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Ann Thorac Surg 2002;74:261-263
© 2002 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Barts and the London NHS Trust, London, United Kingdom
b Department of Respiratory Medicine, Barts and the London NHS Trust, London, United Kingdom
Accepted for publication December 5, 2001.
* Address reprint requests to Mr Wong, Department of Cardiothoracic Surgery, Barts and the London NHS Trust, West Smithfield, London EC1A 7BE, UK
e-mail: kit.wong{at}bartsandthelondon.nhs.uk
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On examination he was alert, pyrexial at 39°C, clinically in atrial fibrillation, and tachypneic, although able to complete sentences with no audible stridor. There were no murmurs and no palpable lymphadenopathy or splenomegaly, and testes were normal. Respiratory examination revealed a diffuse expiratory wheeze. Arterial blood gases on air were pH, 7.43; arterial partial pressure of oxygen, 6.42 kPa; arterial partial pressure of carbon dioxide, 5.73 kPa; arterial plasma bicarbonate, 28.2 mmol/L; base excess, 3.9; and oxygen saturation, 84.6%.
A plain chest radiograph showed a large cardiac silhouette, widening of the mediastinum, and compression of the proximal airway. An urgent computed tomographic chest scan was arranged but was not tolerated because of orthopnea.
A full blood count showed severe hypochromic microcytic anemia (hemoglobin, 8.2 g/dL; white blood cell count, 8.1 x 109/L; neutrophils, 6.3 x 109/L; platelets, 325 x 109/L; mean corpuscular volume, 78 fL). A peripheral blood film showed no blasts or other malignant cells. Blood biochemistry and bone profile were normal. An antibody test for human immunodeficiency virus-1 and human immunodeficiency virus-2 was negative.
The patient was treated with high-flow oxygen, nebu1ized bronchodilators, and broad-spectrum intravenous antibiotics. Electrocardiogram confirmed fast atrial fibrillation, and digoxin was commenced. The clinical picture was believed to be that of a rapidly progressive lymphoma causing severe airway obstruction. He was therefore transferred to the oncology unit, and chemotherapy was commenced. However, a subsequent bone marrow trephine was normal.
A transthoracic echocardiogram showed a large exudative pericardial effusion with no tamponade, and the patient underwent elective intubation and ventilation so that a computed tomographic scan could be performed. Figure 1A shows his postintubation chest radiograph. The computed tomographic scans confirmed the presence of pericardial fluid up to 7 cm in depth over the cardiac apex and a separate right anterior mediastinal mass (Fig 2). There were multiple nonenhancing enlarged lymph nodes within the upper and middle mediastinum causing extrinsic compression of the central airway. There were no focal visceral lesions, spleen size was normal, and there was no abdominal lymphadenopathy. During the imaging the patient became dependent on inotropic agents and was transferred to the intensive care unit.
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The patient continued to be cardiovascularly unstable with hypotension and frequent arrhythmias. He required multiple direct current cardioversions, and his ventilatory requirements continued to increase. Streptomycin was added in an attempt to expedite a reduction in airway compression. The hemodynamic instability necessitated ultrasound guided aspiration of 850 mL of pericardial fluid, which produced a clinical improvement. Bilateral pleural effusions were drained the following day.
Tracheostomy was subsequently performed, and the patient was weaned from the ventilator after 21 days. He was discharged home 70 days after admission and is currently followed up in the outpatient department. One year after discharge, he is well, his chest radiograph is normal (Figure 1b), and he has returned to employment.
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Thymomas are the most common primary tumors of the anterior mediastinum. Most patients are asymptomatic; one third complain of chest pain, cough, dyspnea, or other symptoms related to compression of adjacent structures [1]. Thymic tuberculosis is extremely rare. There are only two reported cases in the medical literature in the last decade [2, 3]. Both of these were initially diagnosed as thymomas, the patients having radiologic evidence of an anterior mediastinal mass and no systemic features of mycobacterial infection, and were not acutely unwell. These patients had solid thymic masses, which were excised and found histologically to have tuberculosis. In our patient, the anterior mediastinal mass was cystic and filled with dark blood and was probably caused by a spontaneous hemorrhage in the thymic gland secondary to tuberculosis.
Acute respiratory failure occurs in approximately 1.5% of hospitalized tuberculosis patients, with a mortality of approximately one third of patients [4, 5]. The respiratory failure tends to be associated with tuberculous bronchopneumonia with or without airway obstruction secondary to enlarged mediastinal lymph nodes. Airway obstruction is more commonly seen in children because of the softer cartilage in their bronchial airways. It was therefore unusual for our patient to present with airway compression causing severe dyspnea. His respiratory function was also further compromised by the pericardial and extrapericardial collections and fast atrial fibrillation that was resistant to therapy.
The management of our patient’s airways was also a major problem. It was believed that he was unsuitable for bronchial stenting, and surgical decompression was considered. Surgical debulking of lymph nodes has been reported in the literature when there is no marked initial response to appropriate antituberculous therapy and steroids, although this is more commonly undertaken in children [6]. In this group of patients, an aggressive surgical approach is relatively safe, provided the lymph nodes are decompressed by incision and curettage and not excision, which is associated with increased complications. However, as the patient’s condition dramatically improved after percutaneous aspiration of his pericardial and pleural collections and continued antituberculous chemotherapy, surgical decompression was not necessary.
This case illustrates the extensive clinical problems that can be associated with extrapulmonary tuberculous infection and highlights the importance of early multidisciplinary involvement and a careful joint management strategy.
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This article has been cited by other articles:
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  A. Maydell, P. Goussard, S. Andronikou, F. Bezuidenhout, C. Ackermann, and R. Gie Radiological changes post-lymph node enucleation for airway obstruction in children with pulmonary tuberculosis Eur J Cardiothorac Surg, October 1, 2010; 38(4): 478 - 483. [Abstract] [Full Text] [PDF]
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