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 Table of Contents  
LETTER TO EDITOR
Year : 2018  |  Volume : 7  |  Issue : 3  |  Page : 296-297

Double trouble: Mediastinal lymph nodal tuberculosis complicated by amyloidosis and esophago-nodal fistula after endoscopic ultrasound fine-needle aspiration


Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication6-Sep-2018

Correspondence Address:
Dr. Vishal Sharma
Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_71_18

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How to cite this article:
Sharma V, Prasad KK, Mandavdhare HS. Double trouble: Mediastinal lymph nodal tuberculosis complicated by amyloidosis and esophago-nodal fistula after endoscopic ultrasound fine-needle aspiration. Int J Mycobacteriol 2018;7:296-7

How to cite this URL:
Sharma V, Prasad KK, Mandavdhare HS. Double trouble: Mediastinal lymph nodal tuberculosis complicated by amyloidosis and esophago-nodal fistula after endoscopic ultrasound fine-needle aspiration. Int J Mycobacteriol [serial online] 2018 [cited 2021 Sep 23];7:296-7. Available from: https://www.ijmyco.org/text.asp?2018/7/3/296/240692



Dear Editor,

A 38-year-old male presented with 3 months of dysphagia, fever with night sweats, loose stools, and 12 kg weight loss. The patient was found to have mediastinal lymphadenopathy and endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) done had shown granulomatous inflammation consistent with tuberculosis. Mantoux test was positive (20 mm × 15 mm). Patient had received antitubercular therapy for 6 months but now presented with a history of loose stools. Examination revealed bilateral pitting pedal edema. His hemogram and renal functions were normal. His liver function test was normal except for hypoalbuminemia (serum albumin: 1.1 g/dL). Urine examination revealed albuminuria and 24 h urinary protein was 2.9 g/day. Endoscopy revealed a fistulous opening in the esophagus at 24 cm from incisors [Figure 1]a and reduced fold height with nodularity in duodenum. Computed tomography showed a large subcarinal lymph node with air consistent with an esophago-nodal fistula [Figure 1]b. Histology showed amorphous eosinophilic amyloid deposition in submucosal duodenal blood vessels [Figure 2]a and Congo red stain staining highlighted vessel wall with amyloid (red fluffy material) deposition [Figure 2]b which showed apple-green birefringence under polarized light.
Figure 1: (a) Fistulous opening in the esophagus at 24 cm from incisors. (b) Computed tomography showed a large subcarinal lymph node with air consistent with an esophago-nodal fistula

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Figure 2: (a) Histology showed amorphous eosinophilic amyloid deposition in submucosal duodenal blood vessels. (b) Congo red stain staining highlighted vessels wall with amyloid (red fluffy material) deposition

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The present case is reported for two uncommon events which complicated mediastinal lymph nodal tuberculosis: first, the occurrence of amyloidosis after mediastinal lymph nodal tuberculosis and second, occurrence of esophago-nodal fistula possibly as a complication of previous EUS. Amyloidosis can be diagnosed after a variable interval of diagnosis of tuberculosis as also with concomitant active tuberculosis.[1] In a series of two cases, the diagnosis of secondary amyloidosis was reported as early as 2–4 weeks of diagnosis of tuberculosis.[2] The presence of pedal edema and proteinuria suggests the possibility of amyloidosis in patients with tuberculosis.[3] The diagnosis of secondary amyloidosis portends a grave prognosis and treatment is usually supportive. The occurrence of secondary amyloidosis with concomitant mediastinal lymph nodal tuberculosis is uncommon. Further, the case highlights the possible complication of EUS-guided tissue acquisition. EUS has emerged as an important tool for the evaluation of mediastinal lymph nodes and the diagnosis of esophageal tuberculosis where the subcarinal lymph node is most commonly involved. To the best of our knowledge, esophago-nodal fistula has not previously described as a complication of EUS-guided FNA of tubercular subcarinal lymph node although esophago-nodal fistulization and mediastinitis have been reported after EUS-FNA from malignant lymphadenopathy.[4],[5]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chong SG, Herron M, Dorman A, Little M, Donnelly SC, Keane J, et al. Renal amyloidosis complicating multidrug-resistant tuberculosis. Int J Tuberc Lung Dis 2017;21:476-7.  Back to cited text no. 1
    
2.
Malhotra P, Agarwal R, Awasthi A, Jindal SK, Srinivasan R. How long does it take for tuberculosis to cause secondary amyloidosis? Eur J Intern Med 2005;16:437-9.  Back to cited text no. 2
    
3.
Dixit R, Gupta R, Dave L, Prasad N, Sharma S. Clinical profile of patients having pulmonary tuberculosis and renal amyloidosis. Lung India 2009;26:41-5.  Back to cited text no. 3
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4.
Stigt JA, Boomsma MF, de Vos tot Nederveen Cappel WH. Esophageal fistula after EUS-FNA in a patient treated with bevacizumab for non-small-cell lung cancer. J Thorac Oncol 2013;8:e25-6.  Back to cited text no. 4
    
5.
Aerts JG, Kloover J, Los J, van der Heijden O, Janssens A, Tournoy KG, et al. EUS-FNA of enlarged necrotic lymph nodes may cause infectious mediastinitis. J Thorac Oncol 2008;3:1191-3.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]


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