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Weekly Chest CasesArchive of Old Cases

Case No : 713 Date 2011-06-27

  • Courtesy of Yoo Jin Hong, Hye-Jeong Lee, Ji Eun Nam, MD. / Severance Hospital, Yonsei University College of Medicine
  • Age/Sex 23 / F
  • Chief Complaintpalpable neck mass
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4

Figure 1

Diagnosis With Brief Discussion

Diagnosis
Tuberculous Mediastinal Lymphadenitis
Radiologic Findings
On chest radiograph (Figuew 1), Bulging opacity at right hilar area is noted.
On pre contrast (Figure 2) and post contrast CT images (Figure 3), an irregular shaped necrotic mass is noted in the anterior mediastinum. Adjacent lung collapse and centrilobular nodules at right upper lobe are also noted (not shown). Multiple necrotic lymph nodes are noted at both neck areas (Figure 4).
Brief Review
The patient didn’t have systemic symptoms. But, Tbc PCR and PPD skin test were positive. Lymph node biopsy was done at left supraclavicular lymph node. The pathologic diagnosis was chronic granulomatous inflammation with caseous necrosis, which was consistent with tuberculosis findings. After 6 months’ medication for Tbc, the anterior mediastinal necrotic mass considerably decreased in size. Mediastinal or hilar tuberculous lymphadenitis is a frequent manifestation of primary tuberculosis both in children and in adults. In mediastinal tuberculous lymphadenitis, those patients with large nodes and with symptoms generally have positive disease whereas those patients with small nodes and no symptoms have negative disease. However, in pediatric, geriatric and immunocompromised populations, patients can have no systemic symptoms despite active disease and patients with inactive disease may have large calcified nodes and symptoms due to illness other than tuberculosis. Biopsy and culture of the diseased nodes are considered the gold standard for determination of disease activity in patients with mediastinal tuberculous lymphadenitis.
Patients proven to have active disease had CT findings of nodes with central low attenuation and peripheral rim enhancement that corresponded pathologically to caseation or liquefaction necrosis and granulation tissue
with inflammatory hypervascularity, respectively. With treatment, nodes changed in appearance on follow-up studies, first becoming homogeneous and finally disappearing or resuIting in a residual mass composed of fibrotic tissue and calcifications. Calcifications within the nodes, however, because they were seen in both active and inactive disease, were not so reliable a CT finding for diagnosis of disease activity as were low-attenuation areas within the nodes.
References
Moon WK, Im JG, Yeon KM, Han MC. Mediastinal Tuberculous Lymphadenitis: CT Findings of Active and Inactive Disease AJR Am J Roentgenol. 1998 Mar;170(3):715-8.
Keywords
mediastinum, infection, Bacterial infection, Tuberculosis,

No. of Applicants : 108

▶ Correct Answer : 42/108,  38.9%
  • - Fukuyama daiichi Hospital , Japan Mototsugu Saeki
  • - Hangang sacred heart hospital , Korea (South) You Mie Han
  • - KMC,Manipal , India satish maddukuri
  • - University of British Columbia , Canada Amr Ajlan
  • - Inha University Hospital , Korea (South) Ju Won Lee
  • - DCA, , India Rajesh Gothi
  • - Mallinckrodt Institute of Radiology , United States Travis Henry
  • - Hopital Louis Pradel LYON , France matthieu ROUSSET
  • - royal melbourne hospital , Australia kimchi kings
  • - radiologist, aditya imaging centre , India vivek patel
  • - Okayama University , Japan Akihiro Tada
  • - Himeji Red Cross Hospital , Japan ryota inai
  • - National Jewish Health , United States Jonathan Chung
  • - yeong gwang general hospital , Korea (South) Mokhee Kim
  • - Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - Soon Chun Hyang, Seoul , Korea (South) Yoo Na Kim
  • - Calcutta Heart Research Centre, Kolkata , India Pankaj Nagori
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - CHRU lille , France manuel toledano
  • - Asan Medical Center , Korea (South) Sanghyun Choi
  • - DrRP GMEDICAL COLLEGE TANDA , India DINESH SOOD
  • - ROK air force aerospacemedical center , Korea (South) Daekeon Lim
  • - Youngdong Hospital , Korea (South) Sang Min Lee
  • - 異˜泥œ , Korea (South) heerok jeong
  • - Onomichi municipal hospital , Japan Ryotaro Kishi
  • - Beaulieu clinic Geneva , Switzerland gilles GENIN
  • - Showa general hospital , Japan Ai Sugano
  • - Severance hospital , Korea (South) Saerom Hong
  • - Chungnam National University hospital , Korea (South) sunkyoung you
  • - Ondokuz Mayis University , Turkey Cetin Celenk
  • - Hanam sungshim hospital , Korea (South) CHANG KIM
  • - Seoul national university hospital , Korea (South) Sun Ah Kim
  • - Japanese Red Cross Society Himeji Hospital , Japan Yuichiro Kanie
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - Bupyong Serim Hospital , Korea (South) Hee Seok Choi
  • - Kizawa Memorial Hospital , Japan Yo Kaneko
  • - Seoul National University Gangnam Center , Korea (South) Hua Sun Kim
  • - NASA SCANS , India RAKESH BHATIA
  • - Montreal , Canada D J
  • - IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
  • - Yonsei University College of Medicine, Shinchon Severance hospital , Korea (South) Young Joo Suh
▶ Correct Answer as Differential Diagnosis : 25/108,  23.1%
  • - Seoul National University Hospital , Korea (South) Hyungjin Kim
  • - James Paget Hospital , U.K , United Kingdom nabil mahmood
  • - Chaeil Clinic , Korea (South) Sunkyung Lim
  • - Univ. of Miami/Jackson Memorial , United States mantosh rattan
  • - IRSA , France jean-luc BIGOT
  • - Department of Radiology, Chonnam National University Hospital , Korea (South) Hyungjun Kim
  • - ministry of health , United Arab Emirates jesia mansoor
  • - PingTung Christian Hospital ,China Medical University ,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
  • - Dongnam Institute of Radiological and Medical Sciences , Korea (South) Dae Wook Yeh
  • - All India Institute of medical sciences , India Justin Moses
  • - McGill University Health Center , Canada Alexandre Semionov
  • - CNUH , Korea (South) Seoin Jeong
  • - Chonnam university hospital , Korea (South) LEE JI HYUN
  • - Seoul National University Hospital , Korea (South) YongSub Song
  • - Radnet Teleradiology , Turkey Murat Ulusoy
  • - CHU NANCY , France, Metropolitan LEGOU Fran�ois
  • - Saga University , Japan Ryoko Egashira
  • - snuh , Korea (South) Choo jiyung
  • - Chung-Nam National University Hospital , Korea (South) KI-TAE HAN
  • - Homs National Hospital , Syria Rami Abou Zalaf
  • - Zaid Alsheriti hospital- Alsweida , Syria jehad alakabani
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - Hospital Sotiria, Athens, Greece , Greece Vasilios Tzilas
  • - All India Institute of Medical Sciences , India Ashish Gupta
▶ Semi-Correct Answer : 1/108,  0.9%
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
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