Tuberculosis - multisystem involvement

The patient first presented to the ultrasonography unit for assessment of parotid enlargement and the abdomen.

Neck ultrasound revealed bilateral symmetrical infiltration of both parotid glands with small hypoechoic pseudo-nodules, mostly representing lymphoid infiltration. The submandibular glands are much less affected. Abdominal ultrasound revealed mild hepatosplenomegaly and porta-hepatis lymphadenopathy.

Chest CT was requested that showed generalised mediastinal lymphadenopathies which were non-specific and minor pulmonary changes seen as scattered conluent pulmonary nodules, giving the "galaxy sign". It is most commonly described in sarcoidosis, but is also seen in tuberculosis, progressive massive fibrosis and even tumours. However, it favours a benign aetiology.

These findings mostly represent a multisystem disease. We first thought of sarcoidosis as a possibility. The internest requested video-assisted thoracoscopic surgery (VATS) biopsy from hilar and mediastinal lymph nodes and lung biopsy which revealed tuberculosis. He started antituberculous treatment.

Multiple matted hypodense pathological enlarged mediastinal and bilateral hilar lymph nodes are noted; the largest. They are seen as follows:

At the right hilum measures 4x 3.5 cm in maximum diameter. It isattenuating and partially encasing the right main bronchus attenuating its still patent lumen it also encases the right lowerstem bronchi and middle lobar vessels; attenuatingpulmonary arteries with preserved patency of their lumen.

At the left hilum measures 6x 5.7 cm in maximum dimension. It encases the left main bronchus and attenuates its still patent lumen; as well as encasing the left main pulmonary artery; still showing normal opacification.

Pretracheal soft tissue sheet extending below the level of the carina measures collectively 7x 7 cm in maximum diameters.

This is associated with multiple suspiciousMultiple pulmonary parenchymal and sub-pleuralsubpleural nodules;, some shows Spiculatedirregular outline with peri-lesionperilesional fibrotic bands and centrilobular nodules;, the largest is seen at the apico-posterior segment of the left lower lung lobe measures 1.5x 2.5 cm in maximum diameter.

Scans through the upper abdomen revealed multiple para aortic, aorto-caval, celiac and porta hepatis pathological enlarged hypodense lymph nodes the latter is the largest measures 4x 3 cm.

The parotid glands bilaterally are enlarged with lobulated appearance, diffuse hypoechoic texture and thickening of interlobular septae as well as increased vascularity. No stones or ductal dilatation … features are suggestive of chronic parotitis (non-infective).

Multiple enlarged cervical lymph nodes are noted with heterogeneous hypoechoic texture, largest are both jugulodigastric nodes, the right one measures 3.7 x 0.9 cm … Cervical, in keeping with cervical lymphadenopathies.