Ann Thorac Surg 1995;59:644-646
© 1995 The Society of Thoracic Surgeons
Surgical Treatment of Childhood Mediastinal Tuberculous Lymphadenitis
Jorge Freixinet, MD, PhD,
Andres Varela, MD, PhD,
Luis Lopez Rivero, MD, PhD,
Jose A. Caminero, MD, PhD,
Felipe Rodríguez de Castro, MD, PhD,
Ana Serrano, MD, PhD
Thoracic Surgery, Respiratory, and Intensive Services, Nuestra Señora Del Pino Universitary Hospital, Las Palmas de Gran Canaria, Canary Islands, Spain
Accepted for publication November 11, 1994.
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Abstract
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Between 1985 and 1991, we treated 6 children, aged 2 months to 3 years, who required an invasive procedure for the management of complications caused by enlarged mediastinal lymph nodes secondary to tuberculosis. Radiologic and endoscopic studies revealed bronchial involvement by lymph nodes, with endobronchial granulomas and lobar or pulmonary obstruction in 4 patients and marked tracheal and esophageal stenosis produced by extrinsic compression in the remaining 2. Pathologic study of the lymph node or bronchial samples from the 6 patients disclosed granulomas with caseous necrosis and Langhans' giant cells. All the children were treated with a standard 6-month drug regimen consisting of isoniazid, rifampicin, and pyrazinamide. Five of the patients underwent thoracotomy for the purpose of nodal curettage or excision. In 1, upper right lobectomy and bronchoplasty were necessary. The sixth patient was treated by endoscopic resection of the granulomas. There was no postoperative morbidity, and radiologic and endoscopic evidence of resolution of the lesions was observed in all the patients. In our experience, surgical treatment, when performed as a coadjuvant treatment for tracheobronchial complications stemming from mediastinal tuberculous lymphadenitis, results in the resolution of the lesions and has no related morbidity.
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Introduction
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The prevalence of tracheal and bronchial involvement in patients with tuberculosis (TB) is unknown. In the prechemotherapy era, it was considered to be a rather common complication of cavitary TB of the lung [2, 5–9], but, since the introduction of effective chemotherapy, it has become a rare disorder [2]. Such tracheal and bronchial involvement in children can be a complication of primary TB. Enlarged mediastinal lymph nodes can provoke tracheobronchial compression or perforation, which produces acute and chronic complications. The early diagnosis of this type of involvement is essential, as a significant proportion of the patients will require therapeutic endoscopic or surgical treatment to prevent complications.
We present our experience in the management of childhood mediastinal tuberculous lymphadenitis, which consisted of either the endoscopic resection of the endobronchial involvement or the excision and curettage of the lymph nodes to try and prevent the complications that can evolve from this specific type of TB.
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Material and Methods
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Six children, aged 2 months to 3 years, were treated surgically to deal with enlarged mediastinal masses due to tuberculous lymphadenitis. In all, the masses caused the compression or perforation, or both, of either the trachea or the main bronchi. Bronchoscopy was always performed, and the diagnostic criteria were the detection of extrinsic compression, granulomas, or bronchial lymph fistulas. Rigid bronchoscopy was always performed with the patient under general anesthesia, and biopsy specimens were taken systematically for histologic and microbiologic studies.
All the children were treated with a standard 6-month drug regimen consisting of isoniazid (5 mg/kg) and rifampicin (10 mg/kg), supplemented with pyrazinamide (30 mg/kg) for the first 2 months. Surgical treatment was carried out when bronchoscopic resection of the granulomas did not bring about resolution of the lesions. The operation was performed once the general physical and nutritional condition of the child was assessed, and any severe systemic or nutritional problem detected had resolved.
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Results
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In Gran Canaria Island, between 1985 and 1991, TB was diagnosed in 65 children under 5 years old on the basis of clinical, radiologic, and microbiologic criteria. Six of these 65 children (9.23%) required endoscopic or surgical treatment for the management of mediastinal tuberculous lymphadenitis complications.
All patients had a history of household contact with TB. The result of the tuberculin skin test, performed with 2 units of purified protein derivative RT-23, was positive at the time of diagnosis in 3 patients; the remaining 3 tested positive 2 months later. In all cases, radiologic studies showed enlarged mediastinal lymph nodes compressing the bronchial tree that was causing atelectasis in 3 (Fig 1
) and air entrapment in the other 3. Esophageal compression was found in 2 patients (Fig 2).
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Fig 1. . Plain chest roentgenogram showing enlarged lymph nodes with compressive atelectasis of the right upper lobe.
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Fig 2. . Esophageal transit study showing extrinsic compression of the esophagus by tuberculous lymphadenopathy.
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Bronchoscopy showed obstructive lesions causing extrinsic compression in all the patients; granulomas were detected in 4. The lesions were on the right side in 4 children and on the left in 2, and always involved the upper lobes, although in 2 cases, there were also signs of compression in other lobes (middle and lower left lobes). Tracheal compression was observed in 2 patients and a bronchial lymph fistula in 4.
Histologic study of the tissue samples obtained demonstrated the presence of granulomas with caseous necrosis and Langhans' giant cells. Culture of the gastric lavage specimen in Lowenstein-Jensen medium yielded colonies of Mycobacterium tuberculosis in 4 patients. In 3 of these 4 patients, direct smear of the gastric lavage specimen revealed the presence of acid-fast bacilli.
Posterolateral thoracotomy at the level of the fifth intercostal space was indicated in 5 patients. In the remaining patient, endoscopic resection of the granuloma resolved the obstruction. In the 5 patients who underwent thoracotomy, lymph nodes were removed by curettage or excision. Right upper lobectomy with bronchoplastic resection was carried out in 1 patient because of the presence of irreversible parenchymal damage.
There was no postoperative morbidity or mortality. Clinical improvement and radiologic resolution of the lesions were observed in all the children, and this was confirmed by postoperative bronchoscopic examination in every case.
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Comment
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The first works describing mediastinal lymph node involvement in TB and its complications were published in the 1950s. This was also when the earliest studies were performed dealing with the surgical indications in these cases. In 1952, Thomas [3] published an article describing his experience with the surgical treatment of tuberculous lymph nodes producing obstruction phenomena in the respiratory tract. Later, in 1958, Jacobs [4] supported this treatment in a report of his experience.
The involvement of the trachea and large bronchi by TB can be produced by several mechanisms [2, 5–9]. In children, it is frequently a complication of primary TB, and it is known as tuberculous lymphadenitis involving the bronchi. This can be associated with enlarged mediastinal lymph nodes and endobronchial involvement resulting either from the formation of bronchial fistula, allowing passage of the caseous material contained in the lymph nodes, or from lymphatic dissemination throughout the bronchial tree, causing mucosal ulceration. Direct implantation of tuberculous bacilli from active parenchymatous lesions through the airway is most common in adults, but is unlikely in infants [2, 10, 11].
Mediastinal lymph node involvement usually occurs as a complication of primary TB, and, because of the greater lymphatic compromise in young TB patients, this disorder has been classically associated with childhood [1, 2]. At present, with the pandemic outbreak of the human immunodeficiency virus, there are increasing reports of its onset in adults infected by the virus who have a markedly reduced cellular immunity [12]. Enlarged masses of lymph nodes in the mediastinum may compress and even perforate the tracheobronchial tree [2, 10]. This process was considered common in the past, particularly in the prechemotherapy era, with compressive syndromes detected in up to 67.8% and bronchial perforations in 27.8% of the patients studied [13]. Nowadays, with the early institution of antibacterial therapy, this mode of onset of TB and its complications is thought to be rare [11]. Nevertheless, the real time incidence has not been established; an incidence of 9.23% was observed in our series [2]. Perhaps those children who have to live with sputum smear–positive patients in their early months of life, should receive the bacillus Calmette-Guerin vaccine, which has been shown to be effective in preventing the severe complications of childhood TB [14].
Surgical intervention is indicated when lymph node TB is accompanied by a severe compression picture caused by the lymphadenopathy, or when a bronchial lymph fistula is detected [11]. The predominantly endobronchial lesions can be resected endoscopically, which may circumvent the need for operation [15], as was done in 1 of our patients.
The most important surgical maneuvers are nodal incision and curettage. Attempts to dissect or remove the lymph nodes are not justified when considerable inflammatory adhesions are present, as this might provoke severe vascular accidents. Lung resection is not indicated unless there is irreversible parenchymal damage [11]. We have performed this type of operation only once, and a bronchoplastic procedure was required.
We conclude that, when these complications of childhood mediastinal lymph node TB arise, surgical treatment should be considered. In these cases, surgical intervention can prevent the appearance of residual endobronchial lesions, which could lead to the development of secondary complications. The morbidity and mortality associated with this type of surgical treatment are practically negligible.
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Footnotes
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Address reprint requests to Dr Freixinet, Thoracic Surgery Service, Ntra. Sra. del Pino Universitary Hospital, C/ Angel Guimerá 93, 35005 Las Palmas de Gran Canaria, Canary Islands, Spain.
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References
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Abstract
Introduction
