tuberculosis is one of the most likely causes of mediastinal lymphangitis but the diagnosis is difficult because the frequency of detection of granulomas or bacilli is relatively low . occasionally , no chief complaint is noted and the condition is detected incidentally by colonoscopy . we herein describe the case of a 68-year - old woman who suffered from mediastinal lymphangitis associated with intestinal tuberculosis and whose hoarseness was successfully relieved by anti - tuberculous therapy . intestinal tuberculosis should be included in the differential diagnosis of hoarseness due to mediastinal lymphadenitis . a 68-year - old female presented to our hospital in july 2008 due to hoarseness . the patient had no history of previous diseases , medication or exposure to dust or biomass . the patient presented with hoarseness , and lymphadenopathy 32 cm in diameter was found in the left supraclavicular area . there were abnormal shadow - like coin lesions on the upper portion of the right lung and no parenchymal abnormalities on plain chest x - ray ( fig . computed axial tomography showed lymph nodes in the subcranial , periaortic and aortopulmonary windows ( fig . gastroendoscopy showed a 2-cm deformity of the upper esophageal wall , covered by normal mucosa with deep ulcer , located 25 cm from the anterior incisor teeth ( fig . fine needle aspiration of the tumor was negative for malignancy and acid - fast bacilli . fine needle aspiration of the lymph node located in the supraclavicular area was also negative for malignancy and acid - fast bacilli . pet - ct showed abnormal accumulations on the upper right of the lung and the lower right of the abdomen . therefore , colonoscopy was performed , which revealed multiple erosions on the terminal ileum and bauhin 's valve ( fig . . polymerase chain reaction analysis of mycobacterium tuberculosis from the biopsied specimen from the erosion of the terminal ileum was positive , and intestinal tuberculosis was diagnosed . a quantiferon - tb gold test was also positive , which strongly supported the diagnosis . the patient was treated with anti - tuberculous therapy , comprising isoniazid , rifampicin , ethambutol , and pyrazinamide . four months later , pathological findings were improved on plain chest x - ray ( fig . 2a ) , and a repeat computed tomography of the chest showed that the mediastinal lymphadenopathies had completely resolved . a follow - up gastroendoscopy showed that the ulcer on the esophagus had disappeared ( fig . the anti - tuberculous therapy was continued for 1 year and the patient was in good health 2 years after initiation of anti - tuberculous therapy . a typical clinical presentation of intestinal tuberculosis includes abdominal pain , weight loss , fever , weakness , nausea , vomiting , obstruction and bleeding . this is the first report of intestinal tuberculosis with hoarseness as a chief complaint due to mediastinal lymphadenitis . the etiology of mediastinal lymphadenopathy in this case may be due to tuberculosis because both lymphadenopathy and hoarseness recovered after anti - tuberculous therapy against intestinal tuberculosis . previous studies reported that the majority of tuberculous lesions occurred in the ileocecal region , with ulcer and nodularity being the most common findings . endoscopic biopsies should be taken from the margins of erosions because granulomas often are submucosal . however , the frequency of the detection of granulomas or bacilli is relatively low . on biopsy specimens , polymerase chain reaction assays for the detection of tb dna demonstrated higher sensitivity . recently , the quantiferon - tb gold test has been reported to as useful to aid in the detection of intestinal tuberculosis . in this case , pet was useful for the detection of intestinal lesions . the high accumulation of the metabolic tracer fdg ( fludeoxyglucose f18 ) was observed by fdg - pet analysis . these active inflammatory cells may lead to increased intracellular glycolysis resulting in high accumulation of fdg . tuberculous lymphadenitis is one of the most common forms of extrapulmonary tuberculosis and the first lymphoid tissues encountered during spread are presumably hilar and mediastinal lymph nodes . however , mediastinal lymph nodes are rarely reported at the site of tuberculous lymphadenitis and it is also very rare in adults . clinical conditions are quite variable depending on the affected structures in patients with mediastinal tuberculosis . hoarseness , resulting from involvement of recurrent laryngeal nerve dysphagia due to compression of the esophagus , and typical manifestations of superior vena cava syndrome resulting from involvement of the superior vena cava are sometimes evident . the differential diagnosis includes mediastinal tumors , malignant lymphoma , esophageal carcinoma , lung carcinoma and sarcoidosis . enlarged lymph nodes and inflammatory swelling may predispose the compression and dysfunction of recurrent laryngeal nerve paralysis , resulting in hoarseness . in cases of tuberculous adenitis with esophageal mucosal lesion , confirmation of the diagnosis should be performed by histological or microbiological examination of a specimen obtained by endoscopic biopsy . nevertheless when it is impossible to reach the affected lymph nodes through these approaches , surgery may be necessary in order to establish a diagnosis . mediastinal tuberculous lymphadenitis can affect the esophagus by compressing the esophagus externally , causing rupture in the mediastinum and leading to an inflammatory process with secondary involvement of the esophagus , invasion of the esophagus , ulceration of the mucosa and draining of caseum into the esophageal lumen . the bacilli contained in the caseum may traverse the digestive tract and infect through peyer 's patches on the terminal ileum . as the incidence of tuberculosis in japan is gradually increasing , the differential diagnosis of this disease is likely to become more necessary . the present case provides grounds for hoarseness to be considered as a symptom of intestinal tuberculosis . in the investigation of the causes of mediastinal lymphadenopathy , intestinal tuberculosis
a 68-year - old woman was admitted to our hospital complaining of hoarseness . 
 a chest x - ray detected an abnormal shadow on the upper right lung . 
 bronchoscopic examination revealed that the left vocal cord was fixed in the paramedian position , and therefore left recurrent nerve paralysis was suspected . 
 lymphadenopathy was found in the left supraclavicular area . 
 chest computed tomography showed that the pretracheal and subaortic lymph nodes were swollen . 
 gastroendoscopy showed a 2-cm protruding lesion with ulceration on the upper esophagus . 
 histological examination of the supraclavicular lymph nodes and biopsy specimens from the esophagus revealed non - specific inflammation . 
 pet - ct showed abnormal accumulations not only on the upper right lung but also on the lower right of the abdomen . 
 colonoscopy was performed and multiple erosions on the terminal ileum were found . 
 polymerase chain reaction analysis of a specimen biopsied from the erosion of the terminal ileum was positive for mycobacterium tuberculosis and intestinal tuberculosis was diagnosed . 
 the patient was then treated with anti - tuberculous therapy . after treatment , the erosions on the terminal ileum 
 , the swelling of the mediastinal lymphadenopathy , and the esophageal ulcer were all improved . 
 the hoarseness was subsequently relieved . 
 this is the first report of intestinal tuberculosis with hoarseness as a chief complaint due to mediastinal lymphadenitis .