J Korean Med Sci.  2023 Dec;38(47):e348. 10.3346/jkms.2023.38.e348.

Clinical Course of Patients With Mediastinal Lymph Node Tuberculosis and Risk Factors for Paradoxical Responses

• Choe J
• Han A
• Shin SH
• Lee K
• Um SW
• Kim H
• Kim TY
• Huh HJ
• Choi YL
• Han J
• Jeong BH

• KMID: 2548799
• DOI: http://doi.org/10.3346/jkms.2023.38.e348

Abstract

Background
Paradoxical responses (PR) occur more frequently in lymph node tuberculosis (LNTB) than in pulmonary tuberculosis and present difficulties in differential diagnosis of drug resistance, new infection, poor patient compliance, and adverse drug reactions. Although diagnosis of mediastinal LNTB has become much easier with the development of endosonography, limited information is available. The aim of this study was to investigate the clinical course of mediastinal LNTB and the risk factors associated with PR.
Methods
Patients diagnosed with mediastinal LNTB via endosonography were evaluated retrospectively between October 2009 and December 2019. Multivariable logistic regression was applied to evaluate the risk factors associated with PR.
Results
Of 9,052 patients who underwent endosonography during the study period, 158 were diagnosed with mediastinal LNTB. Of these, 55 (35%) and 41 (26%) concurrently had pulmonary tuberculosis and extrapulmonary tuberculosis other than mediastinal LNTB, respectively. Of 125 patients who completed anti-tuberculosis treatment, 21 (17%) developed PR at a median of 4.4 months after initiation of anti-tuberculosis treatment. The median duration of anti-tuberculosis treatment was 6.3 and 10.4 months in patients without and with PR, respectively. Development of PR was independently associated with age < 55 years (adjusted odds ratio [aOR], 5.72; 95% confidence interval [CI], 1.81–18.14; P = 0.003), lymphocyte count < 800/μL (aOR, 8.59; 95% CI, 1.60–46.20; P = 0.012), and short axis diameter of the largest lymph node (LN) ≥ 16 mm (aOR, 5.22; 95% CI, 1.70–16.00; P = 0.004) at the time of diagnosis of mediastinal LNTB.
Conclusion
As PR occurred in one of six patients with mediastinal LNTB during antituberculosis treatment, physicians should pay attention to patients with risk factors (younger age, lymphocytopenia, and larger LN) at the time of diagnosis.

Keyword

Lymph Node Tuberculosis; Mediastinum; Paradoxical Response; Endosonography

Figure

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  Fig. 1 Study flow diagram.EBUS-TBNA = endobronchial ultrasound-guided transbronchial needle aspiration, LNTB = lymph node tuberculosis, PR = paradoxical response, TB = tuberculosis.

• 

  Fig. 2 A representative case of a paradoxical response. A 52-year-old asymptomatic woman presented with incidentally discovered abnormalities on her chest images. (A) Contrast-enhanced CT scan showed a 15 × 21 mm enlarged LN with necrosis in the right upper paratracheal region. As a result of EBUS-TBNA, culture and histopathology for tuberculosis were negative, however the PCR test for MTB was positive. (B) On the 138th day of standard anti-tuberculosis treatment, an asymptomatic paradoxical response occurred as an enlargement of pre-existing lymphadenopathy (29 × 41 mm). As a result of the second EBUS-TBNA, culture for tuberculosis was negative, however PCR test for MTB was still positive. Histopathological results showed only necrotic tissue. The attending physician maintained standard anti-tuberculosis treatment and took monthly chest radiographs for evaluation of mediastinal widening. (C) On the 346th day of treatment, the size of the LN was reduced to 12 × 22 mm without evidence of necrosis inside the LN. Because the attending physician judged that there was no activity, treatment was completed on the 365th day.CT = computed tomography, EBUS-TBNA = endobronchial ultrasound-guided transbronchial needle aspiration, LN = lymph node, MTB = Mycobacterium tuberculosis, PCR = polymerase chain reaction.

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