Anthracosis and large mediastinal mass in a patient with healed pulmonary tuberculosis

The Curious Case of the Black Buboes

Anthracosis is an environmental lung disease caused by carbon deposition and pigmentation in the airways. However, in rare instances, it can also have systemic involvement. We present a patient with B-symptoms and diffuse lymphadenopathy who was diagnosed with the infrequently described nodal anthracosis. A 64-year-old Vietnamese gentleman with a 50-pack-year smoking history who was recently diagnosed with prostate cancer post-radical prostatectomy and awaiting radiation therapy presented with generalized weakness, low-grade fever, night sweats, and unquantifiable weight loss for a month. He was hemodynamically stable, and examination revealed bilateral inguinal and axillary lymphadenopathy. Computed tomography (CT) showed diffuse lymphadenopathy involving the mediastinum, hilar, axillary, mesenteric, retroperitoneal, and bilateral iliac chains with multiple diffuse pulmonary nodules. Laboratories disclosed anemia, thrombocytopenia, elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), albumin-globulin (A-G) reversal, and sterile blood cultures. The disseminated intravascular coagulation panel was negative with normal fibrinogen and mildly elevated D-dimer. Autoimmune workup, including antinuclear antibody (ANA), was negative. Infectious workup included Babesia, Ehrlichia, Anaplasma, Lyme serology, QuantiFERON-TB Gold, HIV, and hepatitis panel, and all were negative. He was managed with broad-spectrum antibiotics, which were discontinued after a negative infectious workup. He also complained of a new-onset holocranial headache with no features of meningitis; an MRI with contrast revealed focal occipital leptomeningeal involvement and cerebral edema with occipital lymphadenopathy. A lumbar puncture was planned but deferred at the patient's request. An excisional lymph node biopsy of the left axillary lymph node revealed reactive follicular hyperplasia with no evidence of malignancy, with flow cytometry negative for any evidence of B- or T-cell malignancies. He continued to have persistent low-grade fevers. A bone marrow biopsy showed 70% cellularity with paratrabecular interstitial lymphoid aggregates composed of both T and B cells, which was nonspecific, and flow cytometry could not be done due to dry tap. An F-18-fluorodeoxyglucose positron emission tomography (FDG PET) scan showed extensive hypermetabolic disease both above and below the diaphragm with bulky mediastinal adenopathy and splenomegaly. Subsequently, he underwent a mediastinoscopy and biopsy of the mediastinal lymph nodes, which demonstrated reactive hyperplasia and abundant anthracitic pigment on microscopic examination, consistent with the diagnosis of nodal anthracosis. He was managed conservatively, discharged, and found to have spontaneously resolved symptoms at a six-week follow-up. Nodal anthracosis with PET-positive mediastinal and hilar lymphadenopathy is a rare presentation of anthracosis that mimics infectious conditions, granulomatous diseases, and malignancies. The pigment deposition can cause persistent inflammatory activity and should be considered an infrequent but important explanation of lymphadenopathy in patients without known biomass exposure.

EBUS-TBNA Cytology Specimens are Predictive of Occupational Dust Exposure in Patients With Bilateral Mediastinal and Hilar Lymphadenopathy

OBJECTIVES

The aim of this study was to describe the cytological features of patients with significant occupational dust exposure presenting with benign bilateral mediastinal and hilar lymphadenopathy (BHL).

METHODS

A retrospective cohort study including patients undergoing EBUS-TBNA for investigation of benign BHL. Patient characteristics, dust exposure history, radiology, and cytology samples from EBUS-TBNA were assessed.

RESULTS

EBUS-TBNA cytology in patients with exposure showed a significant increase in the presence of birefringent fibers (60.7% vs 19.2%, P = 0.001) and intracellular carbon pigment (75.0% vs 28.9%, P = 0.001) compared with patients without exposure. The presence of these two features together yielded a sensitivity of 53.6% and a specificity of 88.5%.

CONCLUSION

In patients with BHL and a history of occupational dust exposure, the presence of birefringent fibers and intracellular carbon pigment in EBUS-TBNA cytology samples may assist in a diagnosis of lymphadenopathy due to occupational dust exposure.

Benign superior vena cava syndrome with uncontrolled pleural effusion by calcified mediastinal lymphadenopathy: surgical management

This report describes a rare case of benign superior vena cava syndrome (SVCS) accompanying recalcitrant pleural effusion developed secondary to extrinsic compression by anthracotic calcified mediastinal lymphadenopathy which was corrected by surgical bypass graft. An 81-year-old female presented with recalcitrant pleural effusion for several months despite of medical treatments. SVCS developed progressively without any other radiological evidence of malignancy or active infection on initial chest computed tomography (CT). A follow-up chest CT scan taken one month later revealed a poorly-defined mass-like lesion encasing the SVC. Near total collapse of the SVC due to circumferential compression by massive anthracotic calcified lymph nodes was noted in the surgical fields. A bypass graft was performed using an artificial vessel instead of endovascular treatment because of severe adhesion. The abrupt SVCS and uncontrolled pleural effusions completely disappeared after surgical correction.

Comparison of samples obtained from bronchoscopy of patients with and without bronchial anthracosis for investigating the prevalence of Mycobacterium tuberculosis

OBJECTIVE

Bronchial anthracosis is caused by the deposition of carbon, silica or asbestos particles in mucosal and submucosal cells and macrophages, and it can lead to chronic bronchial obstruction. Certain studies have reported an association between bronchial anthracosis and infection with Mycobacterium tuberculosis. This study aimed to compare the samples obtained from bronchoscopy of patients with and without bronchial anthracosis for investigating the prevalence of Mycobacterium tuberculosis.

METHODS

This was a cross-sectional study conducted between 2010 and 2013. A total of 514 patients underwent diagnostic bronchoscopy for pulmonary diseases. A sample of bronchoalveolar lavage fluid was taken from each patient and tested for Mycobacterium tuberculosis through smear and culture techniques. The data were analyzed with Chi-square and Fisher's exact test, with p ≤.05 set as the significant level.

RESULTS

Totally, 514 patients were evaluated through bronchoscopy; bronchial anthracosis was diagnosed in 207 cases, of which 129 (62.3%) were women. The rate of pulmonary tuberculosis was significantly higher (p = .002) in the bronchial anthracosis group.

CONCLUSION

In our study, the prevalence of pulmonary tuberculosis was significantly higher in the bronchial anthracosis group. Given that pulmonary tuberculosis is still one of the health problems of the present century, increased attention to specific risk factors including bronchial anthracosis in patients having pulmonary symptoms is recommended.

Primary nodal anthracosis identified by EBUS-TBNA as a cause of FDG PET/CT positive mediastinal lymphadenopathy

Isolated mediastinal lymphadenopathy can result from a number of potentially serious aetiologies. Traditionally those presenting with mediastinal lymphadenopathy would undergo mediastinoscopy to elucidate a final diagnosis or receive empirical treatment. There is now increased utilization of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), in this setting.

Five cases of mediastinal lymphadenopathy are presented here in which lymph node anthracosis was identified as the primary diagnosis using EBUS-TBNA. They were female, non-smokers presenting with non-specific symptoms, who retrospectively reported cooking over wood fires. Four were from South Asia. Three were investigated by F-18-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) scanning and increased signal was identified in the anthracotic nodes sampled.

With expansion of PET/CT and EBUS-TBNA services it is likely that primary nodal anthracosis will be encountered more frequently and should be considered in the differential diagnosis of those with PET/CT positive lymphadenopathy. It may mimic pathologies including tuberculosis and malignancy, thus accurate sampling and follow-up are essential.