TB mediastinal lymph nodes

Physical examination:

GA:

a young boy with normal consciousness, look well except when he has fever.
BW 13.6 kgs, W/A 82.4 % (at 3rd percentile)
Height 98.5 cms, H/A 94.2% (at 10th percentile)

V/S:

BT 38 C(Max usually 38 – 39 C), BP 112/72 mmHg, PR 120/min, RR 28/min

HEENT:

mild pale, no icteric sclera

Lymph node:

can’t be palpated

Heart:

regular heart rate, normal S1 S2, no murmur

Lung:

no respiratory retraction, no adventitious sound

Abdomen:

no hepatosplenomegaly, no abdominal mass , no ascitis

Extrimities and Skin:

no skin lesion, no edema.

Problem list: Prolonged fever with an anterior mediastinal mass

Investigatons:

CBC: Hb 10.4 g/dL Hct 31.2% WBC 16,200 cells/cu.mm (N 36%, L 55%, M 3%, E 5%) Platelet 584,000 cells/cu.mm

UA: yellow color, clear, no WBC, no RBC.

Hemoculture: no growth for bacteria

CXR: widening of mediastinum, no definite pulmonary infiltration, normal heart size (Figure 1)

CT chest: 3.18 x 3.78 x 5.0 cm, lobulated Rt.anterior mediastinal mass consistent with enlarged anterior mediastinal lymph nodes. The thymus gland is prominent and the pleural lining at Rt. lower chest cavity is thickened.

Figure 1
widening of mediastinum, no definite pulmonary infiltration

Clinical course and further investigations in the hospital:

Because of the finging of present of lymphoblasts in the peripheral blood smear from the referal hospital, bone marrow aspiration was performed which revealed normal finding.

Laparoscopic biopsy: no suspected causes by gross anatomy of mediastinal lymph nodes in the operation field.

Biopsy specimen: the histological examination demonstrated caseating granuloma with typical Langhans’giant cells (Figure 2,3). With Ziehl-Neelsen staining, small amount of beaded bacilli (AFB) were seen among the caseating debris (Figure 4).

	Figure 2 Low power view of the mediastinal node (H&E-stained, 10x): The nodal architecture has been effaced with formation of caseating granuloma. (Courtasy of Assoc. Prof. Nirush Lertprasertsuke, M.D)
	Figure 3 Medium power view of the mediastinal node (H&E-stained, 20x): The granuloma shows central caseation with nuclear debris and amorphous eosinophilic material. There are also typical Langhans’giant cells. (Courtasy of Assoc. Prof. Nirush Lertprasertsuke, M.D)
	Figure 4 High power view (Ziehl-Neelsen staining, 100x): Small amount of beaded bacilli are noted among the caseating debris. (Courtasy of Assoc. Prof. Nirush Lertprasertsuke, M.D)

Tuberculin skin test was repeated using Mantoux test: an induration (20 mm in diameter) was seen within 72 hours. The inflammation was severe as shown by the demonstration of miliaria crystallina rash (“sudamina” rash) on top of the induration (Figure 6)

Figure 5
Tuberculin skin test (Mantoux tes): an induration (20 mm in diameter) was seen within 72 hours. The inflammation was severe as shown by the demonstration of miliaria crystallina rash (“sudamina” rash) on top of the induration

Antituberculosis medications were started: 2IRZE/4IR ( INH 10MKD, Rifampicin 15MKD, ethambutal 15MKD, pyrazinamide 20MKD )

Patient’s general appearance improved within 2 weeks. The fever gradually subsided in 2 weeks after initiating anti-tubuculous drugs.

Discussion

Making the specific diagnosis for TB especially extrapulmanary type in pediatric patient was a challenge because the manifestations of the disease itself are non specific as well as mimicking to signs and symptoms of many diseases. This patient was evaluated only by history of prolonged fever without localizing sign, so the differential diagnosis include tuberculosis, connective tissue diseases and tumor.

CXRs and CT scan showed mediastinal lymphadenopathy and bone marrow aspiration revealed normal finding, histological examination of the mediastinal node is needed as the next choice.

Two types of tuberculin skin tests are currently available, the recommended Mantoux skin test, which uses a needle to place a standard dose of tuberculin just under the surface of the skin and the multi puncture or "tine" test uses multiple tines (pins) dipped in tuberculin. The tuberculin tine test is rarely used anymore because the quantity of the tuberculin administered cannot be precisely controlled. This test is not considered as accurate as the Mantoux test.

Response to anti-tuberculous drugs usually will take 1-2 weeks as in this patient.

The adjuvant steroid therapy which is controversial, usually play role in part of severe forms of TB such as meningitis, pericarditis, pleural effusion in order to hasten reabsorbtion of fluid or in patient with TB mediastinitis with respiratory compromise to minimize inflammation.

The patient does not have to be under respiratory isolation, because he does not have extensive pulmonary involvement, laryngeal involvement nor cavitary pulmonary tuberculosis.

Identification for source case should be actively done. The diagnosis of disease in child represents recent transmission from close source especially house hold contact.

Further Readings::
1.	Munoz FM, Starke JR. Tuberculosis (Mycobacerium tuberculosis). In: Behrman ER, Klingman MK, Jenson BH, editors. Nelson Text book of Pediatrics. 17th ed. Pennsylvania: Saunders; 2003. p958-72.
2.	American Academy of Pediatrics. Tubeculosis. In: Pickering LK, ed. Red book : 2003 Report of Committee on Infectious Diseases. 26th ed. Elk Grove Village, IL: American of Pediatrics; 2003: p642-60.
3.	อังกูร เกิดพานิช. วัณโรคในเด็ก 2006. ใน: อังกูร เกิดพานิช,รังสิมา โล่ห์เลขา,วีระชัย วัฒนเดช,บรรณาธิการ. Upate of Infectious Diseases 2006, กรุงเทพฯ: รุ่งเรืองศิลป์การ(1997) จำกัด 2549. หน้า 15-49.

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Prepared by... Chulaluk Suwanasukho, MD Podjanee Jittamala, M.D. Peninnah Oberdorfer, M.D., Ph.D Virat Sirisanthana , M.D.
Department of Pediatrics, Faculty of Medicine, Chiang Mai University
A 4-year-old Thai boy lives in Tak province. Referred from a private hospital in Chiang Mai, Chiang Mai, Thailand
Chief compliant: Fever for 4 weeks
Present illness:
>	4 weeks prior to this admission, he developed a high grade fever which occurred every other days. Fever was high in the evening and at night. There was neither respiratory tract symptom nor other specific localizing sign. He had no weight loss.
>	2 weeks prior to this admission, his mother brought him to a private hospital where he was admitted and was given ceftriazone for 1 week, doxycycline for 5 days and azithromycin for 5 days. The fever still persisted. Additional investigations included chest x-ray and CT scan of the chest which indicated that he had an anterior mediastinal mass.
>	A tuberculin skin test using “Tine-test” (the multi puncture) was performed which revealed the duration of 10 mm. at 72 hours after the puncture.
>	Lymphoblasts(5%) were found in the peripheral blood smear
>	He was then referred for further investigations and managements.
Past history:
>	He was healthy and had no underlying disease. He has had normal growth and development. His immunization has been up-to-date.
Family History:
>	he has been bringing up by grand-parents who live in Tak province since he was 1 year old. Nobody in the family had chronic cough or other chronic sickness. The father of his grandparent passed away because of a pulmonary TB before the patient was born.