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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 2  |  Page : 199-201

The role of flexible bronchoscopy in lung tuberculosis mimicking mediastinal mass in an Infant: A rare case report


1 Department of Pediatrics, Pediatric Respirology Division, Harapan Kita Women and Children Hospital, Jakarta, Indonesia
2 Department of Child Health, Pediatric Respirology Division, Hasan Sadikin Hospital, Universitas Padjajaran, Bandung, Indonesia

Date of Web Publication14-Jun-2019

Correspondence Address:
Rifan Fauzie
Department of Pediatrics, Pediatric Respirology Division, Harapan Kita Women and Children Hospital, Jl. S. Parman Kav. 87, Slipi, Jakarta 11420
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_63_19

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  Abstract 


Tuberculosis (TB) is a systemic disease that can affect all parts in the body. The clinical manifestations sometimes mislead to other diagnoses. Mediastinal mass-like of TB in children is a rare manifestation. A 5-month-old boy presented to our hospital with respiratory distress, fever for 2 months, body weight loss, cough, and history of recurrent pneumonia. The lung sound decreased on the right hemithorax. Lung computed tomography revealed multiple irregular cysts with thick walls on the anterosuperior mediastinal area, consolidation on the right lobe, and suspected gangrenous lung disease. The right main bronchus stenosis with cheesy-like vegetation was found on flexible bronchoscopy procedure. Xpert/MTB RIF from bronchoalveolar lavage revealed Mycobacterium tuberculosis and sensitive to rifampicin. Anti-TB drugs were given for 12 months. He has clinical and radiological improvement. We must increase the awareness of TB disease in case of mediastinal mass-like appearance in the high-endemic area. The flexible bronchoscopy plays an important role in diagnostic purpose.

Keywords: Bronchoalveolar lavage, flexible bronchoscopy, mediastinal mass, tuberculosis, Xpert/MTB RIF


How to cite this article:
Fauzie R, Nataprawira HM. The role of flexible bronchoscopy in lung tuberculosis mimicking mediastinal mass in an Infant: A rare case report. Int J Mycobacteriol 2019;8:199-201

How to cite this URL:
Fauzie R, Nataprawira HM. The role of flexible bronchoscopy in lung tuberculosis mimicking mediastinal mass in an Infant: A rare case report. Int J Mycobacteriol [serial online] 2019 [cited 2019 Jul 15];8:199-201. Available from: http://www.ijmyco.org/text.asp?2019/8/2/199/260386




  Introduction Top


Tuberculosis (TB) is systemic disease that can affect all parts in the body. The clinical manifestations can be diverse and sometimes misleading to other diagnoses.[1],[2] In adults, the most common radiological presentation is segmental or lobar consolidation on the upper lobe or the superior segment of the lower lobe of the lung.[3],[4] In children, most cases are primary TB infection and the greatest risk of developing disease.[5] Hilar and mediastinal lymphadenopathy is the radiologic hallmark in children with TB and may be transiently seen in asymptomatic patients.[6]

The extrapulmonary TB occurs in approximately 20%–30% of all cases. The common EPTB is lymphatic disease and meningeal disease.[1],[7] A mediastinal mass in children is a challenging problem. There are several organs present in the posterior mediastinum areas such as esophagus, thoracic duct, nerves, aorta, veins, and lymph nodes,[8] while anterior mediastinum contains thymus, thyroid, and ectopic parathyroid gland.[9] The challenging and urgent diagnostic is important due to the differential diagnoses range from benign to highly malignant conditions, and delay in diagnosis may be fatal. Mediastinal mass-like of TB in children is a rare manifestation. Respiratory distress is often seen in infants, but not in older children.[6],[8],[10]

Herein, we want to report a rare case of an infant with lung TB mimicking a mediastinal mass on the right lung. We also want to show the important role of flexible bronchoscopy procedure in this case.


  Case Report Top


A 5-month-old boy presented to our hospital with respiratory distress. He suffered from febrile for the last 2 months, body weight loss, cough, and shortness of breath. He had recurrent pneumonia and was hospitalized several times. On admission, he was suffered from tachypnea, chest indrawing, and decreased of the lung sound on the right upper and middle areas. We treated him with ceftriaxone first for several days as pneumonia.

On chest X-ray (CXR), there was right and middle lobe consolidation [Figure 1]. We then performed lung computed tomography (CT) that revealed multiple irregular cysts with thick walls on the anterosuperior mediastinal area, a consolidation on the right lobe, and a suspected gangrenous lung disease with no clear lymph node enlargement [Figure 2].
Figure 1: Chest X-ray showed right lung consolidation, a huge mediastinal mass-like lesion

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Figure 2: Lung computed tomography showed right lobe consolidation, a huge mediastinal mass-like lesion, with suspected right main bronchus stenosis

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We found right main bronchus stenosis with cheesy-like vegetation from flexible bronchoscopy examination [Figure 3]. Mycobacterium tuberculosis was detected and sensitive to rifampicin from Xpert/MTB RIF of the bronchoalveolar lavage (BAL). We then gave him antituberculosis drugs (ATDs) consisting of rifampicin, isoniazid, pyrazinamide, and ethambutol for the first 2 months and continued with rifampicin and isoniazid for the next 10 months. He has clinical and radiological improvement [Figure 4] and [Figure 5].
Figure 3: Right main bronchus stenosis and cheesy-like vegetation from flexible bronchoscopy procedure

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Figure 4: Chest X-ray improvement after 12 months of antituberculosis drugs

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Figure 5: Lung computed tomography improvement after 12 months of antituberculosis drugs

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  Discussion Top


Lesions in the mediastinal region can be caused by numerous diseases in perspective of various anatomical structures in the area. Accurate and early diagnosis is important to differentiate the nonneoplastic and benign lesion from malignant ones.[11] The appropriate management depends on accurate diagnosis. Integrated and comprehensive in-depth history-taking and clinical, radiological, and histological approaches are important.[11],[12]

TB disease with the manifestation of mediastinal mass is a very rare case in the pediatric population, especially in infants.[1],[9],[13] In the adult, TB commonly presents as consolidation which may be segmental or lobar usually involving the upper lobe or the superior segment of the lower lobe, but sometimes, unusual presentation like mimicking mediastinal mass.[3]

This patient came to our hospital with a history of recurrent pneumonia. He was already being hospitalized for more than twice. There was a history of slight fever and decreased body weight, in the last 2 months before admission. Cough and fast breathing came as they worsen in the last 1 month. All these symptoms were unnoticed previously as other origins other than recurrent pneumonia. The lung sound was decreased at the right upper hemithorax. We found a wide consolidation on the right mediastinal region from CXR, but lung CT showed that it was not a solid lesion and the tumor was unlikely.

Due to inconclusive findings between the imaging and clinical signs, we then performed a flexible bronchoscopy procedure. There were right main bronchus stenosis and cheesy-like vegetations. The Xpert/MTB RIF from BAL detected M. tuberculosis and still sensitive to rifampicin. We gave ATD for 12 months. The improvement was unbelievable. His body weight increased, the cough disappeared, and the respiratory distress subsided.


  Conclusion Top


TB in children can be mimicking a mediastinal mass appearance. It is a very rare case, especially in infants. We must increase the awareness of TB disease in any kind of mediastinal mass-like appearance and respiratory distress in a high-endemic area. The flexible bronchoscopy plays an importance role in diagnostic purpose.

Declaration of patient consent

The authors certify have obtained all appropriate patient consent form. In the form, the patient's parents have given his consent for his images and other clinical information to be reported in the journal. The patient's parents understand that his name and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgement

We would like to thank the patient and his parents for their approval on this rare case for medical education purposes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kim N, Lee HJ, Yi J, Park SE, Chang CL. Tuberculosis presenting as a mediastinal mass in an infant. Ann Clin Microbiol 2017;20:17-20.  Back to cited text no. 1
    
2.
Daulay RS, Majeda A, Nataprawira HM. Unrecognized and delayed to diagnose of adolescence tuberculosis case in a boarding school in West Java, Indonesia. Int J Mycobacteriol 2018;7:387-9.  Back to cited text no. 2
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3.
Agarwal A, Sharma R, Verma A, Verma A. Pulmonary tuberculosis mimicking a lung mass. Int J Adv Med 2015;2:294-5.  Back to cited text no. 3
    
4.
Collu C, Fois A, Crivelli P, Tidore G, Fozza C, Sotgiu G, et al. Acase-report of a pulmonary tuberculosis with lymphadenopathy mimicking a lymphoma. Int J Infect Dis 2018;70:38-41.  Back to cited text no. 4
    
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Faddoul D. Childhood tuberculosis: An overview. Adv Pediatr 2015;62:59-90.  Back to cited text no. 5
    
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Nachiappan AC, Rahbar K, Shi X, Guy ES, Mortani Barbosa EJ Jr., Shroff GS, et al. Pulmonary tuberculosis: Role of radiology in diagnosis and management. Radiographics 2017;37:52-72.  Back to cited text no. 6
    
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Sepulveda EV, Yunda LF, Herrera KC, Moreno GC. Extrapulmonary tuberculosis in Colombian children: Epidemiological and clinical data in a reference hospital. Int J Mycobacteriol 2017;6:132-7.  Back to cited text no. 7
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8.
Sabouni F, Movahedi Z, Mehdizadeh M, Rahimi A, Rezaei N. Posterior mediastinal mass: An unusual presentation of pediatric tuberculosis. Turk J Pediatr 2014;56:103-6.  Back to cited text no. 8
    
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Khilnani GC, Jain N, Hadda V, Arava SK. Anterior mediastinal mass: A rare presentation of tuberculosis. J Trop Med 2011;2011:635385.  Back to cited text no. 9
    
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Chen Y, Yang Y, Chen L, Fan M. Large pulmonary solitary mass caused by Mycobacterium tuberculosis mimicking a malignant tumor in a child. Radiol Inf Dis 2018;5:131-4.  Back to cited text no. 10
    
11.
Dixit R, Shah NS, Goyal M, Patil CB, Panjabi M, Gupta RC, et al. Diagnostic evaluation of mediastinal lesions: Analysis of 144 cases. Lung India 2017;34:341-8.  Back to cited text no. 11
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12.
Garey CL, Laituri CA, Valusek PA, St. Peter SD, Snyder CL. Management of anterior mediastinal masses in children. Eur J Pediatr Surg 2011;21:310-3.  Back to cited text no. 12
    
13.
Chadha R, Tripathi RK, Singh D, Choudhury SR. Extensive unilobar primary pulmonary tuberculosis in an infant: A diagnostic dilemma. J Indian Assoc Pediatr Surg 2005;10:52-4.  Back to cited text no. 13
  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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