Mediastinal lymphadenopathy – A case report

A Vasudevan; Gayathri Anur Ramakrishnan

doi:10.4103/japt.japt_10_23

CASE REPORT

Year : 2023 | Volume : 6 | Issue : 1 | Page : 29-30

Mediastinal lymphadenopathy – A case report

A Vasudevan, Gayathri Anur Ramakrishnan
Department of Pulmonology, Apollo Hospitals, Chennai, Tamil Nadu, India

Date of Submission	11-Mar-2023
Date of Decision	11-Apr-2023
Date of Acceptance	12-Apr-2023
Date of Web Publication	29-Apr-2023

Correspondence Address:
Dr. A Vasudevan
Department of Pulmonology, Apollo Hospitals, Greams Road, Chennai - 600 006, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/japt.japt_10_23

Abstract

In our day-to-day practice, as a pulmonologist, the mediastinal lymphadenopathy is a common finding, the cause of which is difficult to diagnose. Although in endemic countries like India, tuberculosis is the common cause, there are also other causes which are associated with it. Therefore, it is important to get a tissue diagnosis before we arrive at a conclusion.

Keywords: Endobronchial ultrasound, endoscopic ultrasound, mediastinal lymphadenopathy, transbronchial needle aspiration

How to cite this article:
Vasudevan A, Ramakrishnan GA. Mediastinal lymphadenopathy – A case report. J Assoc Pulmonologist Tamilnadu 2023;6:29-30

How to cite this URL:
Vasudevan A, Ramakrishnan GA. Mediastinal lymphadenopathy – A case report. J Assoc Pulmonologist Tamilnadu [serial online] 2023 [cited 2023 May 29];6:29-30. Available from: https://www.japt.in//text.asp?2023/6/1/29/375455

Introduction

The causes of mediastinal lymphadenopathy include both benign and malignant causes. Malignant causes such as lymphoma or lung cancer make up most mediastinal lymphadenopathy cases. Benign causes include infective causes like tuberculosis and inflammatory causes such as sarcoidosis, amyloidosis, and certain autoimmune conditions. Contrast-enhanced computed tomography (CT) scan of the chest remains the most important diagnostic tool for diagnosing mediastinal lymphadenopathy. Here, we discuss different modalities to obtain tissue sampling for microbiological and histopathological analysis.

Case Report

This 22-year-old female presented to our outpatient department with complaints of cough and loss of weight of about 4 kg for the past 40 days. She denied any history of fever in the past. On examination, she was afebrile, saturating well on room air and her chest was clear on auscultation. She had a CT chest done in an outside hospital which revealed a right paratracheal lesion of 5 cm × 4 cm indenting the lung parenchyma and a subcarinal lesion of 4 cm × 3 cm [Figure 1]. There were tiny nodules in the anterior segment of the right upper lobe [Figure 2].

Figure 1: Right paratracheal lesion of 5 cm × 4 cm indenting the lung parenchyma and a subcarinal lesion of 4 cm × 3 cm

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Figure 2: Tiny nodules in the anterior segment of the RUL. RUL: Right Upper Lobe

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Based on these radiological features, our differentials were toward (1) tuberculosis, (2) lymphoma, and (3) sarcoidosis. We went ahead with our investigations which revealed a negative Mantoux test and serum angiotensin-converting enzyme levels were within the normal limits. Then, we decided to go ahead with a CT-guided fine-needle aspiration cytology from the subcarinal nodes (Station 7). Tissue Gene Xpert for Mycobacterium tuberculosis was detected, and rifampicin resistance was not detected. She was then started on anti-tubercular therapy. On follow-up, after 3 months of anti-tubercular therapy, her clinical condition has improved.

Discussion

An approach toward a patient with mediastinal lymphadenopathy depends on the involved lymph nodes station [Table 1].

Table 1: Mediastinal Lymph node station

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There are various procedures used for biopsy from these sites. These include (1) transthoracic needle aspiration, (2) transbronchial needle aspiration (TBNA), (3) endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA) (4) endoscopic ultrasound FNA (EUS-FNA), (5) mediastinoscopy, (6) CT-guided biopsy, (7) Video-assisted thoracoscopic surgery (VATS)

The high lymph nodal stations, i.e., 1, 2, 3, and 4 can be approached using a cervical mediastinoscopy. The advent of EBUS and EUS has significantly improved the diagnostic yield of TBNA sampling of the mediastinum.^[1],[2] There are also case studies stating that EUS, when combined with EBUS, the mediastinum can be sampled extensively.^[3] If our clinical diagnosis is in favor of an infective etiology, then EBUS and EUS-guided TBNA have a good diagnostic yield. However if lymphoma is the main suspect, then VATS and CT-guided biopsy have a good yield.

Conclusion

Thus, in a case of mediastinal lymphadenopathy, the further workup of the patient is based on our differentials and the level of nodal stations so that we can go ahead with the appropriate procedure, which can aid in our diagnosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Acknowledgment

We thank the Department of Pulmonology and Radiology Apollo Hospitals, Chennai, Tamil Nadu, India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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2.	Ost DE, Ernst A, Lei X, Feller-Kopman D, Eapen GA, Kovitz KL, et al. Diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration: Results of the AQuIRE bronchoscopy registry. Chest 2011;140:1557-66.
3.	Vilmann P, Krasnik M, Larsen SS, Jacobsen GK, Clementsen P. Transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) biopsy: A combined approach in the evaluation of mediastinal lesions. Endoscopy 2005;37:833-9.