Seeing Through the Chest: EBUS-TBNA Diagnosis of Tuberculous Mediastinal Lymphadenitis

A 45-year-old female homemaker presented with a three-week history of dry cough, progressive weight loss, and exertional dyspnoea. Investigations revealed an elevated ESR of 65 mm/hour. CT thorax demonstrated a right lower paratracheal mediastinal mass causing significant tracheal narrowing and leftward deviation — demanding urgent, precise evaluation.

Flexible bronchoscopy confirmed extraluminal tracheal compression. Endobronchial Ultrasound with Transbronchial Needle Aspiration (EBUS-TBNA) was performed — a real-time ultrasound-guided technique enabling direct sampling of mediastinal lymph nodes through the airway wall. The 4R (right lower paratracheal) lymph node was sampled.

Histopathology revealed necrotising granulomatous inflammation with caseation and Langhans giant cells — the hallmark of tuberculosis. Microbiological confirmation followed: acid-fast bacilli staining, TB PCR, and culture were all positive. Standard first-line anti-tuberculous therapy (HRZE) was commenced alongside nutritional support.

Follow-up imaging demonstrated marked radiological resolution of the mediastinal mass, tracheal decompression, and full clinical recovery. This case powerfully illustrates the transformative diagnostic role of EBUS-TBNA — delivering tissue-proven diagnosis with minimal patient risk, enabling targeted early treatment and an excellent outcome.

Key Learning Points:

• EBUS-TBNA is the first-line minimally invasive tool for mediastinal mass diagnosis.
• TB must remain in the differential diagnosis of mediastinal lymphadenopathy.
• Caseating granulomas on histology plus positive TB PCR and culture provide definitive diagnosis.
• Early diagnosis enables prompt treatment, preventing life-threatening complications including tracheal obstruction.

Credit: Case managed and reported by Dr. Shamil P.K. , Specialist Interventional Pulmonologist, Critical Care & Sleep Medicine