Physical examination revealed an alert male, febrile to 39.4°C with a pulse of 104 beats per minute; findings from the remainder of the examination were unremarkable. Laboratory studies, including acid-fast smears, blood, urine, sputum, and stool cultures were nondiagnostic, and a tuberculin skin test and anergy panel were nonreactive.
Chest roentgenogram showed a widened mediastinum (Fig 1) and computed tomography of the chest confirmed the presence of paratracheal, hilar, and subcarinal lymphadenopathy (Fig 2). Bronchoscopy was performed and revealed a widened carina with some smooth extrinsic bulging into the right main-stem bronchus medially. Two transcarinal aspirates were performed at this site (Olympus NA-2C 21 gauge x 13-mm needle) with acid-fast smear and cytology specimens obtained. Following transcarinal aspiration, bronchoalveolar lavage and transbronchial biopsy specimens were obtained from the right upper lobe. Acid-fast smear and fungal stains were negative from the bronchoalveolar lavage, transbronchial biopsy specimens, and postbronchoscopy sputa. The transcarinal needle aspirate revealed respiratory mucosa with lymphocytes and plasma cells and on smear was positive for numerous acid-fast bacilli.
Figure 1. Posteroanterior roentgenogram revealing a widened superior mediastinum.
Figure 2. Axial section just below the carina demonstrating subcarinal lymphadenopathy.