Beyond the lymph node: empyema necessitans in pediatric tuberculosis

Abstract Background Tuberculosis can present in various ways and cause numerous complications. Empyema necessitans is an uncommon complication of lymph node tuberculosis. A literature review suggests that pediatric empyema necessitans secondary to primary mediastinal lymph node tuberculosis is rare. Case-description A 13-year-old boy under treatment for tuberculosis presented with a 2-week history of fever and progressive right paravertebral swelling. Examination showed supraclavicular lymphadenopathy, decreased air entry on the right side, and a tender swelling over the right side of the back. Suspecting disease progression, a computed tomography scan revealed empyema necessitans along with an increase in the size of mediastinal and hilar lymph nodes. Ultrasound-guided aspiration subjected to Xpert/Rif assay confirmed tuberculosis with rifampicin sensitivity. Discussion Evaluation for primary and secondary immunodeficiencies was negative. Therapeutic drug monitoring revealed subtherapeutic serum levels of isoniazid, following which doses were optimized and the child was advised weekly follow-up visits but was eventually lost to follow-up. Learning points