Mediastinal tuberculous lymphadenopathy presenting with dysphagia.

To the Editor: Dysphasia is rarely a presenting feature of tuberculous, more often associated with direct esophageal involvement. (1,2) Very few cases of tuberculosis mediastinal lymphadenopathy causing dysphasia have been reported from the Asian subcontinent and even fewer from the West. We came across a similar case, interesting not only from the geographical aspect but also in presentation.

A 45-year-old, nonsmoker, Asian postman complained of vomiting and dysphasia for 3 days. All investigations, including imaging, were normal. He was diagnosed with viral gastroenteritis and discharged. Six weeks later, he was readmitted with dysphasia, abdominal discomfort, lethargy, night sweats, and a 10 kg weight loss over 3 weeks. The latter was ascribed to inability to eat solid foods. No family, travel, or contact history to suggest tuberculosis (TB) was noted. Right upper quadrant guarding was present, and the chest was clear to auscultation. No lymphadenopathy was noted. Hepatitis and autoimmune screen, blood and stool cultures, abdomen ultrasound and upper gastrointestinal endoscopy were normal. C-reactive protein and angiotensin-converting enzyme (ACE) were raised at 22 (normal <10) and at 86 (normal <54), respectively. Sputum was negative for acid-fast bacilli (AFB) on 3 consecutive samples. After 2 weeks as an inpatient, a quotidian fever pattern was seen and a bilaterally symmetrical itchy rash on his lower shins was confirmed by dermatologists as erythema nodosum (EN). Chest imaging showed bilateral hilar lymphadenopathy, consistent with lymphoma or infection (Fig. 1). A transesophageal biopsy showed caseating epithelioid-cell granulomas with Langhans-type of giant cells and a lymphocytic rim, highly consistent with tuberculosis, although ZN stain was negative (Fig. 2). Antituberculous treatment was started. After 10 weeks, the culture results were AFB negative. The patient is currently asymptomatic and is being followed up as an outpatient.

Histoplasmosis, lymphoma, TB, sarcoidosis and neoplasia are the common causes of mediastinal lymphadenopathy. Our case was interesting because dysphasia was the only presenting symptom preceding other features by 6 weeks, without esophageal wall or mucosal involvement. (3) Mediastinal tuberculous lymphadenopathy, though common in children, is rarely ever seen in adults without pulmonary involvement. Our patient had been a UK resident for 30 years and had been vaccinated with BCG without travel or contact history. These findings could suggest primary TB, but no active or healed Ghon's foci were seen on chest imaging. The presence of EN also favors primary TB. (4)

The differential diagnosis was between TB and an early stage of sarcoidosis. Features favoring TB were the quotidian fever pattern, caseating granulomas, symptomatic response to anti-TB therapy and absence of distal bronchopulmonary lymphadenopathy. Features favoring sarcoidosis were raised ACE levels and bilateral hilar lymphadenopathy with EN. (5)

However, these are explainable by TB, and it has recently been suggested that the foremost cause of EN was TB. On balance, TB was the favored diagnosis. Although positive cultures are diagnostic of TB, in absence of a nonproductive cough, negative cultures do not exclude TB.

This case underscores the importance of clinical judgment in unusual presentations of common diseases, and the high degree of suspicion for TB, indeed the greatest mimic of all.

Naveen Bhatt, MD

Department of Medicine

Nidhi Bhatt, MD

Department of Pathology

University Hospital of Wales, Heath Park

Cardiff, United Kingdom

Gloucestershire Royal Hospital 

Gloucester, United Kingdom

References

1. Park SH, Chung JP, Kim IJ, et al. Dysphasia due to mediastinal tuberculous lymphadenitis presenting as an esophageal submucosal tumor: a case report. Yonsei Med J 1995;36:386-391.

2. Sood R, Gupta R. Tuberculous mediastinal adenopathy presenting as dysphagia. J Assoc Physicians India 2000;48:1135-1136.

3. Ghimire MP, Walker RJ. Painful dysphagia in a case of mediastinal tuberculous lymphadenopathy. Postgrad Med J 1985;61:427-428.

4. Mert A, Ozaras R, Tabak F, et al. Primary tuberculosis cases presenting with erythema nodosum. J Dermatol 2004;31:66-68.

5. Holgate ST. A Frew: Respiratory disease. Clinical Medicine. Kumar P, Clark M. (eds). Philadelphia. WB Saunders Co, 5th ed. 2002, p 899.