Treatment Failure in a Case of Fully Susceptible Tuberculous Lymphadenitis; Time to Consider Dual Pathology

The clinical presentation of tuberculous lymphadenitis (TBL) can mimic that of other pathologies; obtaining a tissue diagnosis is therefore essential. Dual pathology can manifest as apparent treatment failure and rare cases of coexistent lymphoma have been reported.

A 54-year-old fit and well man of African-Caribbean origin presented with an 8-week history of dysphagia, breathlessness and weight loss. He was tachypnoeic and thin with right supraclavicular and axillary lymphadenopathy.

An HIV test was negative. A CT thorax demonstrated clear lung fields and a 7.2cm mediastinal soft tissue mass compressing the oesophagus and trachea.

US-guided core biopsies of a supraclavicular lymph node showed necrotising granulomatous inflammation. There was no evidence of lymphoma on immunohistochemistry. An acid-fast bacillus was seen on Wade-Fite staining.

Voractiv was commenced for suspected TBL. Tissue culture subsequently grew Mycobacterium tuberculosis. Susceptibility to treatment was confirmed by whole genome sequencing.

After two months of treatment he remained symptomatic with continued weight loss. The possibility of dual pathology was considered, and the index biopsy revisited. Steroids were commenced for a possible paradoxical reaction, resulting in some initial clinical improvement.

Ten weeks into treatment, he further deteriorated requiring artificial nutrition and tracheal stenting. Repeat CT imaging showed enlargement of the mediastinal mass, now extending into the oesophageal lumen. Oesophageal biopsy demonstrated adenocarcinoma.

We report a case of TBL with coexistent adenocarcinoma, which whilst rare highlights the importance of reassessment for dual pathology in cases of biopsy proven TBL that fails to respond to appropriate anti-tuberculous therapy.