Not your ‘Garden Variety’ Atelectasis

133 A 20-year-old Ecuadorian woman had a positive purified protein derivative (PPD) test during routine prenatal evaluation. A chest radiograph (CXR) performed at that time was normal. Treatment for latent tuberculosis infection was not initiated. She had an uneventful delivery and then presented more than one year later with cough, fever and night sweats. Posteroanterior and lateral CXR performed in the emergency department revealed atelectasis of the right upper lobe (RUL), with superomedial retraction of the minor fissure (Figure 1A and 1B). Sputum cultures for acid fast bacilli (AFB) subsequently grew Mycobacterium tuberculosis, and the patient was started on a multidrug regimen, which was narrowed once the organism was confirmed to be sensitive. To further evaluate the nature of her RUL atelectasis, computed tomography (CT) of the chest was performed following administration of intravenous contrast, which was consistent with compression of the RUL bronchus by an adjacent mediastinal lymph node (Figure 1C and 1D). Bronchoscopic inspection undertaken to exclude neoplasia revealed a mass-like protrusion at the level of the RUL bronchial orifice that was covered with normal-appearing mucosa (Figure 1E and 1F). Endobronchial biopsies of this entity were negative for malignancy and granulomas. The patient’s RUL atelectasis was, thus, attributed to extrinsic obstruction by a tuberculous mediastinal lymph node.