No signs of malignant cells were found in histology or bronchial lavage.
The patient was started on quadruple drug anti-TB therapy with isoniazid, rifampicin, pyrazinamid, and ethambutol for 2 months and subsequently with isoniazid and rifampicin, with reduction of mediastinal mass and complete healing of the tracheal lesion (Fig. 4).
Tuberculous lymphadenitis is the most frequent form of extrapulmonary TB. It was previously considered a disease of the childhood, however, the peak age of its onset in developed countries has shifted from childhood to ages of 20 to 40 years. Contemporary series report a median age of approximately 40 years in developed countries.2,8,9
An increase in the total incidence of TB and in proportion of miliary, disseminated, and extrapulmonary TB cases including lymphadenitis has been associated with the epidemic of human immunodeficiency virus infection.10
Taking into account of our patient’s age, he had an atypical radiologic presentation; finding of a middle mediastinal mass reflects features of primary TB, an unusual finding in older patients. Apical infiltrates, cavities, and air-fluid levels are the most frequent features in adult patients, reflecting postprimary TB.11,12
The differential diagnosis of a mass of the middle mediastinum includes goiter, thyroid or tracheal tumors, aortopulmonary paraganglioma, bronchogenic cysts, and lymphomas. It may also represent lymphadenopathy as a result of fungal infection, malignancy, and idiopathic etiologies as sarcoidosis.13 Thymic masses and pericardial cysts have also been reported although it generally occurs in the anterior mediastinum.14
Given the age of our patient, the clinical presentation and the endoscopic features, the most probable diagnosis was primary or metastatic malignancy with invasion of the anterior wall of the trachea. As the patient had severe expiratory stridor, laser ablation was performed with clinical improvement. The presence of non-necrotizing granulomas on histology and a positive nucleic acid amplification test and culture for M. tuberculosis in the histology sample and bronchial lavage made a definite diagnosis of mediastinal TB with tracheal involvement.
Our patient underwent EBUS-TBNA of the mediastinal mass, and cytologic examination had shown non-necrotizing granulomas, supporting the diagnosis of mediastinal TB. Nevertheless conventional TBNA is still a helpful tool in the diagnosis of tuberculous lymphadenopathy. In endemic areas it has been reported to have a diagnostic yield of 85% and is much more cost effective.15
The trachea can be involved by TB because of spread along the peribronchial lymphatic channels or direct tracheal spread by infected sputum. It can also occur by local extension from adjacent mediastinal tuberculous lymphadenitis as in our case.16,17
Patients with central airway lesions from TB can be classified into 2 groups: (1) an active disease group, in which hyperplastic changes and inflammatory edema lead to obstruction; and (2) fibrotic disease group in which stenosis occurs by fibrosis and tuberculomas are usually absent in the bronchial wall. CT in active airway disease shows irregular luminal narrowing with wall thickening, contrast enhancement, and enlarged adjacent mediastinal lymph nodes. In contrast, in fibrotic disease, smooth narrowing of the tracheal lumen with minimal wall thickening is typically seen.18
In the active form of tracheal TB anti-TB therapy is the treatment of choice but, like our patient, some cases with central airway obstruction may need therapeutic bronchoscopy to restore the patency. Stenosis is a fibrotic process and is resistant to medical treatment, and bronchoscopic or surgical intervention is usually needed to restore the luminal patency, depending on its extent and severity. Helical CT is useful in the evaluation before surgical resection, bronchoscopic dilation, or insertion of a stent.19
In our patient regression of the mediastinal mass and healing of the endotracheal lesion were observed after 9 months of anti-TB therapy. As cases of TB and concurrent malignancy have been reported in literature, close follow-up of clinical, radiologic, and endobronchial response to anti-TB therapy should be performed.
1. Amorosa JK, Smith PR, Cohen C, et al. Tuberculous mediastinal lymphadenitis in adults. Radiology. 1978;126:365–668
2. Geldmacher H, Taube C, Kroeger C, et al. Assessment of lymph node tuberculosis in northern Germany: a clinical review. Chest. 2002;121:1177–1782
3. Polesky A, Grove W, Bhatia G. Peripheral tuberculous lymphadenitis: epidemiology, diagnosis, treatment, and outcome. Medicine (Baltimore). 2005;84:350–362
4. Raffy O, Sleiman C, Roue C. Fibreoptic bronchoscopy for diagnosis of isolated tuberculous mediastinal lymphadenopathy. Thorax. 1996;51:967–968
5. Baran R, Tor M, Tahaoğlu K, et al. Intrathoracic tuberculous lymphadenopathy: clinical and bronchoscopic features in 17 adults without parenchymal lesions. Thorax. 1996;51:87–89
6. Hassan T, McLaughlin AM, O’Connell F, et al. EBUS-TBNA performs well in the diagnosis of isolated thoracic tuberculous lymphadenopathy. Am J Respir Crit Care Med. 2011;183:136–137
7. Navani N, Molyneaux PL, Breen RA, et al. Utility of endobronchial ultrasound-guided transbronchial needle aspiration in patients with tuberculous intrathoracic lymphadenopathy: a multicentre study. Thorax. 2011;66:889–893
8. Wark P, Goldberg H, Ferson M, et al. Mycobacterial lymphadenitis in eastern Sydney. Aust N Z J Med. 1998;28:453–458
9. Mert A, Tabak F, Ozaras R, et al. Tuberculous lymphadenopathy in adults: a review of 35 cases. Acta Chir Belg. 2002;102:118–121
10. Hill AR, Premkumar S, Brustein S, et al. Disseminated tuberculosis in the acquired immunodeficiency syndrome era. Am Rev Respir Dis. 1991;144:1164–1170
11. Barnes PF, Verdegem TD, Vachon LA, et al. Chest roentgenogram in pulmonary tuberculosis. New data on an old test. Chest. 1988;94:316–320
12. Farman DP, Speir WA Jr. Initial roentgenographic manifestations of bacteriologically proven Mycobacterium tuberculosis.
Typical or atypical? Chest. 1986;89:75–77
13. Strollo DC, Rosado-de-Christenson ML, Jett JR. Primary mediastinal tumors: part II. Tumors of the middle and posterior mediastinum. Chest. 1997;112:1344–1357
14. Minniti S, Valentini M, Pinali L, et al. Thymic masses of the middle mediastinum: report of 2 cases and review of the literature. J Thorac Imaging. 2004;19:192–195
15. Bilaçeroğlu S, Günel O, Eriş N, et al. Transbronchial needle aspiration in diagnosing intrathoracic tuberculous lymphadenitis. Chest. 2004;126:259–267
16. Kyung M, Jung GI, Kyung MY, et al. Tuberculosis of the central airways: CT findings of active and fibrotic diease. AJR Am J Roentgenol. 1997;169:649–653
17. Yasuo I, Teruomi M, Noriaki K, et al. Interventional bronchoscopy in the management of airway stenosis due to tracheobronchial tuberculosis. Chest. 2004;126:1344–1352
18. Smati B, Boudaya MS, Ayadi A, et al. Tuberculosis of the trachea. Ann Thorac Surg. 2006;82:1900–1901
19. Schmidt B, Olze H, Borges A, et al. Endotracheal balloon dilatation and stent implantation in benign stenoses. Ann Thorac Surg. 2001;71:1630–1634
Keywords:© 2013 by Lippincott Williams & Wilkins.
mediastinal tuberculosis; endotracheal mass; stridor