Posterior mediastinal tuberculous lymphadenitis with dysphagia as the main symptom: a case report and literature review

Abstract

Introduction: Mediastinal tuberculous lymphadenitis (MTL) is mostly seen in primary tuberculosis in children, uncommon observed in adults. It usually presents the toxic symptoms of tuberculosis but rarely with symptoms characteristic of esophageal compression, such as dysphagia. Such patients can easily be misdiagnosed as esophageal neoplasm and get delayed or faulty treatment.

Case report: A 32-year-old man presented with dull chest pain of one month and dysphagia of five days. CRP was elevated, and a skin test was strongly positive. At upper endoscopy, a protruding lesion covered by normal mucosa was seen at 26 cm from the upper incisor. Barium swallow showed visible external compressive stricture on the middle-lower esophagus with normal mucosal pattern. Chest computed tomography (CT) scan showed a subcarinal mass adjacent to the esophageal wall in posterior mediastinum. An endoscopic ultrasonography (EUS) revealed a hypoechoic lesion suspected of esophageal stromal tumor in the fourth layer. A tissue was obtained by ultrasound-guided fine-needle aspiration (EUS-FNA), but cytopathology, bacilliculture and PCR test had no special findings. The patient required experimental antitubercular treatment and the protruding lesion shrank gradually during therapy period.

Conclusions: MTL could not be ignored in the differential diagnosis of posterior mediastinal mass with dysphagia. Analyzing and evaluating test results comprehensively is the key to make correct diagnosis and timely treatment. The experimental antituberculous treatment should be used if MTL is highly suspected.

Keywords: Mediastinal; dysphagia; tuberculous lymphadenitis.

Figure 1

Endoscopic view of a protruding lesion covered by normal mucosa located 26 cm from the upper incisor.

Figure 2

Barium swallow showing visible external compressive stricture on the middle-lower esophagus with normal mucosal pattern.

Figure 3

Computed tomography chest scan showing a subcarinal mass adjacent to the esophageal wall in posterior mediastinum.

Figure 4

Endoscopic ultrasonography revealing a hypoechoic lesion suspected of esophageal stromal tumor in the fourth layer.

Figure 5

(A) Before treatment; (B) After 1-month treatment; (C) After 2-month treatment; (D) after 8-month treatment. Esophagoscopy showing that the size of the protruding lesion reduced gradually during therapy period.

Figure 6

(A) Before treatment; (B) After 9-month treatment. Computed tomography chest showing the disappearance of the posterior mediastinal mass after 9 months of antituberculous therapy.