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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 7  |  Issue : 1  |  Page : 101-103

Mediastinal ganglionar tuberculosis postcardiac transplantation


Thoracic Surgery Division, Faculty of Medicine, University of São Paulo (FMUSP), São Paulo, Brazil

Date of Web Publication7-Mar-2018

Correspondence Address:
dr Joćo Bruno Ribeiro Machado Lisboa
Thoracic Surgery Division, Faculty of Medicine, University of São Paulo (FMUSP), Av. Dr. Enéas de Carvalho Aguiar, n° 44, 05403-900 - São Paulo/SP
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_184_17

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  Abstract 


The diagnosis and treatment of tuberculosis (TB) in transplanted receivers presents several challenges. TB is an opportunistic infection with high morbidity and mortality in solid organs of transplanted patients, therefore, the diagnosis difficulties. A case of a 30-year-old male, heart transplanted patient, who after being submitted to mediastinoscopy, obtained a result of lymph node TB.

Keywords: Heart transplantation, mediastinum, tuberculosis


How to cite this article:
Machado Lisboa JB, Rodrigues Gd, Mondadori DC, Cassiano de Macedo JP, Filho OD, Pêgo-Fernades PM. Mediastinal ganglionar tuberculosis postcardiac transplantation. Int J Mycobacteriol 2018;7:101-3

How to cite this URL:
Machado Lisboa JB, Rodrigues Gd, Mondadori DC, Cassiano de Macedo JP, Filho OD, Pêgo-Fernades PM. Mediastinal ganglionar tuberculosis postcardiac transplantation. Int J Mycobacteriol [serial online] 2018 [cited 2019 Jul 15];7:101-3. Available from: http://www.ijmyco.org/text.asp?2018/7/1/101/226779




  Introduction Top


Postprimary TB is a condition rarely associated with lymphadenopathy. Its presentation almost always occurs in the parenchyma, airways, and pleura. The hilar and mediastinal lymph nodes are seldom affected, occurring in only about 5% of the immunocompetent patients.[1] The diagnosis and treatment of tuberculosis (TB) in transplanted receivers presents several challenges.[2] TB is an opportunistic infection with high morbidity and mortality in patients in solid organs of transplanted patients, therefore, the diagnosis difficulties.[3] The assessment of risk for the development of TB in solid organs receivers depends on, among other factors, the expected local prevalence of Mycobacterium tuberculosis infection in the target population.[4] The transplant (TPL) is a therapeutic option for ending organ disease. After TPL receivers are given immunosuppressive agents to prevent rejection, which results in impaired immune status and thus, an increased risk of infectious complications. Conventionally, TB is known to be associated with poor clinical outcomes in TPL recipients.[5]


  Case Report Top


The DPT patient, 30-years-old, male, with a history of progressive dyspnea, orthopnea, edema of the lower limb, assisted by the cardiology group of the Instituto do Coração (InCor) due to heart failure (HF), sought the InCor emergency room (PS-InCor) in 2016 with worsening dyspnea and abdominal pain, diagnosis of decompensated HF, being hospitalized for clinical compensation. This man had been already presenting an eCard of FE25% for that year. AE57. DSVE 79. DDVE67. Diffuse systolic dysfunction of the left ventricle of important degree. Diffuse systolic dysfunction of the right ventricle of discreet degree. An important degree of insufficiency of aortic, mitral and tricuspid valves. Pulmonary arterial hypertension (PSAP: 63). During hospitalization, he developed aortic insufficiency and underwent valve replacement in 2016. Due to biventricular dysfunction and aortic insufficiency, mitral regurgitation, tricuspid insufficiency, cardiac failure undergoing orthotopic cardiac transplantation (Tx) in July 2016. Progressing accordingly, presented rejection of the graft being controlled with immunosuppressants, being discharged with clinical improvement on the 15th postoperative period. Two months after cardiac Tx, he sought PS-InCor referring to daily fever in the morning, with no chest complaints. He was diagnosed with right pneumonia after computed tomography (CT), which also showed retrosternal collection and enlarged mediastinal and higher number of hilar lymph nodes without setting up lymph node enlargements. The patient presented worsening the infectious condition, and a new CT scan was performed, which showed a better characterization of the mediastinal lymph nodes [Figure 1]. Changing the antibiotic and applying an immunosuppressive strategy reflected on a satisfactory response; however, the fever reappeared, and a moderate intensity positron emission tomography (PET)-CT was applied on mediastinal lymph nodes, larger ones measuring up to 1.3 cm in the left paratracheal (SUVmax: 7,8) and subcarinal (SUVmax: 6,9) chain. Due to the maintenance of fever and radiological findings, diagnostic mediastinoscopy with freezing biopsy was performed by InCor's thoracic surgery team, whose diagnosis of chronic granulomatous lymphadenitis, with the presence of extracellular alcohol-acid resistant bacilli in the middle of caseous necrosis in the center of granulomas [Figure 2], compatible with TB, after a complete analysis. The patient took up treatment with the RIPE scheme, showing an improvement in the conditions. Due to the interaction between rifampicin and a calcineurin inhibitor, it was replaced by levofloxacin. Currently, he is clinically stable in outpatient follow-up and treatment for lymph node TB of 12 months.
Figure 1: Chest tomography with bulky lymph node disease

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Figure 2: Tuberculosis bacillus (circles) isolate in Ziehl-Neelsen (×100)

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  Discussion Top


The mediastinal tuberculous lymphadenopathy is a rare entity in adults.[6] The diagnosis of a mediastinal mass is a common challenge in clinical practice, especially in immunocompromised patients, the symptoms of these cases can range from asymptomatic to mass effect due to the compression of local structures.[7] The differential diagnosis of mediastinal masses is widespread and includes lymphoma, thymic mass, germ cell tumor and tissue ectopic thyroid, primary thymic neoplasms, thyroid masses and rarely TB, lymphoma being the most commonly diagnosed in adults.[8]

In the case presented here, the patient started the oligosymptomatic condition, presenting worsening the symptoms during hospitalization. The patient was assessed using clinical semiology and imaging tests in which an increase of the mediastinal lymph nodes was evidenced, both in CT and PET-CT, as well as mediastinal uptake in the latter. According to Feraco et al. PET-CT is a powerful tool to determine the diagnosis of anterior mediastinal mass. To a large extent in context, the method is used in malignant diseases. The sensitivity was 85%–95% and specificity was 95% in the detection of lymphoma. However, infectious and inflammatory diseases present high metabolism of glucose, providing a comprehensive assessment of the anatomic and metabolic extention of the infection and the inflammation involving soft-tissues and bone structures. PET/CT can facilitate the identification of extrapulmonary TB, TB staging, and differentiation between TB and malignant neoplasms.[8],[9],[10],[11]

There are few documented cases of TB that present as an isolated anterior mediastinal mass in an immunocompetent patient, most of them occurring in the pediatric population. In the study conducted by Maguire, it was raised in the literature, 03 cases in occurred in adult male patients, aged between 32 and 76 years, and 10 cases in the pediatric population aging 2 years or under. A counterpoint to the literature is that the clinical presentation was initially frustrated with clinical worsening, with no mass effect, as shown by the published data on adult presentations of mediastinal TB in immunocompetent patients.[11],[12],[13] The diagnosis was confirmed after histopathology both aspects observed in the case shown.

Nalladaru and Wessels in their series studied 31 cases in which he underwent mediastinoscopy, of which 96% had isolated medisatal lymphadenopathy. Of these, 77.4% of cases presented benign disease in histopathology. The accurate diagnostic obtained by mediastinoscopy resulted in the empirical pharmacotherapeutic approach to anti-TB early.[14],[15],[16] Other methods such as endobronchial ultrasound guided trans-bronchial needle aspiration, endoscopic ultrasonography-guided fine-needle aspiration, and thoracoscopy (video-assisted thoracic surgery) are alternatives for research on mediastinal TB.[17],[18]

TB is an entity that has an atypical presentation in transplanted patients, and its hypothesis should not be excluded, timely treatment allows the patient to present a favorable outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nin CS, de Souza VV, do Amaral RH, Schuhmacher Neto R, Alves GR, Marchiori E, et al. Thoracic lymphadenopathy in benign diseases: A state of the art review. Respir Med 2016;112:10-7.  Back to cited text no. 1
[PUBMED]    
2.
Subramanian AK, Morris MI, AST Infectious Diseases Community of Practice. Mycobacterium tuberculosis infections in solid organ transplantation. Am J Transplant 2013;13 Suppl 4:68-76.  Back to cited text no. 2
    
3.
Doblas A, Alcaide F, Benito N, Gurguí M, Torre-Cisneros J. Tuberculosis in solid organ transplant patients. Enferm Infecc Microbiol Clin 2012;30 Suppl 2:34-9.  Back to cited text no. 3
    
4.
Bumbacea D, Arend SM, Eyuboglu F, Fishman JA, Goletti D, Ison MG, et al. The risk of tuberculosis in transplant candidates and recipients: A TBNET consensus statement. Eur Respir J 2012;40:990-1013.  Back to cited text no. 4
[PUBMED]    
5.
Yoo JW, Jo KW, Kim SH, Lee SO, Kim JJ, Park SK, et al. Incidence, characteristics, and treatment outcomes of mycobacterial diseases in transplant recipients. Transpl Int 2016;29:549-58.  Back to cited text no. 5
[PUBMED]    
6.
Sahin F, Yildiz P. Mediastinal tuberculous lymphadenitis presenting as a mediastinal mass with dysphagia: A case report. Iran J Radiol 2011;8:107-11.  Back to cited text no. 6
[PUBMED]    
7.
Maguire S, Chotirmall SH, Parihar V, Cormican L, Ryan C, O'Keane C, et al. Isolated anterior mediastinal tuberculosis in an immunocompetent patient. BMC Pulm Med 2016;16:24.  Back to cited text no. 7
    
8.
Feraco D, Al-Faham Z, Roumayah Y, Jolepalem P. Mediastinal masses in nuclear medicine studies: A Diagnostic algorithm. J Nucl Med Technol 2016;44:261-2.  Back to cited text no. 8
[PUBMED]    
9.
Foerter J, Sundell J, Vroman P. PET/CT:First-line examination to assess disease extent of disseminated coccidioidomycosis. J Nucl Med Technol 2016;44:212-3.  Back to cited text no. 9
[PUBMED]    
10.
Wachsmann JW, Gerbaudo VH. Thorax: Normal and benign pathologic patterns in FDG-PET/CT imaging. PET Clin 2014;9:147-68.  Back to cited text no. 10
[PUBMED]    
11.
Micera R, Simoni N, Liguoro M, Vigo F, Grondelli C, Galaverni M, et al. The key role of 18F-FDG PET/CT for correct diagnosis, staging, and treatment in a patient with simultaneous NPC and TB lymphadenitis: Case report. Tumori 2016;102(Suppl 2):S22-5.  Back to cited text no. 11
    
12.
Jain N, et al. Cystic mediastinal mass: A rare presentation of tuberculosis. Chest 2013;144:212.  Back to cited text no. 12
    
13.
Kumar N, Gera C, Philip N. Isolated mediastinal tuberculosis: A rare entity. J Assoc Physicians India 2013;61:202-3.  Back to cited text no. 13
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14.
Nalladaru ZM, Wessels A. The role of mediastinoscopy for diagnosis of isolated mediastinal lymphadenopathy. Indian J Surg 2011;73:284-6.  Back to cited text no. 14
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15.
Porte H, Roumilhac D, Eraldi L, Cordonnier C, Puech P, Wurtz A, et al. The role of mediastinoscopy in the diagnosis of mediastinal lymphadenopathy. Eur J Cardiothorac Surg 1998;13:196-9.  Back to cited text no. 15
    
16.
Sevinc S, Ors Kaya S, Unsal S, Dereli S, Alar T, Can Ceylan K, et al. The role of the tissue culture in granulomatous mediastinal lymphadenitis: Tuberculosis or not. Med Glas (Zenica) 2014;11:44-8.  Back to cited text no. 16
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17.
Kim J, Jang Y, Kim KO, Kim YJ, Park DK, Chung DH, et al. Mediastinal tuberculous lymphadenitis diagnosed by endosonographic fine needle aspiration. Korean J Gastroenterol 2016;68:312-6.  Back to cited text no. 17
[PUBMED]    
18.
Eom JS, Mok JH, Lee MK, Lee K, Kim MJ, Jang SM, et al. Efficacy of TB-PCR using EBUS-TBNA samples in patients with intrathoracic granulomatous lymphadenopathy. BMC Pulm Med 2015;15:166.  Back to cited text no. 18
    


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