International Journal of Current Research and Review
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IJCRR - Vol 06 Issue 06, March, 2014

Pages: 14-19

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ISOLATED MEDIASTINAL LYMPHADENOPATHY - ETIOLOGICAL ANALYSIS

Author: Mandal A., Pan K., Maity P. K., Panchadhyayee S., Sarkar G., Chakraborty S., Choudhury R., Chakrabarti S.

Category: Healthcare

Abstract:Background: The etiology of isolated mediastinal lymphadenopathy (without lung involvement or peripheral lymph node enlargement) is difficult to approach. Though various methods are available for histopathological confirmation, few literatures are there regarding the etiological diagnosis of isolated mediastinal lymphadenopathy. Aims and objective: This study was taken up with the aim to investigate the pattern of involvement of isolated mediastinal lymphadenopathy and to analyze the etiology among the adult patients presenting to a tertiary care institution in Eastern India. Materials and methods: A total of 50 patients were subjected to our study. Non-invasive investigation such as x-ray, CT scan, mantoux test etc. were done and these investigations established only a indirect evidence of etiological diagnosis. For definitive diagnosis, fine needle aspiration biopsy cytology ( FNABC) or biopsy from peripheral lymph node( if any) or various invasive investigations such as CT guided biopsy from mediastinal lymph node, bronchoscopy with transbronchial biopsy, mediastinoscopy or endobronchial ultrasound-guided transbronchial needle aspiration were done wherever feasible. Results: Overall tubercular lymphadenopathy was the most common (45 among 50 patients; 90%) followed by sarcoidosis (3 among 50 patients; 6%), lymphoma (1 among 50 patients; 2%) and carcinoma of lung ( 1 among 50 patients; 2%). Conclusion: So tuberculosis is the leading cause of isolated mediastinal lymphadenopathy.

Keywords: Mediastinal lymphadenopathy.

Full Text:

INTRODUCTION

Common causes of mediastinal lymphadenopathy include tuberculosis, sarcoidosis, lymphoma, metastatic lymph node, fungal infections, etc. In 1959, Lyons and coworkers1 reported lymphoma as a group was the most common (26%) followed by sacoidosis (20%), nonlymphomatous neoplasm including metastatic disease (16%), histoplamosis ( 7%) and Tuberculosis. Tubercular mediastinal lymphadenopathy is common in pediatric age group. However, isolated tubercular mediastinal lymphadenopathy without a parenchymal lung lesion in adults is unusual. The reason why different individuals respond differently to infection with mycobacterium tuberculosis had been reviewed by Crofton J et all2 . The prevalence of the tubercular mediastinal lymphadenopathy is encountered as high as 49% in children below the age of 3 years3 and the prevalence decreases with age4 . The prevalence of tubercular mediastinal lymphadenopathy has been reported to be from 4% to 67% in adults5-10 . Sarcoidosis has been reported from all over the world. It is prevalent in western countries. In India, the first proven case of sarcoidosis was described by Ghose andChakraborty in1956. In reported study, Gupta (1985) observed an incidence of 150 per100,000 among the hospital population in south Calcutta, while Chakraborty in Delhi found the incidence to be 61.2 per 100,000 population11 . In carcinoma lung, a mass lesion with or without collapse of lung is the most common finding , the chest skiagram is normal only in rare occasion. Though the finding of mediastinal widening in carcinoma of lung was 16.7% seen in a large Indian series of 1009 patients12 . In Hodgkin, s lymphoma, most patients present with palpable lymphadenopathy in the neck, supraclavicular area and axilla. More than half of the patients will have mediastinal adenopathy at diagnosis, and this is sometimes the initial manifestation13 . The aim of the study was to investigate the pattern of involvement of the isolated mediastinal lymphadenopathy and to analyze its etiological diagnosis in adult patients attending this tertiary care institution.

STUDY DESIGN AND

METHODS This is a prospective study carried out over a period of two years (January 2010 –January 2012) at the Institute Of Post Graduate Medical Education And Research, Kolkata. Those patients having mediastinal lymphnode enlargement demonstrated by chest x-ray without presence of other organ involvement like lung, liver, bone, spleen other than cervical lymphnode were included in this study. Besides routine investigations including complete haemogram, liver function tests, mantoux tests, chest x-ray, the following investigations were done accordingly – 1) Contrast enhanced computed tomography (CECT) of chest 2) Fine needle aspiration biopsy cytology (FNABC) and/or cervical lymph node biopsy . 3) Mediastonoscopy guided biopsy from mediastinal lymphnode 4) CT guided FNABC from mediastinal lymph node and bronchoscopy were done 5) Sputum for AFB (3 times) 6) HIV serology was done by ELISA with consent 

RESULTS

A total of 50 patients with isolated mediastinal lymphadenopathy diagnosed by chest X Ray were subjected to this study. Age at presentation ranged from 14-62 years. In this study population, 37 out of 50 patients were male. CECT scan was done in all 50 cases, It is evident that most common site of lymphadenopathy in tubercular group was right paratracheal nodes. Peripheral rim enhancement with low attenuation at the centre of the node was the most frequent pattern in tubercular group. Homogenous enhancement, inhomogenous enhancement and calcification of the involved lymphnodes were also seen in the same group. In sarcoidosis, both hilar and right paratracheal lymphnode involvement were seen. More than one site was involved in all cases. The distribution of lymphadenopathy and the pattern of nodal involvement have been depicted in table-1 and table-2 respectively. CECTscan revealed—lung infiltration in 16 cases, consolidation in 4 cases, retro-peritoneal lymphadenopathy in 4 cases, hypodense lesion in spleen in 2cases and in liver in 1 case in tubercular group. In sarcoidosis, lung involvement including peribronchial thickening and subpleural reticulo-nodular changes were seen in all 3 cases. Retro-peritoneal lymphadenopathy was seen in lymphoma. In carcinoma lung, lung involvement was seen. For confirmation of the diagnosis, peripheral lymph node biopsy from cervical region was done in 21 cases, CT guided mediastinal lymphRESULTS A total of 50 patients with isolated mediastinal lymphadenopathy diagnosed by chest X Ray were subjected to this study. Age at presentation ranged from 14-62 years. In this study population, 37 out of 50 patients were male. CECT scan was done in all 50 cases, It is evident that most common site of lymphadenopathy in tubercular group was right paratracheal nodes. Peripheral rim enhancement with low attenuation at the centre of the node was the most frequent pattern in tubercular group. Homogenous enhancement, inhomogenous enhancement and calcification of the involved lymphnodes were also seen in the same group. In sarcoidosis, both hilar and right paratracheal lymphnode involvement were seen. More than one site was involved in all cases. The distribution of lymphadenopathy and the pattern of nodal involvement have been depicted in table-1 and table-2 respectively. CECTscan revealed—lung infiltration in 16 cases, consolidation in 4 cases, retro-peritoneal lymphadenopathy in 4 cases, hypodense lesion in spleen in 2cases and in liver in 1 case in tubercular group. In sarcoidosis, lung involvement including peribronchial thickening and subpleural reticulo-nodular changes were seen in all 3 cases. Retro-peritoneal lymphadenopathy was seen in lymphoma. In carcinoma lung, lung involvement was seen. For confirmation of the diagnosis, peripheral lymph node biopsy from cervical region was done in 21 cases, CT guided mediastinal lymph node biopsy was done in 2 cases, bronchoscopy was done in 9 cases (bronchoalveolar lavage and transbronchial lung biopy were done), mediastinoscopy with mediastinal lymphnode biopsy was done in 2 cases, cold abscess aspiration in cervical region was done in 1 case. Diagnosis was made in 30 cases by isolation of organism( acid fast bacilli) or by presence of caseating granuloma as tubercular lymphadenopathy. Diagnosis of sarcoidosis was made by bronchoscopy (broncho-alveolar lavage and trasbronchial lung biopsy was done) in 3 cases. 1 case of carcinoma lung and 1 case of lymphoma were diagnosed by cervical lymph node biopsy. Investigation procedure required for diagnosis is shown in table-3. In the remaining 15 cases, the Mantoux reaction, presence of necrosis in mediastinal lymphnodes on CT scan finding and response to anti-tubercular treatment were the only evidence of tuberculosis and included in tubercular group. Tuberculin test - it is observed that 36 patients were positive in tubercular mediastinal lymphadenopathy group. So, among randomly taken 50 cases, tubercular lymph-adenopathy was the most common finding (45 cases) followed by sarcoidosis (3 cases), lymphoma (1 case) and carcinoma of lung (1 case).

DISCUSSION

We are prompted to undertake this study on account of several number of patients having isolated mediastinal lymphadenopathy are found in our outpatient department(O.P.D). Most of the patients had isolated mediastinal lymphadenopathy without any significant pulmonary parenchymal lesion, at least on plain x-ray of chest. CECT of chest is the standard investigation in patients with mediastinal lymphadenopathy. Radiologically, right paratracheal lymphnodes were most commonly involved in tubercular mediastinal lymphadenopathy5 . In our study, it is observed that in tubercular group, right paratracheal nodes was the most common site (89%) of involvement followed by subcarinal (66%) , pretracheal (55%) and hilar nodes in decreasing order of frequency. In tubercular mediastinal lymphadenopathy, peripheral rim enhancement with relative low attenuation at centre was the commonest pattern of nodal involvement 14-16 . In our study, it is observed that peripheral rim enhancement was the commonest pattern 53% followed by inhomogenous enhancement 24%. Homogenous enhancement was seen in 22% and nodal calcification was seen in 08%. Distribution of lymphadenopathy in tubercular group has been depicted in table-4.Pattern of nodal involvement in tubercular group of patients is shown in table-5.Determining the presence peripheral rim enhancement with relative low attenuation at centre of lymphnodes and location of lymphnodes in young adults with appropriate clinical setting is very helpful in differentiating tuberculosis from other causes of mediastinal lymphadenopathy. In sarcoidoisis, low density in mediastinal nodes is unusual. Lymphadenopathy in sarcoidosis is usually bilateral and hilar. Calcification is also described in sarcoid glands16. The associated reticulonodular pattern of lung parenchymal disease if present, may be a additional help. In our study, bilateral hilar lymphadenopathy was seen in all 3cases. Calcification of lymph nodes and reticulonodular pattern of lung involvement were seen in all 3 cases. In lymphoma group, the typical CT appearance of a nodal mass in a patient with Hodgkin , s disease is usually that of homogenous soft-tissue mass with sharply defined and often lobulated borders. Occasionally the centre of the nodal mass contains an area of decreased attenuation due to necrosis.17 In patient with metastatic lymphnode from lung cancer, the primary lung lesion is usually visible on CT scan. Visible low density within the metastatic nodes are not unusual15 . The granuloma in sarcoidosis may sometimes caseate, where in tuberculosis there may be absence of caseation. In view of above, diagnosis of tubercular mediastinal lymphadenopathy in present series of patients can only be considered to be a provisional one, except in those few in whom the AFB could be demonstrated. In area of high endemicity of tuberculosis, response to antituberculosis treatment may also consider to be diagnostic criteria for tubercular mediastinal lymphadenopathy. This is specially important, as methods for obtaining tissue diagnosis are sparingly available in developing countries where the disease is prevalent. CT scan is useful tool for diagnosis of mediastinal lymphadenopathy. The morphology of lymphnode on CT scan may help in diagnosing etiology, however, it is not specific. All efforts should be made to attend a cytological, microbiological, and histological diagnosis18. Invasive diagnostic tests including mediastinoscopy19 , bronchoscopy20,21 and endobronchial ultrasound- guided transbronchial needle aspiration22 should be undertaken for definitive diagnosis of mediastinal lymphadenopathy where facilities are available. CONCLUSION To conclude, though various differentials are there, tuberculosis is the leading cause of isolated mediastinal lymphadenopathy in our country. CECT of chest is the initial standard investigation to assass the pattern and characteristics of involved lymph nodes. Right paratracheal nodes was the most common site and peripheral rim enhancement with relative low attenuation at centre was the commonest pattern of nodal involvement in tubercular group.

 

References:

REFERENCES

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5. Amorosa JK, Smith PR, Cohen JR, Ramsy C, Leons HA. Tuberculous mediastinal lymphadenitis in adults. Radiology 1978;126:365-368.

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11. Gupta SK. Pande JN. Sarcoidosis. In : Pande JN.(ed).Respiratory Medicine In The Tropics. Oxford University Press :1998, p.366.

12. Jindal. S.k. Pulmonary neoplasm. In: Pande JN. (ed). Respiratory Medicine In The Tropics. Oxford University Press: 1998, p.443.

13. Longo .DL. Malignancies of lymphoid cells. In : Longo, Fauci, Kapser, Hauser, Jameson,Loscalzo (eds): Harrisons Principles Of Internal Medicine: 18th ed. Mc Graw Hill Medical.2012. p.934.

14. Pombo F, Rodriguez E,Mato J, Perez-Fontan J, Rivera E, Valuena L. Patterns of contrast enhancement of tuberculous lymph nodes demonstrated by computed tomography. Clin Radiol 1992;46:13-17.

15. Im JG, Song KS, Kang HS, Park JH, Yeon KM, Han ML. Mediastinal tubercular lymphadenitis: CT manifestation. Radiology 1987;164: 115-119.

16. Gulati M, Suri S, Kaur G, Jindal SK, Behera D. CT manifestations of tuberculous madiastinal lymphadenopathy. Indian J Chest Dis Allied Sci. 1994jan-mar;36(1) : 3-7

17. Graham R Cherryman, Bruno Morgan. The lymphatic system. In :Sutton D.(ed). Textbook of Radiology And Imaging. Elsevier Churchill livingstone.2012, p.527.

18. Tiwari M, Aryal G, Shrestha R, Rauniyar SK, Shrestha HG. Histopathologic diagnosis of lymph node biopsies. Nepal Med Coll J. 2007 Dec;9(4): 259-61.

19. Nalladaru ZM, Wessels A. The role of mediastinoscopy for diagnosis of isolated mediastinal lymphadenopathy. Indian J Surg. 2011 Aug; 73(4): 284-6.

20. Straddling P (ed). In : diagnostic bronchoscopy a teaching manual. Churchill Linvinstone 6 th edition,1991,p.72.

21. Trisolini R, Anevalvis S, Tinelli C, Orlandi P, Patelli M. CT pattern of lymphadenopathy in unteated patients undergoing bronchoscopy for suspected sarcoidosis. Respire Med. 2013 jun; 107(6):897-903.

22. Navani N, Lawrence DR, Kolveker S, Hayward M, McAsey D, Kocjan G, Falzon M, Capitanio A,Shaw P, Morris S, Omar RZ, Janes SM; REMEDY Trial Investigators. Endobronchial ultrasound- guided transbronchial needle aspiration prevents mediastinoscopies in the diagnosis of isolated mediastinal lymphadenopathy : a prospective trial. Am J Respir Crit Care Med. 2012 Aug 1; 186(3): 255-60.

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One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

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‘Emerging Researcher Award’ is instituted to encourage student researchers to publish their work in IJCRR. Student researchers, who intend to publish their research or review work in IJCRR as the first author are eligible to apply for this award. Editorial Board members decide on the selection of student researchers for the said award based on originality, novelty, and social applicability of the research work. Under this award selected student researcher is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.


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A Study by Monica K. entitled "Risk Predictors for Lymphoma Development in Sjogren Syndrome - A Systematic Review" is awarded Best Article for Vol 14 issue 13
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A Study by Gupta R. et al. entitled "A Clinical Study of Paediatric Tracheostomy: Our Experience in a Tertiary Care Hospital in North India" is awarded Best Article for Vol 13 issue 16
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A Study by Badritdinova MN et al. entitled "Peculiarities of a Pain in Patients with Ischemic Heart Disease in the Presence of Individual Combines of the Metabolic Syndrome" is awarded Best Article for Vol 12 issue 24
A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23
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A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21
A Study by Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20
A Study by Avijit Singh"Comparison of Post Operative Clinical Outcomes Between “Made in India” TTK Chitra Mechanical Heart Valve Versus St Jude Mechanical Heart Valve in Valve Replacement Surgery" is awarded Best Article for Vol 12 issue 19
A Study by Sonali Banerjee and Mary Mathews N. entitled "Exploring Quality of Life and Perceived Experiences Among Couples Undergoing Fertility Treatment in Western India: A Mixed Methodology" is awarded Best Article for Vol 12 issue 18
A Study by Jabbar Desai et al. entitled "Prevalence of Obstructive Airway Disease in Patients with Ischemic Heart Disease and Hypertension" is awarded Best Article for Vol 12 issue 17
A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
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A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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Disclaimer: International Journal of Current Research and Review (IJCRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal.



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International Journal of Current Research and Review (IJCRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal

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