Retropharyngeal Tuberculous Lymphadenitis as a Paradoxical Reaction in an Immunocompetent Child: A Case Report
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Abstract
Background: Paradoxical reactions during antituberculous therapy represent an immunologically driven worsening of clinical or radiological findings in patients with confirmed tuberculosis responding to appropriate treatment. Retropharyngeal localization of such a reaction constitutes an exceptionally rare and potentially life-threatening complication due to its close proximity to the airway.
Case Presentation: We report the case of a 12-year-old immunocompetent girl with no significant past medical history, presenting with bilateral cervical lymphadenopathy (level IIb) over a two month period in the context of close household TB contact. Histopathological examination of an excised cervical node confirmed tuberculous lymphadenitis, and antituberculous treatment was initiated. Six weeks into treatment, the patient developed a paradoxical reaction manifesting as dysphagia, dyspnoea, and nocturnal snoring. Clinical examination revealed oropharyngeal bulging and nasofibroscopy confirmed significant narrowing of the upper airway. Cervical CT Scan revealed a retropharyngeal conglomerate of necrotic lymphadenopathies on the left side, the largest measuring 20×15 mm, causing anterior displacement and bulging of the pharyngeal wall. The patient underwent successful transoral surgical excision of the retropharyngeal lymphadenopathic mass. GeneXpert MTB/RIF assay and histopathology confirmed the diagnosis of tuberculosis. The patient was maintained on ATT with favourable outcome at three-month follow-up.
Conclusion: Retropharyngeal tuberculosis lymphadenitis presenting as a paradoxical reaction is a rare but potentially fatal entity requiring prompt multidisciplinary management. Combined diagnostic workup with CT imaging, GeneXpert, and histopathology, along with timely surgical intervention via a transoral approach, was key to a good recovery.
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