An 18-year-old female patient (school student) was hospitalized in the Affiliated Hospital of Xuzhou Medical University (Xuzhou, Jiangsu, China) in November 2017, due to intermittent left chest pain. Chest computed tomography (CT) showed left pleural effusion. Hydrothorax analysis demonstrated adenosine deaminase activity of 67 U/L and T cell test positive for TB infection, which suggested high possibility of TB infection. She thus received anti-TB treatment, including 0.3 g isoniazid (INH) (quaque die, qd), 0.6 g rifampicin (qd), 0.5 g pyrazinamide (ter in die, tid), and 0.75 g ethambutol (qd).
On January 14, the patient was hospitalized again in the initial hospital for repeated fever. During the treatment, she was found enlargement of supraclavicular and mediastinal lymph nodes, hypoechoic nodules outside the envelope of the left external lobe of liver (suggestive of involvement of lymph nodes), splenomegaly, multiple hypoechoic area within spleen (suggestive of TB), and a small amount of pelvic effusion. On February 2, she received supraclavicular lymph node puncture for histological observation, which showed many neutrophils, lymphocytes and phagocytes and a few epithelioid cells. This indicated that the possibility of scrofula could not be excluded. Since April 1 she began to exhibit symptoms of chest distress. The chest CT reexamination on April 6 revealed patchy and nodular shadow with increased density in the right upper lung, enlarged lymph nodes in the mediastinum and right supraclavicular region, with uneven enhancement, and necrotic areas (liquefaction area) in the interior. Enlarged mediastinal lymph nodes obviously compressed to narrow the trachea. The main bronchus on both sides were clear, and no obvious effusion was observed in the thorax on both sides (Fig. 1).
The patient was then admitted to Shanghai Pulmonary Hospital (Shanghai, China) for further treatment. After admission, the patient underwent physical examination: temperature 37 °C, pulse 80 times/min, respiration 18 times/min, and blood pressure 130/80 mmHg. She had a clear consciousness, without cyanosis in the mouth and lips, and had thick breath sound from both lungs, without obvious dry and wet rales. The heart rate was 80 times/min and heart rhythms were regular. Abdomen was smooth and soft, liver and spleen did not reach below costal, and pathological sign was (−). No edema was seen in both lower limbs. Blood gas analysis for pulmonary function on April 9, 2018 showed: pH 7.41, partial pressure of carbon dioxide 39.4 mmHg, oxygen partial pressure 108 mmHg↑, total hemoglobin 11.1 g/dL↓, oxygen saturation 99.2%, standard base excess 0.6 mmol/L, actual base excess 0.6 mmol/L, actual bicarbonate 24.7 mmol/L, standard bicarbonate 25.0 mmol/L, and alveolar artery oxygen partial pressure difference 0.0 mmHg ↓. Blood routine analysis on April 10, 2018 were as follows: hemoglobin 106.0 g/L↓, red blood cells 4.11*1012/L, white blood cells 5.19*109/L, neutrophils % 66.3, lymphocytes % 21.4, monocytes % 9.6↑, eosinophils % 2.5, basophils % 0.2, absolute neutrophils amount 3.44*109/L, absolute lymphocyte amount 1.11*109/L, absolute monocytes count 0.50*109/L, platelets 269*109/L, hematocrit 0.323 L/L↓, mean red blood cell volume 79 fL↓, and mean hemoglobin content 26 pg↓. Blood biochemical assay on April 10, 2018 showed: r-glutamine transferase 42 U/L, alanine aminotransferase 13 U/L, aspertate aminotransferase 27 U/L, aspertate aminotransferase isoenzyme 6 IU/L, alkaline phosphatase 87 U/L, total bilirubin 11.0 μmol/L, direct bilirubin 3.6 μmol/L, total bile acid 2.9 μmol/L, total protein 78 g/L, albumin 42 g/L, globulin 35 g/L, albumin/globulin 1.2 ↓, prealbumin 185 mg/L ↓, α- L-fucosidase 17 U/L, uric acid 530 μmol/L ↑, urea nitrogen 3.3 mmol/L, creatinine 43 μmol/L↓, glucose 5.2 mmol/L, potassium 3.6 mmol/L, sodium 139 mmol/L, chlorine 106 mmol/L, calcium 2.40 mmol/L, and phosphorus 1.52 mmol/L.
The patient continued receiving systemic anti-TB treatment during the whole course, including 0.3 g INH (peros, po/qd), 0.6 g rifampicin (po/qd), 0.75 g ethambutol (po/qd), and 0.5 g pyrazinamide (po/tid). All the drugs were purchased from the Shanghai Sine Pharma (Shanghai, China). On April 11, she received EBUS- TBNA treatment, namely, EBUS examination, with the help of an ultrasonic tracheoscope (UMBS20-26R, Olympus, Shinjuku, Tokyo, Japan) and the corresponding EU-C2000 ultrasound processing apparatus (Olympus), to observe the enlarged mediastinal lymph nodes at the Four Right group, followed by puncturing and aspirating all the pus (about 5 ml) from the abscess with a specific 21-G needle (NA-201SX-4022, Olympus) (Fig. 2). Then 0.1 g INH injection (Southwest Pharma, Chongqing, China) was administered through the needle during EBUS-TBNA. The pus underwent smear detection to show positive for acid bacillus and simultaneously, the pus was sent out for cytopathological examination. There was no obvious main complaint of discomfort from the patient after operation.
Cytopathological examination for the aspirated pus indicated inflammatory necrosis tissues and a few epithelioid cells (Fig. 3). Polymerase chain reaction (PCR) assay showed the pus sample was positive for the detection of prokaryotic 16S RNA gene, RV0577 coding an important antigen RV0577 in TB patients [11, 12], and IS6110 fragment, an insert fragment within TB [13, 14], indicating the presence of featured DNA fragments of TB. The smear examination of pus showed positive for acid bacillus. These indicate the infection of Mycobacterium TB in the patient. Collectively, the MLNTB was determined.
On April 24 and May 10, she received two times of EBUS-TBNA to puncture and aspirate pus, 2 ml for each time, and to administer 0.1 g INH injection each time. After that, the symptoms of chest distress were obviously relieved. On May 29, she received electronic bronchoscopic examination and was found granulomatous neoplasm at the EBUS-TBNA site on the trachea wall (Fig. 4).
To treat the granulomatous neoplasm occurring after the EBUS-TBNA procedure, the patient then received local clamp removal treatment and cryotherapy for 90 s after EBUS-TBNA on May 29 and Jul 19, respectively, by using a K320 cryosurgery treatment machine (Beijing Kooland Medical Equipment Co., Beijing, China), with the probe temperature of − 40 ~ − 75 °C. Chest CT reexamination on May 30 indicated the MLNTA lesion was obviously decreased (Fig. 5). Chest CT reexamination on July 17 revealed that the MLNTA lesion had been basically absorbed, and that on September 28 confirmed that the MLNTA lesion had been completely absorbed (Fig. 6). Electronic bronchoscopic reexamination on July 19 showed the granulomatous neoplasm at the EBUS-TBNA site on the trachea wall was obviously decreased, and that on September 30 demonstrated that the granulomatous neoplasm on the trachea wall was entirely invisible (Fig. 7). At this point, the symptoms of chest distress were completely disappeared, and the patient achieved satisfactory treatment. The timeline for the diagnosis and treatment of MLNTA in this patient was summarized in Fig. 8.
This study was approved by the Ethics Committee of the Shanghai Pulmonary Hospital, Tongji University School of Medicine. Informed consent was obtained from the patient.
