Case Presentation:

A 19‐year‐old African American male presented with 50‐pound of weight loss and poor appetite for 2 months. He reported difficulty in swallowing both solids and liquids. He experienced anterior and lower chest pain with every bite he swallowed. He reported occasional fever, generalized fatigue, malaise and mild dyspnea with exertion but no chest pain, nausea, or vomiting. He felt constipated but had no melena or hematochezia. He was a high school student with no recent travel, sick contacts, or pets. He reported no smoking, alcohol, drug abuse, or incarceration. His vitals were stable, and complete physical examination was normal. Laboratory investigations showed normal CBC, electrolytes, and liver panel. Chest x‐ray showed abnormal right hilar and right upper mediastinal density but clear lungs. Computerized tomography scan confirmed prominent mediastinal lymphadenopathy involving upper mediastinum and right hilum. Fungal serology revealed histoplasma antibody titer (1:64), but urinary histoplasma antigen was negative. LDH was normal and tuberculin skin test was inconclusive. Mediastinoscopy and peritracheal lymph node biopsy was performed. Tissue samples were negalive on fungal, acid‐fast, and gram staining. Aerobic and anaerobic cultures were negative after 2 weeks. Pathology showed necrotizing granulomas, and special stains reveal no definitive organisms. Cytology was negative for any malignant cells. Treatment for histoplasma was considered but not initiated because of insufficient evidence to suggest acute Infection. Four weeks later, cultures grew Mycobacterium tuberculosis, making the diagnosis of extrapulmonary tuberculosis involving the mediastinal lymph nodes. He was treated with isoniazid, pyrazinamide, rifampin, and ethambutol, and significant improvement in symptoms and chest x‐ray was noted within 2 months.

Discussion:

Tuberculosis in adults is traditionally thought to involve the lungs, but extrapulmonary presentation is found in up to 15% of cases. Isolated mediastinal tuberculous lymphadenitis is a relatively rare form of extrapulmonary tuberculosis that has a very nonspecific clinical presentation. The tuberculin skin test is usually positive, although not in our case. Our patient presented with dysphagia and odynophagia secondary to external compression on the esophagus caused by the tuberculous mediastinal lymph nodes. With treatment, the lymphadenopathy reduced in size and his dysphagia resolved. This case highlights the importance of considering extrapulmonary tuberculosis in the differential diagnosis of dysphagia associated with mediastinal lymphadenopathy.

Conclusions:

Dysphagia is an alarm symptom and needs immediate evaluation to establish the underlying etiology, especially when associated with weight loss.

Author Disclosure:

A. Verma, none; S. Vysetti, none; A. Moonat, none: D. Main, Nnone.