Approaching a patient with poststernal pain after eating: A case report

Area of Science:

• Pulmonology
• Infectious Diseases
• Diagnostic Imaging

Background:

• Mediastinal lymph node tuberculosis (MLNT) often presents with nonspecific symptoms, complicating diagnosis.
• Delayed diagnosis can lead to prolonged patient suffering and potential disease progression.

Observation:

• A 33-year-old male presented with retrosternal pain, initially misdiagnosed despite multiple gastroscopies and ultrasound-guided biopsies.
• Chest-enhanced CT identified a mediastinal mass compressing the esophagus, raising suspicion for enlarged lymph nodes.
• T-cell testing for tuberculosis was positive, prompting further investigation.

Findings:

• Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) revealed enlarged lymph nodes in area 7.
• Microscopic examination showed lymphocytes and necrotic tissue; Xpert MTB/RIF testing of the biopsy was weakly positive, but the puncture fluid tested positive for Mycobacterium tuberculosis.
• The patient was diagnosed with mediastinal lymph node tuberculosis.

Implications:

• This case highlights the diagnostic challenges of occult MLNT.
• EBUS-TBNA, combined with molecular testing (Xpert MTB/RIF), is effective in diagnosing challenging cases of MLNT.
• Prompt antituberculosis treatment led to symptom resolution and reduction in lymph node size, validating the diagnostic and therapeutic approach.