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CASE REPORT
Year : 2015  |  Volume : 32  |  Issue : 6  |  Page : 609-610  

An unusual cause of posterior mediastinal cyst


Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, Haryana and Punjab, India

Date of Web Publication23-Oct-2015

Correspondence Address:
Sahajal Dhooria
Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh-160 012, Haryana and Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-2113.168123

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   Abstract 

Cystic lesions of the mediastinum may be congenital or acquired. The differential diagnosis depends on their location in the mediastinum. Cysts in the posterior mediastinum are generally developmental cysts and are neurogenic or of foregut origin. We report the case of a 14-year-old boy, who presented with dry cough and progressively increasing breathlessness, and was found to have a cystic lesion in the posterior mediastinum. Fine needle aspiration from the cyst helped make a diagnosis of tuberculosis.

Keywords: Abscess, cystic, mass, mediastinum, tuberculosis


How to cite this article:
Dhooria S, Muthu V, Agarwal R. An unusual cause of posterior mediastinal cyst. Lung India 2015;32:609-10

How to cite this URL:
Dhooria S, Muthu V, Agarwal R. An unusual cause of posterior mediastinal cyst. Lung India [serial online] 2015 [cited 2019 Dec 14];32:609-10. Available from: http://www.lungindia.com/text.asp?2015/32/6/609/168123


   Introduction Top


Cystic lesions of the mediastinum constitute 10–15% of all radiographically detected mediastinal masses.[1] The cyst may either be congenital (developmental) or acquired. To a large extent, the differential diagnosis depends on its location in the mediastinum (anterior, middle or posterior compartments).[2],[3] The cysts of non-infective etiology may be complicated by secondary infection and certain primary infectious conditions such as hydatid disease can also present with mediastinal cysts.[4],[5],[6] Tuberculosis presenting as a posterior mediastinal cystic lesion has rarely been described.[7]


   Case Report Top


A 14-year old boy presented with a history of dry cough and progressively increasing breathlessness for a duration of three months. This was associated with dysphagia and stridulous noises on lying down (both supine and prone). There was no anorexia, weight loss or history of abdominal or back pain. His past medical history and family history were unremarkable. On examination, there was pallor. The rest of the physical examination was unremarkable.

A chest radiograph was performed, which revealed a widening of the superior mediastinum [Figure 1]. Computed tomography (CT) of the chest revealed the presence of a multiloculated cystic mass located posterior to the trachea, starting at the level of the thoracic inlet and extending to the level of the carina [Figure 2]. Laboratory investigations revealed anemia (hemoglobin 10.2 g/dL), with normal leucocytes (5,800/µL) and platelet counts (232,000/µL). He had deranged liver functions (bilirubin 0.3 mg/dL, aspartate transaminase 54 U/L [N, 0-35], alanine transaminase 103 U/L [N, 0-35], and alkaline phosphatase 212 U/L [N, 0-130]). An ultrasound of the abdomen showed normal liver size and echotexture.
Figure 1: Chest radiograph showing mediastinal widening in the superior part

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Figure 2: (a and b) Computed tomography (CT) of the chest depicting the cystic lesion posterior to the trachea

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The following diagnoses were considered: (a) Secondarily infected foregut duplication cyst, (b) bronchogenic cyst, (c) hydatid cyst, and (d) cystic schwannoma with secondary infection. The possibility of a paravertebral abscess due to tuberculosis was considered. However, it was deemed unlikely, as the patient did not have any fever or back pain, and the chest tomogram did not show any vertebral involvement.

Ultrasound-guided needle aspiration from the mass revealed well-defined epithelioid cell granulomas and multinucleated giant cells, with necrotic material in the background. Ziehl-Neelsen staining revealed acid-fast bacilli (AFB). A diagnosis of tuberculosis was made. The patient was started on antituberculosis treatment with rifampicin, isoniazid, pyrazinamide, and ethambutol in doses according to his weight. His symptoms improved and he became completely asymptomatic in a month. A CT chest repeated at three months showed complete disappearance of the mass [Figure 3].
Figure 3: (a and b) Computed tomography (CT) of the chest showing complete resolution of the lesion after treatment

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   Discussion Top


Mediastinal involvement with tuberculosis usually occurs in the form of enlarged lymph nodes.[8],[9] On a contrast-enhanced CT, tuberculous mediastinal lymph nodes show a central hypodense area, which is suggestive of central necrosis.[8] On an endobronchial ultrasound, such nodes demonstrate a heterogeneous echotexture and presence of a central necrosis sign.[10] Rarely, can tuberculosis cause mediastinal abscesses.[11],[12],[13] This occurs either as a result of extensive necrosis in the conglomerate tuberculous lymph nodes or as a result of a direct extension from a cervical cold abscess.[11],[12],[13]

The location of tuberculous mediastinal abscess is usually in the anterior or middle mediastinum, secondary to extensive involvement of the lymph nodes.[12] It appears in the paravertebral area when the vertebral column is involved.[11] The appearance of a cystic lesion in the retrotracheal and paravertebral area without involvement of the spine is unusual. Cases of posterior mediastinal masses due to tuberculosis have been reported previously.[7],[14] The index patient did not have back pain and there was no spinal involvement, as seen on the chest CT. We did not perform any specific imaging of the spine, as the diagnosis was already established and the clinical suspicion of spinal tuberculosis was low in view of lack of symptoms and no spinal involvement on CT.


   Conclusion Top


In conclusion, tuberculosis may present as a cystic lesion in the posterior mediastinum without any vertebral involvement. It may respond completely to anti-tuberculosis treatment without the need for surgical drainage.

 
   References Top

1.
Kirwan WO, Walbaum PR, McCormack RJ. Cystic intrathoracic derivatives of the foregut and their complications. Thorax 1973;28:424-8.  Back to cited text no. 1
    
2.
Goodman LR. The Mediastinum. Felson's Principles of Chest Roentgenology. 3rd ed. Philadelphia, Pennsylvania: Elsevier, Saunders; 2007.p. 155-74.  Back to cited text no. 2
    
3.
Hansell DM, Armstrong P, McAdams HP, Lynch DA. Mediastinal and Aortic Disease: Imaging of Diseases of the Chest. 5th ed. London, UK: Elsevier, Mosby; 2010.p. 881-1002.  Back to cited text no. 3
    
4.
Desai MB. Mediastinal multivesicular hydatid cyst. AJR Am J Roentgenol 1988;151:203.  Back to cited text no. 4
    
5.
Aghajanzadeh M, Khajeh Jahromi S, Hassanzadeh R, Ebrahimi H. Posterior mediastinal cyst. Arch Iran Med 2014;17:95-6.  Back to cited text no. 5
    
6.
Kabiri el H, Zidane A, Atoini F, Arsalane A, Bellamari H. Primary hydatid cyst of the posterior mediastinum. Asian Cardiovasc Thorac Ann 2007;15:e60-2.  Back to cited text no. 6
    
7.
Fisher D, Hiller N. Case report: Giant tuberculous cystic lymphangioma of posterior mediastinum, retroperitoneum and groin. Clin Radiol 1994;49:215-6.  Back to cited text no. 7
    
8.
Andreu J, CáceresJ, Pallisa E, Martinez-Rodriguez M. Radiological manifestations of pulmonary tuberculosis. Eur J Radiol 2004;51:139-49.  Back to cited text no. 8
    
9.
Agarwal R, Srinivas R, Aggarwal AN. Parenchymal pseudotumoral tuberculosis: Case series and systematic review of literature. Respir Med 2008;102:382-9.  Back to cited text no. 9
    
10.
Dhooria S, Agarwal R, Aggarwal AN, Bal A, Gupta N, Gupta D. Differentiating tuberculosis from sarcoidosis by sonographic characteristics of lymph nodes on endobronchial ultrasonography: A study of 165 patients. J Thorac Cardiovasc Surg 2014;148:662-7.  Back to cited text no. 10
    
11.
Mehtani A, Jha A, Kanojia RK, Sud A, Rath B. Tuberculosis of upper dorsal spine causing respiratory distress due to tracheo-oesophageal compression: An unusual presentation. J Indian Med Assoc 2013;111:192-3.  Back to cited text no. 11
    
12.
Naha K, Vivek G, Ramachandran P, Kansal N, Gupta MK, Rajagopal KV, et al. Tuberculous mediastinal abscess as a paradoxical reaction in an immunocompetent individual. BMJ Case Rep 2012; 2012. pii: bcr0120125498.  Back to cited text no. 12
    
13.
Samitas K, Marinakis E, Birbilis C, Thanos L, Zervas E, Gaga M, et al. Multiple tuberculous abscesses and mediastinal lymphadenitis with no pulmonary involvement in an immunocompetent patient. Indian J Tuberc 2012;59:235-9.  Back to cited text no. 13
    
14.
Xiong L, Mao X, Li C, Liu Z, Zhang Z. Posterior mediastinal tuberculous lymphadenitis with dysphagia as the main symptom: A case report and literature review. J Thorac Dis 2013;5:E189-94.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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