Tuberculous lymphadenitis with endobronchial rupture

A 32 yr old male^† presented to the department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India, in December 2016 with the complaints of hoarseness of voice for one month with no associated fever. The laryngoscopic examination confirmed left vocal cord paresis. Computed tomography of the chest demonstrated left paratracheal lymphadenopathy with central hypodensity (Figure A). Flexible bronchoscopy revealed a bulge in the proximal left main bronchus, causing partial occlusion likely due to the rupture of the underlying necrotic lymph node (Figure B). A trans-oesophageal ultrasound-guided fine-needle aspiration from the left paratracheal lymph node revealed necrotizing granulomatous inflammation with positive MTB-Rif assay (rifampicin resistance not detected) confirming a diagnosis of tuberculosis. He was initiated on standard four-drug antitubercular therapy and shifted to three drugs after two months of therapy. He had complete resolution at one year follow up. Compression or invasion of the bronchial tree due to enlarged lymph nodes in tuberculosis is reported more often in children as compared to adults, due to their soft bronchial tree. Other causes of bronchial perforation may include histoplasmosis and lymphoma. Tuberculosis presenting with vocal cord palsy is also an uncommon entity. This case highlights these two important yet not so common presentations of tuberculosis.

Figure: (A) Computed tomography thorax demonstrating left paratracheal necrotic lymphadenopathy (yellow arrow), (B) bronchoscopic view demonstrating left main bronchus opening having nodule (black arrow) due to endobronchial rupture of lymph node.

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