Abstract
A 62-year-old Japanese man had been started maintenance hemodialysis due to diabetic nephropathy two years earlier. High inflammatory reaction persisted, and he developed high fever that did not respond to several antibiotics. Although there was no superficial lymphadenopathy during the clinical course, chest computed tomography showed enlargement of mediastinal lymph nodes. Whole-body positron emission computerized tomography demonstrated multiple foci of intense FDG uptake in the mediastinal lymph nodes. Evidence of Mycobacterium tuberculosis infection could not be obtained from sputum or urine specimens either by staining for acid-fast bacilli or with a polymerase chain reaction specific for tuberculosis (TB), or by culture. Although there was no history of TB, tuberculin-positive reaction and QuantiFERON® TB-2G (QFT) were positive. Since an increase in tumor markers, was also detected thoracoscopy mediastinal lymph node biopsy was performed, in order to differentiate mediastinal lymph node TB from lung cancer and malignant lymphoma. The specimen showed pathologic findings typical of Mycobacterium tuberculosis infection, with epithelioid granuloma including the multinucleate giant cell. Four anti-tuberculous combination therapies (INH, RFP, PZA, and SM) were initiated. After treatment, fever subsided, inflammatory response decreased. Although, TB is important as a cause of fever of unknown origin, a high rate of extrapulmonary TB in dialysis patients makes it more difficult to diagnose. Not only diagnostic imaging and organization diagnosis, but also serologic diagnosis QFT is useful for the diagnosis of TB in dialysis patients.
