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A Young Individual With Mediastinal Lymphadenopathy: Unleashed With EBUS FREE TO VIEW

Raghupathi Narasimhan*, MD; Meghena Mathew, MBBS
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Apollo Hospital, Chennai, India

Chest. 2012;142(4_MeetingAbstracts):887A. doi:10.1378/chest.1389400
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SESSION TYPE: Bronchology Global Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Endobronchial ultrasound is a hybrid technique that combines bronchoscopy with ultrasound and has helped expand bronchoscopists view beyond the airway and this idea dates back to 1990s .1 Endobronchial Ultrasound has helped in extracting samples from lymph nodes and masses in the central regions of the lung and optimizing treatment in case of malignancy. However more studies are yet awaited to demonstrate its role in benign disorders. We report a case of mediastinal lymphadenopathy in a young patient , which was diagnosed as Tuberculous in origin following histopathological guided specimen obtained by EBUS TBNA. The evaluation for etiology of mediastinal lymphadenopathy with no coexisting parenchymal involvement is often difficult.

CASE PRESENTATION: A 31 year old lady from North Eastern India presented with complaints of fever with cough of two months duration and dyspnea of one week history. There was no other significant past medical history. On examination she was hemodynamically stable. Physical examination was non contributory. Routine blood investigations were non diagnostic except for an elevated ESR. Mantoux test was strongly positive . Chest X ray revealed widening of superior mediastinum. CT chest done which showed enlarged mediastinal lymph nodes involving station 2R and 4R with compression of trachea. She was planned for endobronchial ultrasound guided evaluation of the mediastinal lymph nodes. Vascular structures and lymph nodes were well identified with Doppler. EBUS guided TBNA from station 2R and 4R was performed. Histopathological examination of the specimen was suggestive of granulomatous inflammation and consistent with diagnosis of tuberculosis. She was started on Anti tuberculosis treatment and reviewed after a period of two weeks. She showed good symptomatic improvement and is on follow up.

DISCUSSION: Etiology for mediastinal lynmphadenopathy is varied , which includes infection , malignancy, reactive hyperplasia and granulomatous diseases . Infections usually include Tuberculosis and certain other fungal infection. Although bronchoscopy has been useful in the early diagnosis of endobronchial lesions, it has limitations in diagnosing extra-bronchial disease. Hence the technique of EBUS was developed to obtain histological specimens without risk of injuring vital vascular and mediastinal structures. The most readily accessed nodes via EBUS includes the station 1, 2R, 2L, 4R, 4L, 7, 10, and 11 . Role of EBUS has been well established in the staging of lung malignancy. However this novel method can also be used in the diagnosis of other mediastinal diseases. A thorough review of literature showed that its role in diagnosis of other conditions like tuberculosis is still limited. 2,3 India continues to have a high burden of tuberculosis and thoracic lymphadenopathy remains very prevalent. With no coexisting parenchymal abnormality it poses a diagnostic challenge due to low diagnostic yield with sputum analysis. In a retrospective analysis the microbiologic and cytomorphologic diagnostic accuracy of EBUS-TBNA in patients diagnosed with tuberculosis was 63% and 84%, respectively with a 95% sensitivity and 100% specificity .In this era of emerging TB resistance it would be ideal to establish the diagnosis of Tuberculosis by histopathological diagnosis of caseating granuloma or TB isolates on culture and obtain samples for drug susceptibility before initiation of treatment rather than empirical treatment.

CONCLUSIONS: In conclusion , EBUS has good potential in diagnosing mediastinal lymphadenopathy secondary to benign conditions and in particular even Tuberculosis.

1) Hurter T, Hanrath P. Endobronchial sonography: feasibility and preliminary results. Thorax 1992;47:565-567.

2) Bilaceroglu S GO, Eris N, Cagirici U, et al. Transbronchial needle aspiration in diagnosing intrathoracic tuberculous lymphadenitis. Chest 2004; 126: 259-267.

3) Baron KM, Aranda CP. Diagnosis of mediastinal mycobacterial lymphadenopathy by transbronchial needle aspiration. Chest 1991;100: 1723-1724.

DISCLOSURE: The following authors have nothing to disclose: Raghupathi Narasimhan, Meghena Mathew

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Apollo Hospital, Chennai, India




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