Case Report

Journal of International Medical Research

49(1) 1–7
Mediastinal tuberculous ! The Author(s) 2021
Article reuse guidelines:
lymphadenitis presenting with sagepub.com/journals-permissions
DOI: 10.1177/0300060520987102
insidious back pain in a male journals.sagepub.com/home/imr

adult: a case report and

review of the literature

Xuli Ren#, Kai Li#, Longyun Li and

Guoqing Zhao

Abstract
Mediastinal tuberculous lymphadenitis (MTL) is mostly observed in primary tuberculosis in
infants, children and adolescents, and is not found commonly in adults. Mediastinal tuberculous
lymphadenitis cases may present with an insidious progression of tuberculous symptoms, includ-
ing gradual deterioration in the lungs and a variety of clinical characteristics; however, initial
symptoms are rarely only chronic back pain. We present the case of a 33-year-old man with
mediastinal tuberculous lymphadenitis misdiagnosed as myofascitis. Since such individuals do not
develop respiratory symptoms in the initial stages, they often go undiagnosed and can potentially
spread tuberculosis.

Keywords
Lymphadenitis, mediastinum, pain, tuberculosis, imaging, hilum, extrapulmonary tuberculosis
Date received: 5 August 2020; accepted: 10 December 2020

Introduction
Department of Anaesthesiology, China-Japan Union
Occasionally, tuberculosis has an insidious Hospital of Jilin University, Changchun, Jilin, China
progression, including a nonspecific clinical
#
presentation and slow radiographic and These authors contributed equally to this work.
symptomatic development. Tuberculosis Corresponding author:
Guoqing Zhao, Department of Anaesthesiology, China-
can cause several atypical symptoms and Japan Union Hospital of Jilin University, 126 Xiantai Street,
injuries, with devastatingly high mortality, Erdao, Changchun, Jilin 130033, P.R. China.
if left untreated.1 Mediastinal tuberculous Email: [email protected]

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2 Journal of International Medical Research

lymphadenitis (MTL), a phase of primary lymph nodes (Figure 3). These changes sug-
tuberculosis, occurs almost exclusively in gested a likely diagnosis of tuberculosis;
infants, children and adolescents.2,3 MTL therefore, he was admitted to the tubercu-
without lung involvement is rare in adults, losis hospital for further diagnosis and
especially if it presents exclusively with back treatment. The tuberculin skin test result
pain and if the systemic symptoms of tuber- was strongly positive (50 mm with blister
culosis are absent. Herein, we report our formation). Laboratory examinations
experience of a delayed diagnosis of MTL revealed a high erythrocyte sedimentation
during the treatment of a patient with a rate (ESR) of 35 mL/hour (reference range
chronic history of intermittent dull pain in < 15 mL/hour) and a high ratio of mononu-
the upper back. clear leucocytes. A diagnosis of pulmonary
tuberculosis, likely secondary to mediasti-
nal tuberculosis, was made. Fine-needle
Case presentation
aspiration was suggested, but the patient
A 33-year-old man presented with a history refused. A subsequent sputum test was pos-
of progressive fatigue and worsening upper itive for Tuberculosis bacilli, which were
spinal pain (Figure 1a). Previous chest radi- sensitive to anti-tuberculous drugs (rifam-
ography showed enlargement of the right pin, isoniazid, ethambutol, pyrazinamide
hilar lymph nodes, without parenchymal and levofloxacin). Treatment with daily
lesions in either lung (Figure 1b). Thoracic adjusted doses (weight: 70 kg) of rifampin
computed tomography (CT) revealed clear (0.6 g), isoniazid (0.4 g), ethambutol (1 g)
enlargement of the right hilar lymph nodes and pyrazinamide (1.5 g), were initiated.
in the paratracheal and prevascular regions All investigations, including complete
(Figure 2), which had not changed com- blood counts and liver and renal function
pared with imaging results from 3 years tests, were within acceptable limits during
prior. There was no history of trauma and treatment, and he was followed-up routine-
no significant medical history. Spinal mag- ly throughout the treatment period. His
netic resonance imaging and HLA-B27 vaccination history did not reveal a scar
haplotype testing were also performed to that indicated Bacillus Calmette–Guerin
exclude spinal diseases. Considering the (BCG) vaccination. His medical history, as
patient’s previous examination results, and well as that of his family, was unremarkable
unchanged symptoms and imaging results regarding exposure to tuberculosis.
for more than 3 years, the presumed Despite treatment, his back pain wors-
origin for his back pain was ened significantly and was accompanied
musculoskeletal. by painful dysphagia from the first month
On the latest visit, the patient reported of the anti-tuberculous treatment. Thoracic
worsening of his pain, with a choking sen- CT revealed newly increased inflammation
sation in his chest, fatigue and night sweats. owing to MTL (Figure 4). The continuation
Physical examination revealed a body tem- phase of his anti-tubercular treatment was
perature of 37.2 C. The patient had no maintained, and he was followed-up close-
cough, expectoration, joint pain, haemopt- ly. Three months later, he visited the hospi-
ysis or dyspnoea. Repeat thoracic CT tal and reported symptom improvement.
revealed clear changes in the pulmonary Significant shrinkage and improvement
interstitial tissue along with consolidation with calcification were observed in the
in the right upper pulmonary lobe, pleural hilar and mediastinal nodes and less lung
parenchymal thickening and bronchial ero- and bronchial compression were seen after
sion and compression near the enlarged 12 months of anti-tuberculous treatment
Ren et al. 3

Figure 1. (a) Interscapular and spinous process region tenderness. (b) Chest radiograph clearly showing
enlarged right hilar and paratracheal lymph nodes (red arrow).

Figure 2. Thoracic computed tomography, which was performed at a local hospital, showing enlarged
lymph nodes in the right hilar, paratracheal and prevascular regions (arrows) with no obvious compression
or erosion of the trachea. There were no prominent changes in the imaging signs of the pulmonary inter-
stitial tissue at this point in the patient’s progression.

(Figure 5). Because this case involved Discussion

pleura, hilar and mediastinal tuberculosis,
the patient was advised to maintain the con- Mediastinal lymph node involvement usual-
tinuation phase treatment for 18 months, ly occurs as a complication of primary
which consisted of three drugs (isoniazid, tuberculosis, almost exclusively in infants,
rifampicin and ethambutol) with frequent children and adolescents.4 Isolated MTL
follow-ups. These lesions heal with fibrosis without a parenchymal lung lesion in
and calcification. His back pain gradually adults is unusual, with an incidence of
resolved and did not recur, and he is cur- 0.25% to 5.8%. MTL occurs most com-
rently in follow-up and is at risk of relapse. monly in Asian and Black people from
4 Journal of International Medical Research

Figure 3. Enlarged lymph nodes causing extrinsic bronchial compression and erosion through the bronchial
wall into the bronchial airway (arrow 1). There are obvious changes in the images of the pulmonary
interstitial tissue (arrow 2).

Figure 4. Thoracic computed tomography showing newly increased inflammation owing to mediastinal
lymphadenitis after 2 months of antituberculosis treatment (arrows). The patient’s back pain worsened
significantly, accompanied by painful dysphagia.

developing countries, and presents a diag- and vena cava through inflammation and
nostic problem.5 Mycobacterium tuberculo- necrosis, occasionally with fatal consequen-
sis enters the lymphatic system from lung ces.3,6–8 Most of these adjacent structures
lesions and causes hilar and mediastinal are located in or near the posterior medias-
lymphadenopathy owing to inflammatory tinum, and their damage may contribute to
granulomatous tissue. Tuberculous medias- back pain. This finding also indicates that
tinal lymph nodes can erode adjacent struc- MTL is a cause of fibrosing mediastinitis or
tures, including pleural tissues, thoracic constrictive pericarditis, which may cause
vertebrae, paravertebral muscles, airways, respiratory insufficiency owing to compres-
the oesophagus, pericardium, heart, aorta sion of intrathoracic vascular structures,
Ren et al. 5

Figure 5. Obvious shrinkage is visible in the images regarding the lung and bronchial compression, along
with a significant improvement in hilar lymphadenitis after 12 months of antituberculosis treatment (arrows).
The patient experienced considerable relief from his back pain.

including the pulmonary arteries, veins and treatment.13,14 Spinal tuberculosis, an

the superior vena cava.9 Nerves affected by extrapulmonary form of tuberculosis, is
granulation tissue and caseation necrosis also known as Pott’s disease, tuberculous
are responsible for tubercular neuritis.10 A spondylitis or tuberculous vertebral osteo-
complication in our case was bronchial myelitis.15,16 A similar case of a 35-year-old
compression or lymph node erosion woman involved misdiagnosis of ankylos-
through the bronchial wall owing to the ing spondylitis.17 Kim et al. reported that
pressure of nodal enlargement on the a case of post-traumatic back pain was
main bronchus. This phenomenon is some- eventually diagnosed as early-phase tuber-
times called epituberculosis in primary culous spondylitis.18 Fortunately, our
tuberculosis.11 patient did not develop tuberculous
Tuberculosis can often exhibit rheuma- spondylitis.
toid symptoms, including spinal and joint An unusual finding in this case was that
pain. As the disease progresses, inflamma- the patient developed painful dysphagia,
tion and necrosis can dissect along the and the back pain worsened significantly
tissue planes, increasing the degree and after the first month of antituberculosis
area of pain. Localised back pain may be therapy. Although not verified through gas-
one of the first symptoms of MTL tubercu- troscopy, this was easily visualised by tho-
losis. In our case, MTL presented as isolat- racic CT imaging after antituberculosis
ed pain prior to the development of treatment. Thoracic CT revealed that new
pulmonary lesions. In the early stage, exclu- enlargement of the mediastinal lymph
sively back pain or stiffness is present, nodes eroded the oesophagus. MTL can
which is often misdiagnosed as myofascitis, present with oesophageal erosion, dyspha-
including supraspinous ligamentitis and gia and vocal cord paralysis owing to adja-
ankylosing spondylitis.12 Thus, many cent oesophageal and laryngeal nerve
patients with back pain owing to tubercu- involvement. The paradoxical occurrence
lous spondylitis were referred to rheumatol- of these signs after antituberculosis treat-
ogy outpatient departments or other ment has been defined as tuberculosis–
departments for diagnosis and immune reconstitution inflammatory
6 Journal of International Medical Research

syndrome, an excessive immune response to vigilance for MTL. This case report aimed
Mycobacterium tuberculosis.19 Such para- to highlight the importance of considering
doxical reactions generally do not indicate MTL in adult patients without lung
treatment failure. In addition, peripheral involvement in populations with a high
neuropathy with tuberculosis contributes prevalence of tuberculosis, such as the gen-
to patients’ pain. A number of factors can eral population in developing countries and
lead to peripheral nerve damage and the the immunocompromised population in the
development of neuropathy, namely the developed world.
tuberculosis itself, anti-tuberculosis bacteri-
al drugs and other comorbid conditions.20 Acknowledgement
Notably, the majority of patients with The authors thank the Tuberculosis Hospital
MTL have no radiographic evidence of pul- (Changchun, China) for providing the diagnosis
monary tuberculosis or common symptoms and valuable advice regarding the patient’s
of tuberculosis. The signs and symptoms treatments.
are sometimes nonspecific, and disease pro-
gression can be insidious; therefore, MTL is Ethics statement
a challenging diagnosis. Because patients We have read the journal’s ethics policies, and
who suffer only mediastinal tuberculosis we believe that neither the manuscript nor the
do not excrete bacteria, sputum cultures study violates any of these policies. The patient’s
and GeneXpert analyses are not well- informed consent was obtained throughout the
recognised modalities in the diagnosis. treatment process. We have de-identified all
Laboratory examination findings can pro- patient details.
vide partial information, such as an increase
in C-reactive protein and prolonged ESR. Declaration of conflicting interest
Tuberculin skin testing as a traditional The authors declare that there is no conflict of
method continues to be a useful diagnostic interest.
procedure for tuberculosis. The T-SPOT
test has also been recommended for the Funding
diagnosis of tuberculosis in clinical practice. This research received no specific grant from any
Thoracic CT has a disadvantage in that it funding agency in the public, commercial or not-
can provide tuberculous information usual- for-profit sectors.
ly only after considerable progression of
lung tissue destruction. Lymphadenectomy ORCID iD
or biopsy are alternative methods for objec- Guoqing Zhao https://orcid.org/0000-0003-
tive and accurate diagnosis of tuberculous 4962-4773
lymphadenitis, which should be considered
carefully because these methods can cause
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