'Beehive-like'appearance in thoracic tuberculous lymphadenopathy.

Sir,

A 12-year-old girl presented with intermittent fever of moderate grade, since 15 days with normal examination findings. Mantoux test was positive. Radiograph of chest showed hilar lymphadenopathy (Figure 1: Panel a: Red arrow). Computerised tomography of the thorax and abdomen with oral and intravenous contrast showed enlarged lymph node mass in the mediastinum with hypointense spaces giving 'beehive like appearance' likely due to necrosis/caseation at the centre of lymph nodes. Lymph node groups involved included superior mediastinal (Figure 1: Red arrows in panels b and e) and inferior mediastinal (yellow arrow in panel c and d) but sparing groups on the left of the aorta. Lung fields were clear. No lymph node masses were present in the abdomen. Blood tests revealed lymphocytosis and elevated erythrocyte sedimentation rate (100 mm/h). She was treated with standard antituberculous therapy [isoniazid 300 mg once a day [OD], rifampicin 450 mg OD, ethambutol 800 mg OD and pyrazinamide 1 g OD] and on follow-up after 1 month was responding to treatment with absence of fever and good appetite. Tuberculous lymphadenopathy has been reported in several publications.[12] However, the 'beehive appearance' in this case is striking in appearance and is important to be recognized for distinguishing from other causes of mediastinal masses in children such as lymphoma, germ cell tumour and neuroblastoma.[3] It is especially important when there is no primary lung focus visible on the chest X-ray as in our case. And it is an important non-invasive sign for tuberculous lymphadenopathy for early and proper management.

Figure 1

(a) X-ray chest: widened mediastinum due to enlarged lymph node mass. (b-d) Computerised tomography scan chest coronal view, e (axial view): beehive sign in tuberculosis-enlarged lymph node mass with cavities of various sizes surrounding tracheobronchial tree

Teaching point: This is a useful sign to distinguish tuberculous adenopathy from other mediastinal masses. This will help minimise the need for invasive tests such as fine-needle aspiration cytology studies or biopsy to detect tuberculosis.

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