splenomegaly. Laboratory results showed a raised erythrocyte sedimentation rate. Chest radiograph was normal (Figure 1). CT of the chest revealed multiple confluent rim-enhancing necrotic lymph nodes in the right axilla (Figure 2a). There was no mediastinal or hilar adenopathy and the lungs were clear (Figure 2b). Axillary lymph node biopsy was positive for acid fast bacilli. The patient was started on a modified antitubercular treatment regimen; however, her compliance for the chemotherapeutic drugs was poor and she continued to have constitutional symptoms. 5 months later, her condition worsened and she again presented to us with high-grade fever, anorexia, fatigability