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Having cough. CT scan showed mediastinal lymph nodes. Not on medication. Looking for second opinion

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Pulmonologist
Practicing since : 2003
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Hi doctor, I am writing on behalf of my father, who has had a persistent cough for many months. A CT Scan was done last month which revealed mediastinal lymph nodes with possible parenchymal infiltration. Following this an ultrasound bronchoscopy was done and tissue samples taken for histopathology and cytology. No malignancy has been found. A second opinion was taken and again no malignancy has been found. There is evidence of non-specific lymphadenitis. The AFB culture reports are awaited. He still has his cough - not continuous but off and on. He is not currently on any medication as the doctor is awaiting the final test results (AFB) which will take another three weeks. I wanted a second opinion on how to proceed. Details of tests performed are being uploaded as a pdf.
Posted Sat, 28 Jul 2012 in Lung and Chest disorders
 
 
Answered by Dr. Gyanshankar Mishra 3 hours later
Hi,
Thanks for posting the query on XXXXXXX
After going through your query, I would like to comment the following:

1. The possibilities are
1. TB 2. Sarcoid 3. Malignancy 4. Infection

2. Till the reports are awaited, a 3 to 4 week course of antibiotics is recommended. Culture will confirm the diagnosis.
EBUS TBNA is currently the diagnostic modality of choice in such cases of mediastinal adenopathy and has been correctly done as per the existing protocols in your case.

3. Please get a mantoux test done & serum ACE levels done.

4. Keeping the pulmonary infiltrates in mind, TB and infective causes are a possibility followed by malignancy.

5. A course of broad spectrum antibiotics may be considered currently.

6. Since twice, the malignancy reports are negative hence it should be low on the possibility list.

I hope I have answered your query. I will be glad to answer follow up queries if any.
Please accept my answer if you have no follow up queries.

Regards

Dr. Gyanshankar Mishra
MBBS MD DNB
Above answer was peer-reviewed by
 
Follow-up: Having cough. CT scan showed mediastinal lymph nodes. Not on medication. Looking for second opinion 10 hours later
Thanks. Based on the reports so far, what are the likely infections (apart from TB)? Since there are no granulomas in the tissue, isn't it unlikely to be sarcoidosis?
 
 
Answered by Dr. Gyanshankar Mishra 14 hours later
Hi,
Thanks for writing back.
Although granulomas are characteristic of sarcoidosis, we must remember that the biopsy is always taken from a small portion and may not always be absolutely representative of the whole tissue,
As far as the infections are concerned, we could be looking at rarer varieties like atypical mycobacterial infection, actinomycosis, blastomycosis, tularemia and maybe even leishmania. But TB tops the list for probability.
Hope this helps.
Let me know if you need any more information
Above answer was peer-reviewed by
 
Follow-up: Having cough. CT scan showed mediastinal lymph nodes. Not on medication. Looking for second opinion 12 hours later
Thanks doctor. The pulmonologist we have been seeing here seems to think it is not TB but does not know what it is. Are there non-biopsy tests for the infections that you have mentioned above? I forgot to mention that my father has no other symptoms other than the cough - no weakness, shortness of breath, nodes in neck/collar bone region, loss of weight or appetite, pain etc. If TB is ruled out, what course of action would you advise? Thanks again.
 
 
Answered by Dr. Gyanshankar Mishra 10 hours later
Hi,
Thanks for the follow up.
After going through your followup query, I would like to comment the following:
1. The causes of mediastinal adenopathy can be either infective or non infective.
2. In infective causes -TB, non tb mycobacteria, bacterial infections, non specific adenitis. Remember, TB is never ruled out till culture is negative on the biopsy specimen and also one cannot dis regard the pulmonary infiltrates. If possible go for PCR based test along with traditional culture for diagnosis of TB. As I have already stated a course of broad spectrum antibiotics can definitely be tried in this case.
3. In non infectious causes malignancy tops the list. Other causes are very less likely in absence of any other feature or any other involvement elsewhere in the body.
4. My recommended line of action will be :
1. Wait for culture reports.
2. Meanwhile get mantoux test, esr, serum ace levels, if possible paraneoplastic markers, also just a collagen vascular profile done.
3. An empirical course of antibiotics of 3 to 4 weeks,and then titrate treatment as per culture reports.
4. In such cases depending on the merit if no response to anti biotics and in absence of any evidence of malignancy, an empirical course of anti tb drugs can be tried.

I hope I have answered your query. I will be glad to answer follow up queries if any.
Please accept my answer if you have no follow up queries.

Regards

Dr. Gyanshankar Mishra
MBBS MD DNB
Above answer was peer-reviewed by
 
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