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.     

Case of disseminated tuberculosis complicated with tuberculous meningitis while investigating an abdominal lymphadenopathy

In February 2005, a 33-year-old man visited A hospital complaining of fever. The blood screening test revealed the liver dysfunction, then computed tomography showed swelling of abdominal lymph nodes. In April, headache and disorientation appeared. He was diagnosed as disseminated tuberculosis and tuberculous meningitis based on chest X-ray and computed tomography findings and examination of cerebrospinal fluid. After admission to our hospital, anti-tuberculous drugs were prescribed, but the cerebral infarction happened. The disturbance of consciousness and the left half of his body paralysis appeared. They did not improve and hydrocephalus was complicated in August, though he was treated by steroids. He needed all helps because of the left half of his body paralysis and an advanced sequelae was left. It was thought that the abdominal lymph adenopathy preceded as one of symptoms of the disseminated tuberculosis in this case. It is said to be rare that abdominal lymph node swelling is seen in the early stage of disseminated tuberculosis. But, we think that it is necessary to keep in mind that the possibility of disseminated tuberculosis as one of the diseases in differential diagnosis, when we examine enlargement of abdominal lymph nodes with symptoms suggesting the presence of infection such as fever.     

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 case of IgG4-related disease associated with diffuse large B cell lymphoma

In June 2008, a 74-year-old male was diagnosed with IgG4-related disease including histologically proven IgG4-related prostatitis, and then followed as an outpatient. In July 2011, cervical, chest, and abdominal computed tomography (CT) revealed right parotid gland swelling and lymph node enlargement of the supraclavicular, mediastinal, left hilar, porta hepatis, and para-aorta. A biopsy of the right parotid gland was performed, and we diagnosed diffuse large B-cell lymphoma (DLBCL). As malignancies are possible complications for patients with IgG4-related disease, we must be careful in the follow-up of IgG4-related disease patients.     

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 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.     

Tuberculous dacryoadenitis: a rare manifestation of tuberculosis

A 41-year-old Somalian female inhabitant of The Netherlands presented with malaise and cervical lymph node swelling. Enlarged mediastinal, hilar and abdominal lymph nodes were found on CT scan. Subsequently the left lacrimal gland became swollen, accompanied by periostitis of the lateral orbit margin. Mycobacterium tuberculosis was cultured from lymph node tissue and the diagnosis of tuberculous dacryoadenitis with periostitis was made on CT images and histology. All lesions responded well to tuberculostatic treatment. Although tuberculous dacryoadenitis is a very rare manifestation of tuberculosis, it is still important to recognise this presentation, especially since the incidence of tuberculosis continues to increase in Western countries.     

腹内淋巴结结核的影像学诊断

OBJECTIVE: To evaluate the value of X-ray imaging for diagnosing abdominal tuberculous lymphadenopathy. METHODS: 27 cases of tuberculous lymphadenopathy proved by clinical or pathohistological evidence were collected, all of which were examined with radiological imaging methods. RESULTS: The typical CT findings enlarged lymph nodes with peripheral or multilocular enhancement. Enlarged lymph nodes with multiple flecked or massive calcifications were important for diagnosis. Ultrasound examination showed enlarged lymph nodes with uniform echo (less than 2 cm) and with heterogeneous echo (larger than 2 cm). The aim of the barium meal examination of the gastrointestinal tract was to find tuberculous lymphadenopathy encroaching on intestine or merged with intestinal tuberculosis. Abdominal X-ray plain film was helpful to find the calcified tuberculous lymphadenopathy and intestinal obstruction. CONCLUSIONS: Various imaging methods have shown their diagnostic value, but CT was the most important tool for definite diagnosis of tuberculous lymphadenopathy. Ultrasound was more useful for follow-up cases.     

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.     

Two cases of tuberculous uveitis

Uveitis has many etiologies, but tuberculous uveitis is rare. We herein report 2 cases of uveitis due to tuberculosis infection. The first case was a 28-year-old man who was showed abnormal shadows in the chest radiographic examination performed in search of the etiology of uveitis. Computed tomography (CT) of the chest revealed hilar and mediastinal lymphadenopathy, small nodules, and consolidation, with a small cavity in the right upper lobe. An ulcerated nodule in the truncus intermedius and stenosis of the right middle lobe bronchus were found on bronchoscopy. The biopsy of the nodule in the truncus intermedius showed a small granuloma containing giant cells, consistent with mycobacterial infection. The culture of bronchial washings from the right upper lobe grew Mycobacterium tuberculosis. Diagnosis of pulmonary tuberculosis, tuberculous lymphadenitis, bronchial tuberculosis, and tuberculous uveitis was made. The patient was treated with antituberculosis drugs and his disease, including uveitis, improved. The second case was a 36-year-old man who presented with right hemiparesis, dysarthria, and visual loss of the left eye. He was diagnosed with neuro-Sweet disease causing optic neuritis and visual loss. His chest CT showed a nodule with centrilobular opacities in the left lower lobe that suggested mycobacterial infection. PCR of the bronchial washing from the left lower lobe was positive for M.tuberculosis and the diagnosis of pulmonary tuberculosis was established. Treatment with antituberculosis drugs and corticosteroids was initiated and his pulmonary lesion improved. However, bilateral tuberculous uveitis developed 15 days after initiation of the treatment. The uveitis gradually deteriorated thereafter despite continuation of antituberculosis therapy. Photocoagulation finally halted the disease progression. In both patients with uveitis presented here, chest radiographs and CT scans were important in determining the etiology of the uveitis. It is difficult to find the etiology of uveitis, and general examinations including the lungs are helpful to pinpoint tuberculosis as the etiology of uveitis. As tuberculous uveitis is sometimes asymptomatic and resistant to treatment, ophthalmological examination is recommended for patients with pulmonary tuberculosis.     

肠系膜淋巴结结核的诊断和外科治疗

目的评价肠系膜淋巴结结核的诊断，手术治疗指征和效果。方法回顾性分析１９７６年７月～１９９７年７月两个医院手术治疗的肠系膜淋巴结结核５９例。结果术前确诊１４例，手术治疗并发症少，无手术死亡，效果良好。结论因肠系膜淋巴结结核患者临床表现无特异性，应结合实验室（如聚合酶链反应）、腹腔镜、ＣＴ和Ｂ超检查等结果综合分析。因肠系膜淋巴结结核引起急、慢性肠梗阻不能缓解、消化道出血，肠穿孔或肠瘘，腹腔巨大结核性脓肿不能控制或脓肿穿破腹壁形成窦道等需外科治疗。因有腹部包块诊断不明或不能除外肿瘤时亦需行剖腹术。术后应继续抗结核治疗     

Lymphadenopathy in sclerosing cholangitis: pitfall in the diagnosis of malignant biliary obstruction.

We retrospectively reviewed abdominal computed tomographic (CT) studies from 20 patients with sclerosing cholangitis and found evidence of abdominal lymphadenopathy in 13 patients. Enlargement occurred primarily in areas draining the liver, such as the gastrohepatic ligament or celiac axis (N = 8), the porta hepatis (N = 7), and the pancreaticoduodenal region (N = 2). One patient had reactive adenopathy and retroperitoneal fibrosis. The presence of benign reactive lymphadenopathy in at least one intraabdominal location was confirmed by pathological examination of excised lymph nodes in seven patients. Malignancy was excluded by surgical exploration or clinical follow-up. We conclude that enlarged lymph nodes are a common finding by CT in patients with sclerosing cholangitis. Enlarged reactive lymph nodes in this condition should not be mistaken for evidence of periportal metastasis or cholangiocarcinoma.     

Tuberculosis versus non-Hodgldn''s lymphomas involving small bowel mesentery: Evaluation with contrast-enhanced computed tomography

AIM: To evaluate the specific computed tomography (CT) imaging criteria for differentiating tuberculosis involving the small bowel mesenteric lymph nodes from lymphomas.METHODS: We retrospectively reviewed the anatomic distribution,CT enhancement patterns of lymphoma in 18 patients with mesenteric tuberculosis and 22 with untreated non-Hodgkin's lymphomas (NHL) involving small bowel mesentery (SBM).Of the 18 patients with tuberculosis,9 had purely mesenteric tuberculous lymphadenopathy (TL),and 9 had mesenteric TL accompanied with tuberculous mesenteritis (TLM).RESULTS: CT showed that tuberculosis and NHL mainly affected lymph nodes in the body and root of SBM.Homogeneously enhanced lymph nodes in the body and root of SBM were found more often in the NHL (P＜0.05).Homogeneously mixed peripheral enhanced lymph nodes in the body of SBM were found more often in mesenteric TL and TLM (P＜0.05).Peripheral enhanced lymph nodes in the root of SBM were found more often in mesenteric TL and TLM (P＜0.01)."Sandwich sign" in the root of SBM was observed more often in NHL (P＜0.05).COMCLUSION: Anatomic lymph node distribution,sandwich sign and specific enhancement patterns of lymphadenopathy in SBM on CT images can be used in differentiating between tuberculosis and untreated NHL involving SBM.     

Tuberculosis versus non-Hodgkin＇s lymphomas involving small bowel mesentery： Evaluation with contrast-enhanced computed tomography

AIM： To evaluate the specific computed tomography （CT） imaging criteria for differentiating tuberculosis involving the small bowel mesenteric lymph nodes from lymphomas. METHODS： We retrospectively reviewed the anatomic distribution, CT enhancement patterns of lymphoma in 18 patients with mesenteric tuberculosis and 22 with untreated non-Hodgkin＇s lymphomas （NHL） involving small bowel mesentery （SBM）. Of the 18 patients with tuberculosis, 9 had purely mesenteric tuberculous lymphadenopathy （TL）, and 9 had mesenteric TL accompanied with tuberculous mesenteritis （TLM）. RESULTS： CT showed that tuberculosis and NHL mainly affected lymph nodes in the body and root of SBM. Homogeneously enhanced lymph nodes in the body and root of SBM were found more often in the NHL （P 〈 0.05）. Homogeneously mixed peripheral enhanced lymph nodes in the body of SBM were found more often in mesenteric TL and TLM （P 〈 0.05）. Peripheral enhanced lymph nodes in the root of SBM were found more often in mesenteric TL and TLM （P 〈 0.01）. ＂Sandwich sign＂ in the root of SBM was observed more often in NHL （P 〈 0.05）. CONCLUSION： Anatomic lymph node distribution, sandwich sign and specific enhancement patterns of lymphadenopathy in SBM on CT images can be used in differentiating between tuberculosis and untreated NHL involving SBM.     

应用纵隔镜检查术诊断纵隔淋巴结结核和结节病

目的寻找和探索一种区分良恶性纵隔淋巴结肿大,确诊纵隔淋巴结结核和结节病的有效方法。方法应用纵隔镜检查术对胸部ＣＴ或ＭＲＩ检查发现的纵隔淋巴结肿大、临床诊断不清疑为淋巴结结核或结节病者实施此检查,获取病理组织,做出明确诊断,以指导治疗。结果本组２５例患者接受纵隔镜检查,其中１６例被病理诊断为纵隔淋巴结结核,占６４％（其中增殖性结核１４例,占８８％;干酪性结核２例,占１２％）;８例诊为结节病,占３２％;１例难于确定为淋巴结结核或结节病,占４％。非典型的纵隔淋巴结结核与结节病在影像诊断上难于区别,而且在显微镜下也极易混淆。这两种疾病常与其他原因引起的纵隔淋巴结肿大（如恶性淋巴瘤、淋巴结转移性癌等）在影像检查中不易区分,极易误诊,造成误治。本组病例术前影像诊断及临床诊断大多考虑为恶性疾病,其中第一诊断为恶性疾病的占８４％（２１／２５）,有２例已在外院接受化疗。结论对于纵隔区域发现的肿大淋巴结,纵隔镜检查术是一种很有价值的确诊手段,治疗前应尽一切可能获取明确的病理诊断     

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.     

Abdominal Castleman disease with mixed histopathology in a patient with iron deficiency anemia, growth retardation and peliosis hepatis

In Castleman disease, also known as giant lymph node hyperplasia, lesions are usually located in the chest. Peliosis hepatis is the presence of multiple blood-filled cysts in the liver. The combination of these two disorders in one patient is rare, with only three cases reported to date. We report the case of a 21-year-old man who presented with growth retardation and iron deficiency anemia. Work-up revealed hepatomegaly and multiple conglomerated giant lymph nodes near the splenic hilum. Once the mass was surgically removed, the patient's anemia rapidly resolved and he showed catch-up growth. The lymphoid tissue exhibited mixed histologic type, so the patient was diagnosed with both hyaline vascular type and plasma cell type Castleman disease. A liver biopsy obtained at surgery showed sinusoidal dilatation and blood-filled cysts, indicating peliosis hepatis. This is the fourth documented case of peliosis hepatis associated with Castleman disease. In addition to describing the case features, we discuss the possible pathogenesis of peliosis hepatis in the setting of Castleman disease.     

CT平扫对结核性腹膜炎的诊断价值

目的 探讨结核性腹膜炎的CT平扫表现特征。方法 回顾性分析46例有CT扫描资料的结核性腹膜炎患者,其中经手术病理证实6例,腹腔穿刺证实2例,腹腔镜检证实4例,试验性治疗诊断34例。观察内容包括结核性腹膜炎累及壁腹膜、大网膜、肠系膜及腹膜后间隙的CT表现特征。结果 （1）壁腹膜增厚33例,其中均匀、光滑增厚27例,局部不规则增厚6例;（2）腹腔积液31例,其中20例为少量积液;（3）大网膜增厚26例,表现为污迹样增厚22例,饼状增厚2例;（4）肠系膜受累32例,其中9例合并小结节影：（5）淋巴结增大16例;（6）肠壁增厚1例,肠间距增宽2例。结论 结核性腹膜炎CT平扫的主要表现有少量腹腔积液、均匀性腹膜增厚、大网膜污迹样增厚,以及肠系膜、肠管受累与腹腔淋巴结增大,CT平扫能为结核性腹膜炎的诊断提供重要信息。     

Reversible portal hypertension due to tuberculosis.

Presentation of abdominal tuberculosis with portal hypertension is rare. We report a 25-year-old man with portal hypertension due to compression of the portal vein by tuberculous lymph nodes at the hepatic hilum. After antitubercular therapy, features of portal hypertension disappeared as the nodes regressed.     

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.