Tuberculosis presenting with necrotic retroperitoneal lymphadenopathy in an immunocompetent patient: A case report and literature review

Abstract

Background: Extrapulmonary tuberculosis (EPTB) accounts for 15–20 % of TB, but necrotic retroperitoneal lymphadenopathy is exceptionally rare, particularly in immunocompetent hosts. Case presentation: A 32-year-old immunocompetent man from Peru presented with two weeks of severe abdominal pain and intermittent fever. CT revealed conglomerate necrotic retroperitoneal lymph nodes encasing the pancreatic head and major vessels. Image-guided biopsy showed necrotizing granulomas; acid-fast bacilli smear and GeneXpert MTB/RIF confirmed Mycobacterium tuberculosis. Chest CT demonstrated additional necrotic mediastinal nodes without parenchymal disease. Standard therapy (2HRZE/4HR) was initiated; due to partial radiologic response at six months, isoniazid–rifampicin was extended to complete ten months, achieving full clinical and imaging resolution. Literature review: A structured search identified seven additional immunocompetent adults with necrotic retroperitoneal lymphadenopathy. Abdominal pain predominated; CT consistently showed multiple necrotic nodes. Final diagnoses were tuberculosis (3/7), high-grade B-cell lymphoma (2/7), Kikuchi–Fujimoto disease (1/7), and metastatic esophageal carcinoma (1/7). All cases required tissue confirmation. Conclusions: Necrotic retroperitoneal lymphadenopathy is an uncommon manifestation of TB that can mimic malignancy. In patients from TB-endemic settings, TB should remain high in the differential when CT demonstrates necrotic retroperitoneal nodes. Early image-guided biopsy with mycobacterial testing is decisive. Drug-susceptible disease generally responds to standard six-month therapy, although extended treatment may be warranted for delayed radiologic response