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2020년 제 71차 대한내과학회 추계학술대회
￭S-214 ￭ A case of paradoxical reaction presenting large mediastinal mass
after treatment of TB pericarditis
고려대학교 의과대학 내과학교실 김재우, 배성아, 김소리, 김미나, 박성미
Introduction: Tuberculosis with paradoxical reaction is defined as a temporal exacerbation of symptoms and radiographic manifestation of Tuberculosis after treatment and is considered rare among immunocompetent hosts. Even fewer cases have been reported in TB pericarditis. We present a case of 40- year-old male who had paradoxical reaction with mediastinal abscess formation after treatment of TB pericarditis.
Case Presentation: A 40-year-old male patient visited emergency room for chest pain and febrile sense for 10 days. He didn’t have any past medical history. His heart rate was 116rpm, and his blood pressure was 123/85mmHg. EKG showed sinus tachycardia with low voltage QRS complex. Echocardiography showed massive pericardial effusion with tamponade physiology, then we performed pericardiocentesis. Pericardial fluid analysis showed WBC count 2500/ul (lymphocyte 89%) and ADA 134.9 IU/L and we started TB medication and oral steroids. After 4 months of TB medication the patient he complained skipping heart beats. On follow up echocardiography, no pericardial effusion, but newly developed 3.4x2.7cm sized large echogenic mass was seen between the left atrium and aorta. Chest CT showed peripherally enhancing mediastinal mass with inhomogeneous intensity. Mediastinal abscess or invasive sarcoma was suspected since he took anti-tuberculosis medication well following a standard regimen and there was no pericardial effusion. Surgical removal of mass was proceeded and calcified and hard mass with adhesion to ascending aorta, left atrium and pulmonary artery was found. Fortunately, histopathologic exam showed no malignant cells but chronic inflammation with granuloma. Real time PCR for tuberculosis was positive. After the operation his symptom subsided and the patient continued additional Tuberculosis medication.
Discussion: Tuberculosis with paradoxical reaction presenting large mediastinal mass is rare especially in tuberculosis pericarditis setting. In addition, it should be kept in mind as a differential diagnosis for Tuberculosis treatment failure and others.
