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Reviono et al.

/ Para-aortic and meningitis tuberculosis: A case report

Para-aortic and Meningitis Tuberculosis:


A Case Report
Reviono1,2), Sari Apriliana R1),Yusup Subagio Sutanto1,2),
FX Soetejo3), Subandrio4)
1)Department of Pulmonology and Medical Respiration,Universitas Sebelas Maret
2)Dr. Moewardi Hospital, Surakarta
3)Department of Medical Neurology, Faculty of Medicine,

Universitas Sebelas Maret Dr. Moewardi Hospital, Surakarta


4)Department of Cardiothoracic-Surgery, Faculty of Medicine,

Universitas Sebelas Maret/Dr. Moewardi Hospital, Surakarta

ABSTRACT

Background: In 2018, Indonesia was at the third place as the country with the highest incidence
of tuberculosis (TB) in the world. In addition to pulmonary TB, extrapulmonary TB cases are also
quite large. Lymphadenitis of the aortic TB can cause a fatal risk if not treated immediately. This
study aimed to explore para-aortic and meningitis tuberculosis case in Klaten Hospital, Central
Java.
Case presentation: There was a 24-year-old woman with complaints of missing chest pain for 2
months, fear of seeing light (photophobia), and decreased consciousness. The patient was a referral
from Klaten Hospital with a diagnosis of mediastinal tumor. The chest radiograph shows a picture
of homogeneous opacity in the anterior mediastinum. Bronchoscopy results show compression
stenosis in 1/3 distal and blunt carina. After a sternotomy, it was obtained pus (pus) and tissue
granuloma in the area of the aorta. After the rapid molecular test was carried out, the results
showed that M tuberculosis detected. The results of histopathology of anatomical pathology show
epitheloid tubercle and Datia Langhans cells that suggest an infection with M. tuberculosis.
Therapy was done by giving a standard anti-tuberculosis drug, namely Rifampicin 450 mg, INH
300 mg, Ethambutol 1000 mg and Pyrazinamide 1000 mg. The patient's condition improved
marked by weight gain in 2 months.
Conclusion: In the case of pulmonary masses (mediastinal tumors), we need to be aware of the
possibility of cases of TB lymphadenitis because Indonesia is a country with a high prevalence of
TB. This is because a slow diagnosis can lead to life-threatening conditions

Keywords: Tuberculosis, para aorta limfadenitis, meningitis TB, tumor mediastinum, sternotomy

Correspondence:
Reviono. Department of Pulmonology and Medical Respiration, Universitas Sebelas Maret Jl. Ir.
Sutami 36A, Surakarta 57126, Central Java, Indonesia. Email: reviono@staff.uns.ac.id. Mobile:
+62818474671.

BACKGROUND rium tuberculosis can spread through the


Indonesia was in the third placeas the bloodstream or lymph causing extra pulmo-
country with the highest incidence of TB in nary TB (WHO, 2018; Zumla et al, 2013).
the world in 2018 after India and China. TB bacteria mostly attacked the lungs
Tuberculosis (TB) is an infectious disease but can hit other organs and are referred to
caused by Mycobacterium tuberculosis. as extrapulmonary TB (WHO, 2018;
Tuberculosis is transmitted through inhala- Baddeley et al. 2013; Jong, 2012). Cases of
tion of M. Tuberculosis-infected droplets extrapulmonary TB in the world based on
from patients to other people. Mycobacte- the 2018 Global Tuberculosis Report were

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estimated to be at 14% of 6,400,000 in hospital. Chest pain often arises and go and
2017. Cases of extra-pulmonary TB in does not penetrate backwards.
Indonesia were recorded at 15,697 of all The patient denied having a history
new TB cases totaling 331,424 (Baddeley et of diabetes mellitus, allergies, hypertension
al., 2013). Cases of reducing tuberculosis and heart. Patients often closed their eyes if
and paraaortic tuberculosis lymphadeno- there was bright light, fear of light
pathy were very rare. Management of extra- (photophobia). Patients also experienced a
pulmonary tuberculosis is an anti-tuber- decrease in consciousness. On laboratory
culosis drug. Lymphadenitis of the aortic cerebrospinal fluid examination, cell 3 re-
TB can cause a fatal risk if not treated sults were obtained and glucose decreased
immediately. Progress made in recent years in number 29. From the results of Magnetic
in medical management and tuberculosis resonance imaging (MRI) there were
surgery has encouraged the management of hypodense lesions in the right ganglia ward
tuberculosis which primarily affects the (in figure 1) patients were diagnosed as
aorta. This disease is important because it tuberculous meningitis and received anti-
will cause serious consequences if not treat- tuberculosis drug therapy since August 8,
ed. Generally, the aorta becomes involved 2017, Category 1 month to VII phase anti-
with a direct extension of the periaortic tuberculosis drugs with FDC Rifampicin
focus such as tuberculosis lymphatic nodes 150 mg and INH 150 mg 3 times a week
or abscess and ultimately results in aneu- (Monday, Wednesday, Friday) until now.
rysm or perforation or both. Fatal compli- Cerebrospinal fluid examination his-
cations can be prevented by early recog- tory showed immuno-examination of PCR
nition and immediate surgical intervention TB (-), PCR HSV (-), microbiology CMV
(Jong, 2012). PCR (-). Analysis of cerebrospinal fluid on
This report of a rare case of para- 7/15/2017 found the results of cell number
aorta tuberculosis lymphadenitis is a best 3, protein 15.3, glucose 29, nonne negative,
practice that explains from a radiological pandy negative, chloride L 115.
finding that it looks like a mediastinal mass The condition at admission was
turns out to be a case of tuberculosis infec- moderate, somnolence and nutrition were
tion, and cases of TB meningitis which are sufficient withweight 55 kilograms (kg),
life-threatening cases. This case highlights height 155 centimeters (cm), with Body
the importance of considering the possibi- Mass Index (BMI) 22.89 (normoweight).
lity of tuberculosis in lymphadenopathy Vital signs of 110/70 millimeter mercury
that is suspect as a mediastinal tumor. (mmHg), breath rate 19 times per minute
(x/minute) regularly, sufficient depth, pulse
CASE PRESENTATION rate 92 x/ minute regular rhythm, full
24-year-old woman to the emergency room contents and axillary temperature 36.8ºC,
of Dr. Moewardi hospital on February 28, pain score 5. Lung physical examination
2018 was referred from Klaten Hospital was obtained by inspections of static and
with a suspected mediastinal tumor, dynamic right chest development similar to
because there was a picture of the mass on the left, palpation of fremitus raba right the
the chest X-ray and thorax CT scan. same as left, dim percussion on Costa Inter
Patients present with chest complaints feel Spatium II-IV in right hemithorax and
pain since 2 months before entering the sonor on left, auscultation of right lung
vesicular base sound decreased at SIC II IV

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Reviono et al./ Para-aortic and meningitis tuberculosis: A case report

in the right hemithorax and normal on the extremities was carried out within normal
left, no dry cracks or wheezing are limits.
obtained. Examination of the abdomen and

A B

C D

Figure 1. A-D MRI of the head with enhancement in the right basal ganglia

Figure 2.AP / lateral chest X-ray with suspected anterior mediastinal mass

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Blood laboratory results show that it graph (MSCT), a picture of the mass in the
is within normal limits. Examination of paraaorta was obtained as shown in figure
Human Immunodeficiency Virus (HIV) (2). Bronchoscopy examination February
shows that it is non reactive. PA / lateral 20, 2018 concluded that compression
chest X-ray results in a homogeneous opa- stenosis was partially in 1/3 distal trachea
city in the anterior mediastinum. After con- and OPEN, blunt carina.
trast thoracic multislice computed tomo-

A B

Figure 3.A-B.Description of paraaortic mass on thoracic CT scan

Patients were given therapy for anti- lymph tissue were Mtuberculosis Detected
tuberculosis category I drugs namely Medium, Rifampicin resistance not detect-
Rifampicin (R) 1x450mg, Isoniazid (H) ed, the result of growth-free microorganism
1x300 mg, (E) Ethambutol 1 x 1000 mg, (Z) cultures. Anatomic pathology Thymus and
Pyrazinamide 1 x 1000 mg. The patient is lymph node tissue results from sclerosing
then operated on by a sternotomy. The pus mediastinitis, sarcoidosis/necrotizing sar-
(pus) and granuloma tissue in the aortic coidosis, granulomatosis, as shown in
region as seen in Figure 4, pus exploration figure 6 A-C.
and granuloma tissue extraction are seen. TB lymphadenitis response to the
Then carried out rapid molecular test (gene standard six-month anti-tuberculosis drug
X-pert) network. regimen was the initial phase 2 RHZE and
Postoperative patients were treated in the RH continuation phase is much longer
an intensive care unit (ICU), then an AP / than pulmonary TB, longer treatment for
lateral chest X-ray was performed as shown TB meningitis (Singh et al., 2018). Post-
in figure 6. Performed rapid molecular tests operative evaluation and outpatient care 1
of lymph tissue, culture and sensitivity of month chest pain decreases, appetite incre-
microorganisms and anatomical pathology. ases. The final evaluation of the second
The results of rapid molecular tests of month after surgery and anti-tuberculosis

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Reviono et al./ Para-aortic and meningitis tuberculosis: A case report

drug therapy the patient had no longer felt improvement so that anti-tuberculosis
chest pain, the weight went up 4 kg (BB 54 medication was continued with Rifampicin
kg) and never had a complaint of dizziness. 1x450 mg and INH 1x300 until now. The
Evaluation at the end of the second month patient's condition is now getting better,
after surgery and anti-tuberculosis drug appetite and weight gain (5 kg in 2
therapy showed clinical and radiological months).
A B C

D E F

Figure4.(A-B). Pus in the paraaorta during an exploration sternotomy was seen.


(C). Pieces of thymus tissue. (D-E).Pieces of granuloma tissue
In para aorta.(F). Slide on anatomical pathology examination

A B C

Figure 5.Results of pathology examination of lymphatic anatomy


on March 22, 2018. A. epitheloid tubercles with giant cells (H&E, 40X)
B. Giant cell langhans (H&E, 20X). C. Bone fragments with the focus of Datia
langhans cells (H&E, 20X).

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Figure 6. A. Chest X-ray postoperative evaluation in March 2018


it appears that homogeneous opacity in the mediastinum is reduced compared
to before surgery. B. Chest X-ray evaluation at the end of the 12th month
of anti-tuberculosis drugs, July 4th 2018 the lung is within normal limits

DISCUSSION lymph glands, but leakage occurs so that


Cases of extrapulmonary TB in Indonesia microorganisms enter the bloodstream and
were recorded to be at 15,697 of all new TB spread to distant organs or tissues.
cases totaling 331,424. Pulmonary tuber- Constitutional symptoms of extra-pulmo-
culosis was a TB case involving the pul- nary TB include fever, anorexia, weight
monary parenchyma or tracheobronchial, loss, malaise, and fatigue. Other symptoms
while extrapulmonary TB was a TB case appear according to the infected organ.
involving organs outside the lung paren- Lymph node swelling in the neck or armpit
chyma such as the pleura, lymph nodes, shows the possibility of TB lymphadenitis.
abdomen, genitourinary tract, skin, mem- Stiff neck, impaired consciousness indicates
branes of the brain, joints and bones. Re- the possibility of TB meningitis (Aderaye et
activation of TB can occur in all organs al, 2007).
where the tubercle bacillus spreads during Tuberculosis can occur in all organs
primary infection. The form of extra- where the tubercle bacillus spreads during
pulmonary tuberculosis such as chest wall primary infection. The form of the spread of
cold abces, paravertebral abscess occurs TB germs has several strategies in mani-
due to the displacement of tubercles from pulating the immune response of infected
the pleural cavity to the parasternal lymph hosts so they can avoid elimination and stay
glands and paraaorta followed by rupture of alive. Components of the Mycobacterium
the percutaneous focus in the lymph glands tuberculosis cell wall such as mannosecap-
so that the infection spreads to surrounding ped lipoarabinomannan (ManLAM) and 19-
tissues. Other forms of spread, for example kDa lipoprotein were identified as modu-
in genitourinary TB, were caused by tuber- lating the antigen presentation pathway
cles from the pleural cavity entering the and paralyzing the microbicidal function of

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Reviono et al./ Para-aortic and meningitis tuberculosis: A case report

macrophages and other immune cells. ents with tuberculous meningitis is normal
Other reactivities, for example, in genito- at the onset of the disease. As the disease
urinary TB are caused by tubercles from the progresses, a picture that is often found is
pleural cavity entering the lymph glands, enhancement in the basal area, visible
but leakage occurs so that microorganisms communicant hydrocephalus accompanied
enter the bloodstream and spread to distant by signs of brain edema or early focal
organs or tissues (Sharma et al, 2004). ischemia. It can also be found that silent
Tuberculous meningitis is the most tuberculomas are usually in the cerebral
fatal and deadly form of tuberculosis by cortex or thalamus area. Treatment of TB
causing permanent sequelae. This disease is meningitis starts with a four-drug regimen
the fifth most common pulmonary tuber- (RHZE). Provision of anti-tuberculosis drug
culosis and is estimated to be around 5.2% therapy is recommended for 9-12 months.
of all cases of extrapulmonary tuberculosis Recommended corticosteroids, prednisone
and 0.7% of all tuberculosis cases. TB 60–80 mg once daily and subsequently
meningitis usually occurs due to rupture of reduced in 4–6 weeks. Anti-tuberculosis
the subependimal tubercles into the sub- drug regimens are given postoperatively to
arachnoid cavity or because of hemato- prevent further spread (Sokolove et al,
genous spread of miliary TB. Onset of 2010).
meningitis occurs slowly with symptoms of TB lymphadenitis is the most frequent
subfebric fever, malaise, headache, and manifestation of extrapulmonary TB (42%)
photophobia. Central nerve paralysis espe- (Kreider, 2008). Lymphadenitis in develop-
cially in nerves III, IV, and VI (Sokolove et ing countries is more often caused by
al, 2010). Most involvement of cerebral TB infection with Mycobacterium tuberculosis.
is in the basal brain, with local arterial and TB lymphadenitis is common in children
venous vasculitis. Basal ganglia blood but is most common in young adult women
vessels are most commonly affected and are with an age of 20-40 years. 70% of TB
usually associated with movement dis- lymphadenitis patients only affect the cer-
orders. Current acute clinical symptoms are vical lymph nodes, 7% regarding the ingui-
cranial nerve deficits, headache, meningis- nal area, 7% regarding the axylary region,
mus, and changes in mental status. The and 16% regarding some areas (Golden et
prodromal symptoms that can be found are al, 2005; Lam et al, 2010). TB lympha-
headache, vomiting, photophobia, and denitis is often found in the hilar and
fever. Electrolyte disturbances such as hyp- mediastinal regions. Lymphadenitis often
natremia can occur. Cerebrospinal fluid occurs unilaterally but bilateral abnorma-
protein content (CSS) increases, glucose lities can occur due to lymphatic drainage
levels are low, white blood cell counts are 0- that crosses in the lower chest and neck
1500 cells/cc with the dominance of lym- area. The process of TB lymphadenitis is
phocytes, but at the initial stage is divided into several stages. In the early
dominated by PMN cells. Acid fast bacilli stages the nodules are enlarged, painless,
cultures from CSS with one lumbar punc- supple, well-defined, and semimobile. The
ture gave positive results in 37% of cases. next stage the nodule begins to harden,
Aspirates from serial lumbar puncture give attaches to the surrounding tissue, and the
positive results in 90% of cases. The skin above it starts to appear swollen and
description of CT scan and MRI (Magnetic red. The central part of the nodule fluctu-
Resonance Imaging) examination in pati- ates, indicating an abscess starts and

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eventually forms a sinus. Rupture of often found in the hilum and media
nodules can result in the spread of infection regions. Droplets infected with inhalated
to nearby nodules and the sinus tract that is tuberculosis M bacteria enter the alveoli.
formed can last for years and sometimes Basil M tuberculosis phagocytes by alveolar
requires surgical removal of the sinuses. macrophages and some germs occur hema-
Treatment without treatment can occur at togenously. The form of extrapulmonary TB
any stage with the formation of scar tissue such as chest wall cold abcess, paraverte-
and calcification, but more often develops bral abscess occurs because of the displace-
into caseosa and necrosis (Hopewell et al, ment of tubercles from the pleural cavity to
2010; Starke, 2011). the parasternal lymph glands and paraaorta
First-line management is an anti- followed by rupture of the percutaneous
tuberculosis drug. The response of TB focus in the lymph glands (Sharma et al,
lymphadenitis to the standard six-month 2004).
anti-tuberculosis drug regimen is the initial Patients had a history of TB mening-
phase 2 RHZE and the advanced phase 4 itis complaining of dizziness, fever, weak-
RH is much longer than pulmonary TB. ness, weight loss. Patients often close their
Nodules can enlarge, new nodules may eyes if there was bright light (photophobia).
appear, and fistulas can form during treat- Patients also experienced a decrease in
ment, although at the end of treatment it consciousness. On laboratory examination
can grow and relapse after treatment is of cerebrospinal fluid there were 3 cell
rare. Corticosteroid treatment is used to results and glucose decreased in number
shrink the intrathoracic glands and as a 29, from the results of MRI there was
bronchodilator, especially in children. enhancement in the right ganglia ward. TB
Surgical excision must still be combined meningitis resulted from the spread of
with anti-tuberculosis drugs because hematogenous infection to meninges.
lymphadenitis is part of a systemic During the course of TB meningitis through
infection so that when excision is carried 2 stages. Early lesions are formed in the
out, the infection is resolved (Starke, 2011; brain or meninges due to the spread of
Kreider et al, 2008). hematogenous bacilli during primary infec-
This patient was found to have tion. Hematogenous spread can also occur
extrapulmonary TB infection, namely the in chronic TB, but this condition was rarely
aortic TB lymphadenitis, initially diagnosed found. Furthermore, meningitis results
as a mediastinal mass. The results of rapid from the release of bacilli and TB antigens
molecular test (gene x-pert) examination of from caseous focus (initial lesions in the
lymph tissue obtained M tuberculosis brain) due to trauma or immunological
detected medium. The results of anatomical processes, directly into the sub-arachnoid
pathology of lymph tissue were obtained by space. Treatment of TB meningitis starts
granulomatosis, fibrosis, epitheloid cells with a four-drug regimen (RHZE). The
and giant cell langhans. TB lymphadenitis concentration of isoniazid and pyrazina-
occurs during primary infection or during mide increases in CSS when meninges are
reinfection or reactivation of previous inflamed. Rifampicin can penetrate the
infections. The pathogenesis of TB in this brain barrier. Provision of anti-tuberculosis
case occurs during primary infection or drug therapy is recommended for 9-12
during reinfection or reactivation of months. Corticosteroids namely prednisone
previous infections. TB lymphadenitis is 60–80 mg once daily and subsequently

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Reviono et al./ Para-aortic and meningitis tuberculosis: A case report

reduced in 4–6 weeks. Ventricular shunting monary tuberculosis. In: Getahun H,


may be needed if hydrocephalus occurs. editor. Improving the diagnosis and
Anti-tuberculosis drug regimens in intra- treatment of smear-negative pulmo-
cranial tuberculomas must be given before nary and extrapulmonary tuberculosis
surgery. Corticosteroids can reduce edema among adults and adolescents.
and relieve symptoms of hospitalization. Geneva: World Health Organization.
This case report presented a case of Baddeley A, Dean A, Dias HM, Falzon D,
aortic TB which was very rare, and cases of Floyd K, Garcia I, et al (2013). The
life-threatening TB meningitis. Previously burden of disease caused by TB. In:
the patient was suspected as a mediastin Raviglione M, editor. Global tuber-
tumor, then sternotomy was performed and culosis report 2013. Geneva: World
there was tissue granuloma. The results of Health Organization.
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need to be aware of the possibility of cases culosis. In: Mason RJ, Broaddus VC,
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a country with a high prevalence of TB. It DE, Murray JF, et al., editors. Murray
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AUTHOR CONTRIBUTIONS Jong E (2012). Extrapulmonary tubercu-
Reviono did para-aortic and meningitis losis: a challenging diagnosis. Johan-
tuberculosis surgery. Sari Apriliana R, nesburgh: TB/HIV Symposium; 2012
Yusup Subagio Sutanto, FX Soetejo, and Sept 16 [cited 2013 Jul 2]. Available
Subandrio did pathology assessment. from: http://www.anovahealth.co.za-
/images/uploads/ExtrapulmonaryTB-
CONFLICT OF INTEREST Jong.pdf.
None. Kreider ME, Rossman MD (2008). Clinical
presentation and treatment of tuber-
FUNDING AND SPONSORSHIP culosis. In: Fishman AP, editor. Fish-
None. man’s pulmonary disease and dis-
orders. 4th ed. New York: McGraw-
ACKNOWLEDGEMENT Hill.
We would like to thank to Klaten Hospital, Kreider ME, Rossman MD (2008). Clinical
Central Java, Indonesia for giving permission presentation and treatment of tuber-
in data cases collection. culosis. In: Fishman AP, editor. Fish-
man’s pulmonary disease and dis-
orders. 4th ed. New York: McGraw-Hill.
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Simplified and standardized clinical MC, Lenfant C, editors. Tuberculosis.
management guidelines for extrapul- 4th ed. New York: Informa Healthcare.

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