Case of miliary tuberculosis with esophageal perforation and a tracheal inflammatory polyp secondary to mediastinal lymphadenitis causing massive hematemesis and hemosputum

A 62-year-old man with a history of left nephrectomy due to tuberculosis was referred to our hospital, because chest radiography showed diffuse miliary shadows in the bilateral lung fields, and acid-fast bacilli were detected from his hemosputum after steroid therapy for fever of unknown origin. Chest computed tomography showed mediastinal lymph node enlargement with partial calcification of these lymph nodes together with the presence of air. He was diagnosed with miliary tuberculosis and tuberculous mediastinal lymphadenitis and anti-tuberculosis drug therapy was started. Massive hematemesis occurred 11 days after the start of the treatment. Although gastroendoscopy was performed, the bleeding point could not be identified. The patient's symptoms improved after conservative therapy. Repeat gastroendoscopy showed a submucosal nodule with laceration of the esophageal mucosa, 30 days after admission for the examination of melena and progression of anemia. The episodes occurred because of esophageal perforation secondary to tuberculous mediastinal lymphadenitis. Bronchoscopic examination for hemosputum showed an inflammatory polypoid lesion in the left tracheal wall. These symptoms improved with anti-tuberculosis drug therapy. In our case, mediastinal lymphadenitis progressed to miliary tuberculosis because of endogenous reactivation. We report a rare case of esophageal perforation with a tracheal inflammatory polyp secondary to tuberculous mediastinal lymphadenitis. In cases of tuberculous mediastinal lymphadenitis, if hematemesis or hemosputum is observed, an endoscopic examination should be performed.     

A case of tuberculous lymphadenitis diagnosed by the open abdominal lymph node biopsy

A 16-year-old female was admitted to our hospital six months ago. On X-ray examination of the test, swelling of lymph nodes in the right mediastinum was seen. CT scan showed multiple lymph node swelling in the neck, mediastinum and abdomen. On open abdominal lymph node biopsy, she was diagnosed as tuberculous lymphadenitis and liver tuberculosis. Antituberculous chemotherapy consisting of INH, RFP, EB and SM was started. After regular treatment, right mediastinal lymph nodes were markedly reduced in size on chest X-ray film. At present, she is in fine condition. Surprisingly, her condition has improved to a great extent within six months.     

Four cases of the tuberculous adenitis

We report four cases of tuberuculosis with the lymph nodes swelling in the porta hepatis. Case 1 is 52 years-old man, who was admitted to our hospital because of anorexia. The chest X-ray film showed abnormal shadow and he was diagnosed as tuberculosis by sputum examination. At the time of hospitalization, patient's conjunctiva is icteric on physical examination. The serum T-Bil was 3.21 mg/dL and D-Bil was 2.54 mg/dL. The enhanced CT showed compression of the extrahepatic common bile duct which was caused by enlarged lymph nodes secondary to tuberculous adenitis. Case 2 is 25 years-old man, who was admitted to our hospital because of low grade fever and lower abdominal pain. The chest X-ray film showed abnormal shadow and he was diagnosed as tuberculosis by sputum examination. An enhanced CT showed the swelling of the lymph nodes in the porta hepatis. Case 3 is 21 years-old woman, who visited the outpatient clinic bacause of neck lymph node swelling. And she was diagnosed as tuberculous adenitis of the cervical lymph-nodes by the neck lymph node biopsy. The patient complained of upper abdominal pain during the clinical course. The enhanced CT showed the swelling of the lymph nodes in the porta hepatis. A Case 4 is 31 years-old man, who visited to outpatient clinic bacause of fever. The chest X-ray film showed mediastinal lymphadenopathy, and he was diagnosed as tuberculosis by the thoracoscopic biopsy. The enhanced abdominal CT showed lymph nodes swelling in the porta hepatis. All of lymph nodes swelling found in our four cases markedly reduced in size on abdominal enhanced CT or ultrasonography after the initiation of anti-tuberculous standard chemotherapy. Symptom of all cases got better as well. In these clinical circumstances, it was clinically important to rule out malignant lymphoma and lymphadenopathy caused by cancer. The enhanced abdominal CT were useful for diagnosis and follow-up as tuberculous adenitis.     

An adult case of mediastinal tuberculous lymphadenitis]

A 40-year-old woman was admitted to the hospital with general fatigue and cough. Chest CT films revealed mediastinal lymphadenopathy with multiple low density areas, but no pulmonary lesions. There were no abnormal findings on neck, abdominal or pelvic CT. A PPD skin test was strongly positive, but M. tuberculosis bacilli were not found in the sputum. Mediastinal tuberculous lymphadenitis was diagnosed histologically and bacteriologically from specimens obtained by mediastinoscopy. Fiberoptic bronchoscopy did not reveal tracheobronchial tuberculosis. Follow-up chest CT three months after the start of antituberculosis chemotherapy with isoniazid, rifampicin and ethambutol hydrochloride showed that the mediastinal lymph nodes were decreased in size. Mediastinal tuberculous lymphadenitis in adults is rare, but the number of reports has increased. Mediastinal tuberculous lymphadenitis in adults must be distinguished from other causes of mediastinal masses. In this case, mediastinoscopy was very useful for differential diagnosis.     

A case of primary lung cancer with cervical tuberculous lymphadenitis]

A 66-year-old woman was admitted due to right cervical lymphadenopathy and an abnormal chest radiograph. Acid-fast bacilli smear of fine needle aspiration from a right cervical lymph node was positive. Histopathological examination of the specimen obtained by percutaneous right cervical lymph node biopsy showed necrotizing epithelioid granulomas and no malignant cells. Therefore, right cervical tuberculous lymphadenitis was diagnosed. Partial lung resection of the right S4 was carried out by video-assisted thoracoscopic surgery and primary lung cancer was diagnosed. To our knowledge, there has been no previous report of both primary lung cancer and cervical tuberculous lymphadenitis being present at the time of the first examination. We report this very rare case.     

An adult case of cervico-mediastinal tuberculous lymphadenitis]

We reported a case of cervico-mediastinal tuberculous lymphadenitis followed by the development of pulmonary lesions and recurrent laryngeal nerve palsy. A 48-year-old man was admitted to our hospital due to fever, dry cough, and loss of body weight. He had no medical history of tuberculosis or other significant diseases. On admission, a right cervical tumor was palpable and chest X-ray films revealed widened superior mediastinum. Chest computed tomography showed multiple swollen mediastinal lymph nodes, including multiple low-density areas and contrast medium-enhanced septa and margins. Gallium-67 scintigraphy demonstrated abnormal uptake in the right cervix and mediastinum. A PPD skin test was strongly positive and ribosomal RNA of tubercle bacilli was detected in aspirated gastric juice. Although anti-tuberculous chemotherapy was initiated, fever and cough persisted, and hoarseness due to left recurrent laryngeal nerve palsy developed. One month later, chest X-ray films showed abnormal infiltration in the left upper lung field. The patient was sero-negative for HIV. To confirm the diagnosis, right supraclavicular lymph node biopsy was performed. Microscopic examination of the biopsy specimen revealed acid-fast bacilli and granuloma with central caseous necrosis surrounded by Langhans' giant cells and epithelioid cells. After 9 months of extended anti-tuberculous chemotherapy, the cervical and mediastinal masses receded and the abnormal chest X-ray shadows disappeared. Because the incidence of tuberculosis in Japan is gradually increasing among young people as well as the elderly, the differential diagnosis of this disease will become more necessary.     

Tuberculous lymphadenitis: a clinical study of 23 cases

INTRODUCTION: Tuberculous lymphadenitis is a relatively rare disease in adults. In the absence of pulmonary tuberculosis, tuberculous lymphadenitis is very difficult to differentiate from other diseases. We described our experiences of patients with tuberculous lymphadenitis. RESULTS: We diagnosed 23 patients with tuberculous lymphadenitis out of 207 patients with tuberculosis. Their ages ranged from 18 to 99 years (mean, 45.7 years), and the male-to-female ratio was 7:16. The most common complaints were cervical mass and fever. With the exception of two patients, all diagnosed patients had a strong positive skin test to tuberculin. Observing the site of affected lymph nodes, 16 patients had cervical node involvement, 3 patients had axillary node involvement, 7 patients had mediastinal node involvement, 3 patients had hilar node involvement, 3 patients had abdominal node involvement, and 1 patient had inguinal node involvement. Fifteen patients had neither hilar nor mediastinal node involvement. Eleven patients had no tuberculous lesions other than lymphadenitis. Seven patients underwent biopsy of the lymph nodes. Four of these patients had the evidence of acid-fast bacilli. The remaining three patients were also diagnosed histologically. Five patients underwent fine needle aspiration. Two of them had the evidence of acid-fast bacilli. Acid-fast bacilli were detected in 10 out of 16 sputum samples and in 1 out of 2 pleural effusion samples. Five patients were diagnosed clinically by image (Computed tomography etc.) and by therapeutic effect. Eleven cases underwent contrast-enhanced computed tomography (CT) of the lymph nodes. Seven cases showed central low attenuation with peripheral rim enhancement, whereas the other four cases showed homogeneous attenuation. All patients received chemotherapy for a mean duration of 14.5 months (range, 6-30 years) with apparent improvement, but 1 patient relapsed. CONCLUSION: Tuberculous lymphadenitis remains one of important targets for the differential diagnosis of lymphadenopathy. It is essential that a peripheral lymph node biopsy be performed and examined either histologically and/or microbiologically. A tuberculin skin test and contrast-enhanced CT imaging should also be performed.     

Mediastinoscopy in the case of recurrent uveitis

INTRODUCTION: The authors report the case of a patient who presented for 4 years recurrent anterior uveitis accompanied by asymptomatic tuberculous mediastinal lymphadenitis. EXEGESIS: CT scan of the chest showed the existence of mediastinal lymphadenopathy (< 1 cm). Mediastinoscopy with biopsy of the right laterotracheal lymph node was performed. The culture was positive for Mycobacterium tuberculosis, thus permitting the diagnosis of tuberculosis. CONCLUSION: This case report stresses the advantage of extensive etiological assessment when faced with unexplained uveitis; particularly it emphasizes the importance of investigating potential tuberculosis. The existence of granulomatous uveitis, a positive skin test, the ethnic origin, and mostly results of chest CT scan, were the rationale for the use of mediastinoscopy with lymph node biopsy to help guide diagnosis.     

A case of cervical and mediastinal lymph nodes tuberculosis, tuberculous pleurisy, spinal caries and cold abscess in the anterior chest wall

A 61-year-old woman with schizophrenia that had been treated in a psychiatric hospital was admitted to our hospital because of subileus and back pain. Though subileus was improved, she had a sudden attack of fever 7 days later and developed right pleural effusion, a cold abscess in the anterior chest wall and swelling of a thumb-sized right cervical lymph node which broke through the skin. We made a diagnosis of cervical and mediastinal lymph nodes tuberculosis, tuberculous pleurisy, spinal caries and cold abscess in the anterior chest wall due to the biopsy findings of the specimen taken from the cervical lymph node, examination of pleural effusion, chest CT, bacteriological examination of the cold abscess and spinal MRI. We started chemotherapy with the antituberculous drugs (HRSZ) and symptoms except back pain improved. She complained of paresis of the both lower extremities, which completely paralyzed 8 months later in spite of continued chemotherapy. Thereafter her paralysis was gradually improved and she was able to walk by herself after 12 months chemotherapy.     

A case of cervical-mediastinal lymph node tuberculosis progressed to pulmonary lesion through a bronchial fistula]

The patient was a 25-year-old man who had been admitted to a local hospital due to fever and trachelophyma. Tubercle bacillus was detected in pus culture obtained by biopsy of the trachelophyma, but not in sputum culture. Because combined therapy with 3 antituberculous drugs (RFP, INH and SM) failed to reduce the fever or drainage from the biopsy region, the patient was transferred to our hospital. Chest X-ray films taken on admission revealed dilatation of the superior mediastinal shadow; chest CT images revealed cervical and mediastinal lymphadenopathy and an anterior mediastinal abscess, but no pulmonary lesion. About 2 months after admission, cough developed and Gaffky type 2 was detected in the patients sputum. Bronchoscopy and bronchography revealed a bronchomediastinal fistula. Forty days after the onset of cough, reticulogranular shadows were observed in the right upper lobe on chest X-ray films, and a diffuse centrilobular lesion was observed in the right upper lobe on chest CT images. From these clinical observations, the patient was given a diagnosis of cervical-mediastinal lymph node tuberculosis, which had progressed to pulmonary lesion through a bronchial fistula due to lymphadenitis.     

Case of liver tuberculosis requiring differentiation from liver metastasis of cancer

A 79-year-old woman was admitted to our hospital because of general fatigue. Chest radiograph and computed tomograph showed bronchiectasis and centrilobular nodules in the right middle lobe and lingula, which had not changed from previous examination. Intrahepatic nodular lesions and swelling of the left cervical lymph nodes, supraclavicular lymph node, abdominal paraaortic lymph nodes and inguinal lymph nodes was observed. Biopsy specimen of the liver lesion demonstrated epithelioid cell granulomas. Biopsy of the right inguinal lymph node demonstrated epithelioid cell granulomas with caseous necrosis and culture of the specimen showed Mycobacterium tuberculosis. The patient was diagnosed as having liver tuberculosis and multiple tuberculous lymphadenitis. Antituberculous treatment with isoniazid, rifampicin, ethambutol and pyrazinamide were started and continued for 6 months. All lesions improved after treatment. This was a rare case of liver tuberculosis that was difficult to distinguish from liver metastasis of cancer.     

A case of Poncet's disease (tuberculous rheumatism) in a patient with chronic renal failure undergoing hemodialysis therapy]

A 78-year-old man who was undergoing hemodialysis therapy was admitted to our hospital because of sore throat, remittent cervical lymphadenopathy, and polyarthritis over the preceding 4 weeks. On admission, he had bilateral cervical lymphadenopathy. He complained of arthralgia associated with tenderness, warmth and swelling of both elbows, left side wrist and left shoulder joint. The C-reactive protein level on admission was 15.3 mg/dl. Rheumatoid factor, antinuclear antibodies, tuberculin skin test and blood culture were negative. Joint fluid was not aspirated. Radiographs of the joints did not reveal any abnormalities. Acid-fast bacilli were demonstrated in the smear of the cervical lymph node with a fluorochrome rhodamine-auramine stain. Mycobacterium tuberculosis DNA was identified by polymerase chain reaction. We found the presence of caseating granuloma on the biopsy specimens and M.tuberculosis was detected from culture. At that point, we diagnosed this patient as having tuberculous lymphadenitis. His general symptoms resolved rapidly after starting with a three-drug regimen consisting of isoniazid, rifampin and pyrazinamide. His polyarthritis also improved dramatically. Finally we considered that his polyarthritis was tuberculous rheumatism, also called Poncet's disease. Poncet's disease is characterized by sterile polyarthritis during active tuberculosis infection. It is considered a reactive arthritis, which is a different entity from tuberculous arthritis. Although this is a rare disease, we should be aware of it in hemodialysis patient clinics, because the incidence of tuberculosis infection has been reported to be increasing in patients with end-stage renal failure.     

A case of subacute necrotizing lymphadenitis with localized interstitial pneumonia

A 16-year-old male was admitted with a history of cervical lymph node swelling, high fever, cough and hemosputum. On admission, bilateral cervical lymph nodes swelling and fine crackles in the right lower lung field were noted. A chest X-ray film showed an infiltrative shadow in the right lower lung field and right hilar enlargement. Cervical lymph node biopsy specimens revealed wide areas of necrosis with nuclear debris. Transbronchial lung biopsy showed infiltration of lymphocytes in the interstitium and bronchoalveolar lavage fluid showed increased T-lymphocytes and a decreased T4/T8 ratio. The patient was diagnosed to have subacute necrotizing lymphadenitis with T-lymphocyte alveolitis. Additionally, antinuclear antibodies were positive, and anti HTLV-I antibody was false positive. These findings suggested an immunological abnormality in this case. His cervical lymph node swelling and infiltrative shadow on chest X-ray film improved with steroid therapy. Our case may be the first case of subacute necrotizing lymphadenitis with T-lymphocyte alveolitis.     

Mediastinal tuberculous lymphadenitis with anthracosis as a cause of vocal cord paralysis

Anthracotic pigmentation in the bronchial mucosa has been regarded as a bronchoscopic finding of pneumoconiosis or evidence of heavy atmospheric soot. Anthracotic pigmentation with bronchial narrowing or obliteration, surrounded by calcified or noncalcified lymph nodes is typical finding of anthracofibrosis. There is a potential relationship between bronchial anthracofibrosis and tuberculosis. Tuberculous lymphadenopathy of superior mediastinum presentation with hoarseness is very rare. The paper reports a case of tuberculous mediastinal lymphadenitis with anthracosis causing vocal cord paralysis. A 66-year-old woman was admitted to our clinic with the symptoms of dry cough, hoarseness, malaise, anorexia, night sweats and with the multiple mediastinal lymphadenopathy. Fiberoptic bronchoscopy revealed left vocal cord paralysis, bronchial mucosal inflammation and multiple anthracotic plaques. Bronchial lavage and mucosal biopsy were negative for malignancy and tuberculosis. The thoracotomy was performed and a mediastinal lymph node showing caseating granulomatous inflammation with anthracosis and parenchymal anthracosis were detected. The diagnosis of anthracosis and mediastinal tuberculous lymphadenitis was made and the patients put on antituberculous treatment. But she unfortunately died in the second month of the treatment because of the abdominal complication of gastric adenocarcinoma operation.     

Focal tuberculous lymphadenitis in an HIV-1 infected patient

A 41-year-old man was admitted to the hospital because of focal swelling of the left supraclavicular lymph nodes. Eighteen months prior to admission, he had been diagnosed with human immunodeficiency virus type 1 (HIV-1) infection and was started on highly active antiretroviral therapy (HAART). He responded well to HAART with an increase in CD4+ cell count and improvement in symptoms. However, one year after the initiation of HAART, he developed progressive enlargement of left supraclavicular lymph nodes. An excisional lymph node biopsy was performed for diagnosis, which revealed tuberculous lymphadenitis. Rifabutin, isoniazid, and ethambutol were initiated for treatment.     

Coexisting bronchial carcinoid tumor and pulmonary tuberculosis in the same lobe: a case report

The synchronous occurrence of pulmonary tuberculosis and bronchial carcinoid tumor is unusual. Although pulmonary tuberculosis can coexist with all histological types of lung cancer, few coexisting cases of bronchial carcinoid tumor and pulmonary tuberculosis have been reported. We present coexistent bronchial carcinoid tumor and pulmonary tuberculosis in the same lobe. A 39-year-old woman was admitted to our clinic with chest pain for two months. Chest radiograph showed consolidation in the right lower field. Computed tomography of the thorax demonstrated multiple mediastinal lymphadenopathies, infiltration and atelectasis in the right lower lobe. Fiberoptic bronchoscopy showed a mass lesion totally obstructing the proximal right lower lobe bronchus. The pathological diagnosis was typical carcinoid tumor. Right lower lobectomy with mediastinal lymph node dissection was performed. The pathological examination of resected material revealed coexistent tuberculosis and carcinoid tumor in the same lobe and mediastinal tuberculous lymphadenitis.     

A resected case of mediastinal tuberculous lymphadenitis with pericostal tuberculosis

A case of 22-year-old female with mediastinal tuberculous lymphadenitis and pericostal tuberculosis was reported. Her complaint was right chest pain and subcutaneous mass on the right chest wall. Chest contrast CT showed right paratracheal lymph node swelling with central low density area and surrounding rim enhancement, which has been reported as typical characteristics of mediastinal tuberculous lymphadenitis. Pigeon-egg sized subcutaneous mass with fluctuation was palpable on the right sternal border and the smear of its content showed acid-fast bacilli. In spite of two months therapy with antituberculous drugs, both masses were unchanged in size. The lesions resected surgically, were both encapsulated abscesses containing yellowish pus, and microscopic examination of these specimen disclosed the finding of tuberculosis. Mycobacterium tuberculosis was cultured from contents of both masses. After nine months of anti-tuberculous therapy, no sign of recurrence is observed until now. Both masses were discontinuous and the possibility of lymphangitic spread of organism was speculated as its etiology.     

A case of primary nasopharyngeal tuberculosis

BACKGROUND: Although the prevalence of nasopharyngeal tuberculosis has decreased after the wide use of anti-tuberculous agents, recently the number of reports with the disease has slightly increased in accordance with advances in the diagnostic tools. A case of nasopharyngeal tuberculosis without any tuberculous lesions in other organs (primary nasopharyngeal tuberculosis) was reported. CASE REPORT: A 74-year-old female complained of vertigo and cervical masses, and naso-pharygo-laryngoscopy disclosed a polypoid lesion on her nasopharynx. The biopsy from the mass revealed epithelioid cell granulomas with caseous necrosis and multinucleated giant cells consistent with tuberculosis. Since there were no tuberculous lesions in other organs except cervical lymph nodes in clinical examinations, we diagnosed the case as primary nasopharyngeal tuberculosis with tuberculous cervical lymphadenitis. The nasopharyngeal manifestation disappeared after four months chemotherapy with INH, RFP and EB. DISCUSSION: Most reported case of nasopharyngeal tuberculosis were in the young age group. A rare case of old woman complicated with cervical tuberculous lymphadenitis was reported.     

An adult case of cervico-mediastinal lymph nodes tuberculosis followed by the development of pulmonary lesions during the treatment with antituberculous drugs

A 27-year-old man was admitted to our hospital due to a painful mass in the right neck and fever. Cervical and superior mediastinal computed tomography showed an enlargement of right supraclavicular lymph node and multiple swollen mediastinal lymph nodes, including low-density areas and contrast medium-enhanced septa and margins. Smears of the pus obtained from right supraclavicular lymph node showed acidfast bacilli identified as Mycobacterium tuberculosis by PCR method. He was treated with antituberculous drugs with INH, RFP, EB, and PZA. PZA was given for initial two months. Six months later, productive cough developed and chest X-ray films showed infiltrative shadow in the right upper lung field. One month after the onset of cough, bronchoscopy revealed a polypoid lesion with a white coating in the right main bronchus. Microscopic examination of the specimen obtained by transbrochial biopsy revealed many epithelioid cell granulomas, consistent with tuberculosis. From these findings, pulmonary lesion was suggested to be due to invasion of the mediastinal lymph node into the bronchus. After one year of antituberculous chemotherapy, the swelling of the cervical-mediastinal lymph nodes was reduced and the abnormal chest X-ray shadows disappeared.     

Tuberculous pericardial effusion: features, tamponade, and computed tomography

The clinical features with particular reference to tamponade and mediastinal adenopathy were studied in tuberculous pericardial effusion. Tamponade is a frequent complication and the recognition of tuberculous etiology can be difficult. Involvement of the pericardium is mostly from mediastinal lymph nodes that have not been studied. This was a prospective cohort study. All patients had large effusions, and underwent pericardiocentesis and chest computed tomography. Patients with tuberculosis had specific therapy. Others with viral/idiopathic effusion served as controls for the computed tomography studies. There were 26 patients with tuberculosis: 18 had tamponade on echocardiography. All had symptoms. Fever (n = 23) and dyspnea (n = 20) were the most frequent presenting symptoms. Pericardial rub was heard in 14, and 3 had enlarged cervical or axillary nodes. Pulmonary tuberculosis was present in 6. Tuberculin skin test measured 17 +/- 3.3 mm. The biopsy specimen showed a granuloma in 22 of 24. All 26 had mediastinal lymph nodes > 10 mm with a mean size of 19.5 +/- 8.6 mm that disappeared (81%) or regressed (19%) on treatment (p < 0.001). Aortopulmonary nodes were most frequently enlarged (65.4%) and hilar the least. Three required pericardiectomy. At follow-up all were doing well. None with viral/idiopathic effusion had lymph node enlargement. Fever, dyspnea, and tamponade were frequent with tuberculosis. The prognosis was good with specific therapy. Mediastinal nodes were enlarged in all and only with tuberculosis and not with viral/idiopathic effusion. Nodes disappeared or regressed with treatment. In the appropriate clinical context, mediastinal lymph node enlargement on chest computed tomography along with a strongly positive skin test results could help in the diagnosis of a tuberculous etiology of pericardial effusion.