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.     

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 autopsy case of adenocarcinoma of the lung with signet ring cells, manifesting with aphasia and hemiparesis due to nonbacterial thrombotic endocarditis

A 42-year-old male was admitted to Tokyo University Hospital because of confusion, aphasia and right hemiparesis. Cranial computed tomography and cerebral angiography demonstrated cerebral infarction due to occlusion of the left middle cerebral artery, while chest roentgenography disclosed a nodular shadow in the right upper lobe and swelling of right hilar and paratracheal lymph nodes. These findings suggested carcinoma of pulmonary origin and tumor-associated cerebral thrombosis, but a possibility of gastric cancer was raised by the finding of cervical lymph node biopsy which revealed signet ring cells in metastatic adenocarcinoma. He developed disseminated intravascular coagulation syndrome and died on the 83rd hospital day. Autopsy revealed adenocarcinoma of the lung with signet ring cells and non-bacterial thrombotic endocarditis which appeared to be responsible for the cerebral infarction. The relationship between adenocarcinoma of the lung with signet ring cells and non-bacterial thrombotic endocarditis was discussed.     

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.     

A case of miliary tuberculosis complicated with a tuberculous aneurysm of the aorta]

A 68-year-old man was admitted because of fever and weight loss. A chest high-resolution computed tomography (HRCT) scan revealed diffuse micronodular shadows, and an abdominal CT scan showed an aneurysm spreading from the root of the renal artery to the iliac bifurcation. His fever subsided without treatment and his general condition was good. However, histological studies of a transbronchial lung biopsy specimen and bone marrow aspirate clot revealed non-necrotizing epitheloid granulomas, and mycobacterium tuberculosis was cultured from sputum and bronchoalveolar lavage fluids. Military tuberculosis was diagnosed. One month after the initiation of chemotherapy, the abdominal aneurysm enlarged quickly despite the improvement of the thoracic findings, and graft replacement was performed. Histological findings in specimens of the resected aneurysm suggested that tuberculous inflammation of the surrounding lymph nodes had invaded the aortic wall, leading to the aneurysm. It should be borne in mind that symptoms in elderly patients with miliary tuberculosis may be mild, even when serious extrapulmonary lesions are present.     

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.     

Occurrence of angioimmunoblastic T-cell lymphoma six months after onset of Lyme disease

A 68-year-old man, who had suffered a tick bite one week previously, consulted his home doctor because of fever and an erythematous rash around the bite scar. He underwent a skin biopsy, and Borrelia garinii was detected, from which Lyme disease was diagnosed. He received amoxicillin for two weeks and his symptoms disappeared. After 6 months he noticed swelling of his cervical, axillary and inguinal lymph nodes. A biopsy sample was taken from a left cervical lymph node, and this revealed angioimmunoblastic T-cell lymphoma. The patient achieved a complete remission after chemotherapy. The relationship between Lyme disease and lymphoma is discussed.     

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.     

A Case Report: Systemic Lymph Node Tuberculosis Mimicking Lymphoma on 18F-FDG PET/CT

¹⁸F-fluorodeoxyglucose positron emission tomography—an established modality for evaluating malignancies—exhibits increased uptake under inflammatory conditions.A 21-year-old man came to our hospital with persistent pain in his right lower quadrant of abdomen for more than 1 month, but had no diarrhea, fever, chills, weight loss, or other constitutional symptoms. Colonoscopy analysis showed no organic diseases in his colorectum. Ultrasound results revealed multiple enlarged lymph nodes in the bilateral neck, axilla, and groin. Positron emission tomography analysis was performed and showed intense ¹⁸F-fluorodeoxyglucose accumulation in the bilateral neck, supraclavicular, pulmonary hilar, mediastinum, gastric paracardial, and mesenterium lymph node. These findings were considered typical for lymphoma. To confirm the diagnosis, we obtained a diagnostic biopsy in the left supraclavicular lymph node. The diagnosis of tuberculosis was confirmed in the final pathology.This uncommon case underscores the necessity of considering lymph node tuberculosis as a possible differential diagnosis in lymphoma.     

Abdominal lymph node tuberculosis: diagnostic value of echography and x-ray computed tomography

The aspects of abdominal ultrasonography and computed tomography (CT) were studied in 4 patients (3 African and 1 Haitian) with abdominal tuberculosis. All were markedly debilitated and three patients had protracted fever. Tuberculosis was documented in all cases by demonstrating Mycobacterium tuberculosis in cultures of lymph nodes taken during laparotomy and/or cultures of products of gastric aspiration. Ultrasonography showed enlarged lymph nodes in the pancreatic and peripancreatic areas and also in the mesenteric, perivascular and hepatic pedicle areas. CT showed hypertrophied lymph nodes with low tissue density ranging from 20 to 35 Hounsfield units. Although non pathognomonic, these aspects were suggestive of tuberculosis. Intravenous contrast medium administration failed to increase the density in the center of lymph nodes but disclosed the existence of a thick hyperdense rim surrounding the hypodense center of the caseous lymph nodes. Repeated ultrasound and CT examination allowed to control the efficacy of antituberculous chemotherapy.     

A case of esophageal tuberculosis which developed during the treatment for tuberculous lymphadenitis

A 23-year-old man was admitted to the other hospital complaining of fever and lymph node swelling in the left neck. Computed tomography showed swollen mediastinal lymph nodes without intrapulmonary lesions. Mycobacterium tuberculosis were identified by sputum culture and cervical lymph node biopsy and the case was diagnosed as tuberculous lymphadenitis. Three weeks after starting treatment with four anti-tuberculous drugs, he complained chest pain while eating and chest X-ray showed a new infiltrative shadow in the right cardiophrenic angle, then he was admitted to our hospital. Esophagoscopy revealed a deep ulceration with fistulas at 30 cm from the incisor and he was diagnosed as esophageal tuberculosis by histological examination of the biopsy specimen showing remarkable leukocytes infiltration and epithelioid cell granulomas with a few multinucleated giant cells. After antituberculous chemotherapy for six months, the mediastinal and cervical lymphadenopathy were reduced in size and the esophageal ulceration almost disappeared. Although esophageal tuberculosis is rare, the disease might develop during or after mediastinal or periesophageal tuberculous lymphadenitis.     

A suspected case of perforation of a lymph node into the bronchus during the treatment of adult hilar lymph node tuberculosis]

A 27-year old patient was diagnosed as having post-primary hilar lymph node tuberculosis. First being admitted to the hospital with a high fever, a chest x-ray examination revealed a swelling of the left hilar lymph nodes and a sputum smear tested positive for acid-fast bacilli. Neither regular clinical examination or investigation had reported abnormality. The acid-fast bacilli was successfully treated through treatment using INH RFP SM. However, after two months, swelling was observed in the right para-tracheal lymph nodes, Further, a bronchoscopic examination revealed polyp-like tumors at the left upper and lower bifurcation. The swelling of the para-tracheal lymph nodes was considerably reduced and the tumors non-existent after five months. These lymph node reactions could have likely been a part of the so called early exacerbation. The polyp-like tumors were not found during the bronchoscopy performed during admission to the hospital. It is therefore suspected that the cause was perforation of the hilar lymph node into the bronchus.     

A case report of small cell lung cancer with extrahepatic biliary obstruction and intramedullary spinal cord metastasis

A 62-year-old man was admitted to our hospital because of high serum amylase and neck swelling. His chest radiography revealed a mass lesion in the right upper lung. Open lung biopsy specimen established the pathological diagnosis as intermediate type small cell lung cancer. In his clinical course, obstructive jaundice recurred several times with response to combination chemotherapy. The findings of abdominal echogram, computed tomography and endoscopic retrograde cholangiopancreatography suggested that the jaundice was caused by extrahepatic biliary obstruction with parapancreatic lymph node metastasis. He died of spinal bleeding which spread from the medulla oblongata to the thoracic spinal cord. Bleeding was caused by intramedullary spinal cord metastasis. Both extrahepatic biliary obstruction and intramedullary spinal cord metastasis are rare and their symptoms were more prominent than those of the pulmonary lesion.     

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.     

Case of tuberculous psoas abscess successfully treated with surgery during antituberculosis therapy for miliary tuberculosis

A case of tuberculous psoas abscess complicated during antituberculosis therapy for miliary tuberculosis and successfully treated with surgery was reported. A 20-year-old man visited our hospital because of fever lasting for 3 months. Chest radiography showed miliary nodules in both lungs and transbronchial lung biopsy revealed granuloma. Magnetic resonance imaging of the head showed small lesions in the brain. Computed tomography of the abdomen showed an enlarged paraaortic lymph node and a nodule in the spleen. Needle biopsy of the lymph node revealed necrotic tissue. Mycobacterium tuberculosis was not isolated; however, miliary tuberculosis was highly suspected based on clinical and radiographic findings. Once antituberculosis therapy was initiated with isoniazid, rifampicin, streptomycin, and pyrazinamide, the fever subsided. In spite of improvement of general radiographic findings, a new abscess was found in the right psoas major muscle after 8 months of therapy by computed tomography. A sample of the abscess showed a positive smear, negative culture, and positive PCR test for M. tuberculosis. Although antituberculosis therapy continued for another 6 months, the abscess enlarged to 7 cm and new retroperitoneal lymph nodes also appeared. Surgical drainage and curettage of the abscess was performed. Intra- and post-operative specimens were negative for bacteria, fungi, and M. tuberculosis. The patient was treated with isoniazid, rifampicin, and ethambutol for one year postoperatively. The disease disappeared without any evidence of relapse for 2.5 years after surgery.     

Pleomorphic Carcinoma with Exophthalmos and a Subsequent Diagnosis of Paraneoplastic Syndrome

The patient was a 75-year-old man who developed polyopia and exophthalmos. Chest computed tomography (CT) revealed a mass in the left upper lobe. A CT-guided biopsy suggested lung adenocarcinoma. He was treated by neoadjuvant chemotherapy followed by left upper lobectomy. He was diagnosed with stage IIB pleomorphic carcinoma postoperatively. Preoperative head magnetic resonance imaging revealed exophthalmos and bilateral swelling of the extraocular muscles. The thyroid function of the patient was within the normal range, and he tested negative for autoantibodies. As his symptoms and swelling of the extraocular muscles improved postoperatively, he was diagnosed with paraneoplastic syndrome.     

Broncholithiasis in an immune compromised boy with disseminated Mycobacterium kansasii

A case of broncholithiasis in a child is reported. To our knowledge, it has not been reported in children. Broncholithiasis is a condition in which a peribronchial calcified lymph node erodes into or distorts an adjacent bronchus. Symptoms of broncholithiasis include cough, recurrent episodes of fever, haemoptysis, and purulent sputum. The most common cause of broncholithiasis is Mycobacterium tuberculosis (M. tuberculosis). Here we describe a 14-year-old boy known to have disseminated Mycobacterium kansasii (M. kansasii) infection associated with hypoplastic myelodysplastic syndrome (MDS). He was presented with cough and fever. Computed tomography (CT) and bronchoscopy revealed a large calcified mass eroding in the right main bronchus. While surgical therapy was considered, haemoptysis developed and his condition deteriorated. Bone marrow puncture revealed acute myeloid leukemic transformation of the MDS. Curation was no longer possible. Post mortem examination revealed a large bronchiolith, evolving from a calcified lymph node.     

An Autopsy Case of Ki-1 Lymphoma Associated with Hepatic Failure

A 62-year-old man was admitted to our hospital because of severe jaundice and fever. Physical examination demonstrated hepatosplenomegaly. The laboratory data revealed elevated serum bilirubin, alkaline phosphatase, lactate dehydrogenase, aspartate aminotransferase and alanine aminotransferase, and the reduced hepaplastin test (Normotest). Computed tomography showed hepatosplenomegaly and swelling of the paraaortic lymph nodes. Although he was treated with antibiotics and steroids, he died of hepatic failure 22 days after admission. At autopsy, his liver weighed 1910 grams, and a histological examination of the liver revealed marked infiltration of CD30 (Ki-1) positive lymphoma cells. He was diagnosed as having non-Hodgkin lymphoma, large cell anaplastic type, Ki-1 lymphoma. We herein report our findings of this very rare case of Ki-1 lymphoma associated with hepatic failure.     

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.     

Pancreatic tuberculosis with obstructive jaundice—a case report

Isolated pancreatic tuberculosis (TB) is very rare and its treatment somewhat controversial. We report a case of pancreatic TB diagnosed as pancreatic carcinoma. An 82-yr-old man presented with right upper abdominal pain and obstructive jaundice, without fever or weight loss. Ultrasonography, computed tomography, and endoscopic retrograde cholangiopancreatography showed a mass lesion in the pancreatic head, which caused stricturing of the distal common bile duct and pancreatic duct in the head of the gland. As malignancy was suspected, he underwent a Whipple procedure (pancreaticoduodenectomy). Histological examination of the resection specimen disclosed typical features of tuberculosis in the pancreatic head, lymph nodes, and at the ampulla of Vater. The rest of the abdominal cavity was unremarkable. After receiving antimicrobial therapy for tuberculosis for 6 months, he remains well, without jaundice or a recurrent mass visible by ultrasound.