Title : Isolated Internal jugular vein thrombosis as the initial indicator of disseminated tuberculosis
Abstract:
Tuberculosis is a highly prevalent communicable disease with the most common presentation being of pulmonary origin. It is mostly found in the South Asian and Sub-Saharan African regions. One possible extrapulmonary manifestation is that involving the central nervous system, which poses a diagnostic challenge as it shares common traits with other infectious entities. Of the rare potential complications of tuberculosis is predisposition to venous thrombosis. Only a few cases have been reported in literature with the sites being in the lower limbs and in the brain.
A previously healthy 24-year-old woman presents with asymptomatic neck swelling. Ultrasound of the neck showed unprovoked internal jugular vein thrombosis. Anticoagulation was initiated. A month later, she developed a first-time seizure episode while in her home country and empiric levetiracetam was started. CT imaging of the neck further revealed enlarged necrotic paratracheal lymph nodes. Findings were concerning for high grade lymphoma. Lymph node biopsy was deferred due to travel plans. Later on, patient presented with increasing shortness of breath and occasional headaches. Head CT was performed which showed a large hypodensity involving the white matter of left cerebral hemisphere, associated with brain oedema with underlying lesions causing mass effect with midline shift. An MRI of the head done for further characterization was notable for several ring-enhanced lesions. The differentials included tuberculomas, neurocysticercosis, toxoplasmosis, septic emboli and lymphoma. Mediastinoscopy lymph node biopsy was carried out following the infectious disease team recommendation. Tissue sample showed necrotizing granulomatous lymphadenitis. The diagnosis of Disseminated tuberculosis was made and antitubercular medication was initiated.
The case highlights the diagnostic challenge posed by overlapping symptoms and radiologically indistinct findings seen in both infectious and lymphoproliferative conditions. This emphasizes the importance of tissue sampling for definitive diagnosis and taking into consideration the epidemiological determinants of tuberculosis to help navigate such cases. Moreover, it also affirms the importance of viewing tuberculosis as a potential risk factor for venous thrombosis.
