A 78-year-old woman was diagnosed with disseminated tuberculosis involving the lungs, mediastinal lymph nodes, and intestines. During a standard nine-month antituberculous regimen, follow-up imaging revealed a notable differential response: the pulmonary and intestinal lesions improved, whereas the mediastinal lymphadenopathy paradoxically worsened. Owing to this disparate response, multiple bronchoscopies were performed to exclude organ-specific disease progression or malignancies. These examinations revealed only granulomatous inflammation with no evidence of viable mycobacteria or cancer cells. Post-treatment positron emission tomography/computed tomography scan confirmed increased metabolic activity exclusively in the enlarged mediastinal nodes, with the resolution of other lesions. Lymph node enlargement was ultimately diagnosed as an organ-specific paradoxical reaction (PR). This case is valuable because it macroscopically documented the temporal changes in the endobronchial lesions caused by PR and further revealed that the clinical course can differ among the affected organs.
Nakatsumi et al. (2026) studied this question.