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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 4  |  Issue : 1  |  Page : 33-35

Multi drug resistant tuberculosis presenting as anterior mediastinal mass


Department of Pediatrics, B J Wadia Hospital for Children, Parel, Mumbai, Maharashtra, India

Date of Web Publication23-Dec-2015

Correspondence Address:
Parmarth Chandane
Department of Pediatrics, B J Wadia Hospital for Children, Parel, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-8775.159869

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  Abstract 

Enlargement of the mediastinal lymphatic glands is a common presentation of intrathoracic tuberculosis (TB) in children. However, usually, the mediastinal TB nodes enlarge to 2.8 ± 1.0 cm. In this report, we describe a case of anterior mediastinal lymphnode TB seen as huge mass (7 cm) on computed tomography (CT) thorax without respiratory or food pipe compromise despite anterior mediastinum being an enclosed space. CT guided biopsy of the mass cultured Mycobacterium TB complex which was resistant to isoniazide, rifampicin, streptomycin ofloxacin, moxifloxacin, and pyrazinamide. Hence, we report primary multi drug resistant TB presenting as anterior mediastinal mass as a rare case report.

Keywords: Lymph node, mediastinal mass, tuberculosis


How to cite this article:
Chandane P, Shah I. Multi drug resistant tuberculosis presenting as anterior mediastinal mass. J Assoc Chest Physicians 2016;4:33-5

How to cite this URL:
Chandane P, Shah I. Multi drug resistant tuberculosis presenting as anterior mediastinal mass. J Assoc Chest Physicians [serial online] 2016 [cited 2019 Nov 14];4:33-5. Available from: http://www.jacpjournal.org/text.asp?2016/4/1/33/159869


  Introduction Top


Patients with primary tuberculosis (TB) present commonly with mediastinal or hilar lymphadenopathy with or without parenchymal lesions.[1],[2] The organism Mycobacteriumtuberculosis (MTB) gains access to the lymphatics from the site of infection in the lung parenchyma often resulting in a greater volume of diseased tissue in regional lymph nodes than in the original site.[3]

To our knowledge, little has been written about drug resiatant tuberculous mass in mediastinum. Here, we report a rare case of large mediastinal multi drug resistant (MDR) mass (7 cm) presenting as right hilar lymhadenopathy on X-ray chest, conglomerate necrotic mass in anterior mediastinum on computed tomography (CT) chest and histopathological picture of TB.


  Case Report Top


A 12-year-old boy was admitted with complaints of fever since 1 month and cough since 10 days. General and systemic examination revealed no abnormalities. Basic hematology work up was normal with erythrocyte sedimentation rate of 84 mm at end of 1 h. Mantoux test was positive (12 mm) with 5 TU of purified protein derivative (PPD). X-ray chest showed right hilar convexity suggestive of mediastinal lymphadenopathy with clear lung fields and costophrenic angles [Figure 1]. HIV ELISA was negative. Early morning sputum for acid fast bacilli was negative for 2 consecutive days. CT chest showed conglomerate lobulated mass measuring 7 cm × 5.8 cm × 5 cm with foci of necrosis in the anterior mediastinum [Figure 2]. Initial differentials were either TB or lymphoma. The trachea and esophagus were normal. The noticing feature in CT was no compression of trachea despite such big mass. Lactate dehydrogenase and serum uric acid were 957 IU/L and 11.2 mg/dl, respectively. Alpha feto protein was 201 ng/ml. CT-guided biopsy showed granulomatous inflammation with central necrosis consistent with TB [Figure 3]. Culture of biopsy tissue was done using BACTEC 960 TB MGIT and grown MTB complex which was resistant to isoniazide, rifampicin streptomycin, ofloxacin, moxifloxacin, and pyrazinamide. Patient was started on 6 drugs treatment constituting of amikacin, ethambutol, ethionamide, cycloserine, clofazimine, and para-amino salicylic acid based on the sensitivity pattern.
Figure 1: X-ray chest showing mediastinal widening

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Figure 2: Contrast-enhanced computed tomography showing anterior mediastinal lymphnode mass measuring 7 cm

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Figure 3: Histopathology showing granuloma with necrosis consistent with tuberculous lymphadenitis

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After 3 months of starting treatment, patient developed neuropsychiatric manifestation like sudden bouts of excessive crying and hence cycloserine was stopped, and other five drugs were continued.

Patient was given total 20 months of treatment with amikacin for initial 6 months. Repeat X-ray [Figure 4] showed complete resolution of hilar lymphadenopathy.
Figure 4: X-ray showing complete resolution of hilar lymphadenopathy and no mediastinal widening

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  Discussion Top


Tuberculous mediastinal and hilar lymphadenitis is a frequent manifestation of primary pulmonary TB in childhood. As the tuberculous lesion undergoes necrosis, it forms a firm cheesy (caseous) material. This is different from the process of most other inflammatory diseases, in which necrosis is followed promptly by liquefaction and abscess formation. The persistence of caseum is attributed to either a paucity of proteolytic enzymes or the presence of inhibitors against them. Later, however, liquefaction of caseous material may occur.[3] When this inflammation occur in lymphnodes, multiple adjacent lymph node gets matted together forming localized mass.

Moon et al. in Korea analyzed CT findings of active and inactive disease in adults with mediastinal tuberculous lymphadenitis. With active disease, the nodes varied in size (I.5–6.7 cm: Mean, 2.8 ± 1.0 cm) while with inactive disease, the nodes varied in size (1.0–4.7 cm; mean, 2. 1 ± 1.0 cm).[4] This study was done in adult patients. None of the study conducted describe size of lymphnode in mediastinal TB in children. Similar case report published earlier had anterior mediastinal mass due to TB but it was culture negative and hence no drug sensitivity was done.[5] Our patient had mediastinal mass of 7 cm due to lymphnode TB which was MDR without respiratory compromise despite anterior mediastinum being enclosed space with multiple vital structures such as trachea, esophagus, and great vessels. Furthermore, the unique feature was primary MDR TB presenting as anterior mediastinal mass. Case of MDR mediastinal TB is reported in adults but none in children.[6] Hence we report this as a rare case report.


  Conclusion Top


Even though mediastinal TB is common in children, drug resistance is uncommonly seen. High index of suspicion, tissue culture, and drug sensitivity testing is of prime importance to pick drug-resistant cases.

 
  References Top

1.
Agrons GA, Markowitz RI, Kramer SS. Primary tuberculosis in children. Semin Roenigenol 1993;28:158-72.  Back to cited text no. 1
    
2.
Amorosa JK, Smith PR, Cohen JR, Ramsey C, Lyons HA. Tuberculous mediastinal lymphadenitis in the adult. Radiology 1978;126:365-8.  Back to cited text no. 2
    
3.
Pratt PC. Pathology of tuberculosis. Semin Roentgenol 1979;14:196-203.  Back to cited text no. 3
    
4.
Moon WK, Im JG, Yeon KM, Han MC. Mediastinal tuberculous lymphadenitis: CT findings of active and inactive disease. AJR Am J Roentgenol 1998;170:715-8.  Back to cited text no. 4
    
5.
Khilnani GC, Jain N, Hadda V, Arava SK. Anterior mediastinal mass: A rare presentation of tuberculosis. J Trop Med 2011;2011:635385.  Back to cited text no. 5
    
6.
Dhasmana DJ, Ross C, Bradley CJ, Connell DW, George PM, Singanayagam A, et al. Performance of Xpert MTB/RIF in the diagnosis of tuberculous mediastinal lymphadenopathy by endobronchial ultrasound. Ann Am Thorac Soc 2014;11:392-6.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
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