An unique case report: Unusual presentation of mediastinal lymph node tuberculosis in an adult

Tuberculosis (TB) is a serious public health problem in Bangladesh. National tuberculosis control program recognizes that almost half of the TB cases remain undiagnosed in the country. To increase case detection rate, it is very important to familiarize the physicians with unusual presentation of TB. We describe a 51 years old woman with a past medical history of Hypertension (HTN), Type 2 Diabetes Mellitus (DM), and Nonalcoholic steatohepatitis-chronic liver disease (NASH-CLD) who presented to us with low grade fever, anorexia, nausea, and recurrent vomiting for one month. Physical examination and laboratory tests revealed no significant abnormalities and symptoms were treated symptomatically. After about two months, the condition did not improve. All routine blood biochemistry and imaging reports were not suggestive of any disease except for high ESR and abnormal LFT (mild increase in ALP, ALT and moderate increase in GGTP). To exclude the differential diagnoses (such as abdominal TB), we advised computed tomography (CT) scan of chest and abdomen but the results came out normal. Her PPD came out positive but it was not confirmatory of TB as the patient was previously vaccinated with BCG vaccine. As the patient was immune-compromised we suggested starting Anti-TB drugs based on clinical judgment and in the context of Bangladesh being a TB endemic area. But the patient was not convinced to take anti-Tb drugs without definite diagnosis. After another month of persistent symptoms a repeat CT of the chest was advised that revealed multiple enlarged mediastinal lymph-nodes. As the patient had a history of CLD and high PT, Fine Needle Aspiration Cytology (FNAC) was deferred. Patient was started on Anti tubercular treatment and symptoms subsided within three weeks. Treatment was continued for one year. This case summarizes the unusual presentation of mediastinal lymph node Tuberculosis in an adult.