paradoxical enlargement of lymph nodes in tuberculosis is well established in the early phase of treatment.[13 ] this is more common in hiv co - infection .
mediastinal lymphadenopathy resulting in recurrent laryngeal nerve palsy , pulmonary artery occlusion and superior vena caval obstruction has been described .
we report a case of bronchial obstruction in a patient with fully sensitive organism in the late phase of the treatment .
a 26-year - old somalian woman was diagnosed with mycobacterium tuberculosis infection in january 2008 .
she presented with cervical and mediastinal lymph node enlargement without any obvious lung parenchymal involvement .
acid fast bacilli ( afb ) were seen on fine needle aspiration of the cervical lymph node .
after initial problems with compliance , full standard quadruple therapy was effectively started in april 2008 .
maintenance treatment was commenced in june 2008 . the chest x - ray ( cxr ) on first presentation did show a narrowed left main bronchus in the absence of any clinical signs or symptoms .
the only relevant past medical history was of childhood asthma , for which she had no hospitalizations and did not use any regular inhaled therapy .
she presented in august 2008 to the accident and emergency department with a one - week history of worsening shortness of breath .
inhaled steroids and bronchodilators were started for a possible asthma exacerbation and she was discharged home .
her symptoms deteriorated and when seen in the tb clinic four weeks later , her exercise tolerance was limited to about 100 yards . on examination ,
a repeat cxr showed marked narrowing of the left main bronchus , confirmed on ct scan which showed almost complete occlusion of the left main stem bronchus .
spirometry showed fev1 - 1.09 l / min ( 36.3% of predicted ) , fvc 1.44 ( 41.7% of predicted ) [ table 1a ] .
the flow - volume loop had a characteristic shape of large airway obstruction [ figure 1 ] .
spirometry at presentation flow - volume loop of the patient which is characteristic of large airway obstruction she was commenced on oral prednisolone 30 mg once daily . there was no concern with compliance at this time .
a bronchoscopy also showed complete occlusion of left main bronchus with white necrotic material [ figure 2 ] .
white necrotic matter seen occluding the left main bronchus at bronchoscopy her treatment was continued with both anti - tuberculous therapy and steroids .
three days prior to the clinic visit she said she had coughed up a large lump of white material and her breathing had returned to near normal since .
2.81(81.6% ) [ table 1b ] with normalization of the flow volume loop [ figure 3a ] .
bronchoscopy was repeated and this showed a patent left main bronchus with some necrotic material on the lateral wall [ figure 3b ] .
spirometry after treatment ( a ) flow - volume loop improved with less evidence of airway obstruction , ( b ) patent left main bronchus with only a small amount of necrotic matter remaining at repeat bronchoscopy she continued with anti - tuberculous treatment for a full one year and steroids were slowly tapered off .
her cxr showed marked improvement in the narrowing of the left main bronchus towards the end of treatment .
endobronchial tuberculosis is less common since the advent of effective anti - tuberculous chemotherapy , but mediastinal lymphadenopathy due to mycobacterial infection is still common in developing countries .
paradoxical reactions on the whole are more common with hiv co - infection ( 28% ) than without ( 10% ) .
lymph node enlargement is the most common presentation and bronchial obstruction due to mediastinal lymphadenopathy is more common in the pediatric age group . in adults ,
patients with tuberculous mediastinal lymphadenopathy presenting with recurrent laryngeal nerve palsy , pulmonary artery occlusion and superior vena caval obstruction have been described .
these presentations may be due to either external compression or erosion into the surrounding structure .
in this particular case , the bronchoscopy showed caseating material eroding into the left main bronchus .
nakvi et al . , described this in children , in whom the obstruction was relieved by either aspiration or surgical excision .
response to steroids has not been consistent in many series described but generally paradoxical reactions , unlike endobronchial tb , are thought to be more steroids responsive .
our patient responded well to steroids . even after coughing up necrotic debris and relieving endobronchial obstruction
late paradoxical reactions should be considered in any patient on anti - tuberculous chemotherapy presenting with stridor .
 we present here a case of bronchial obstruction secondary to late paradoxical reactive enlargement and erosion by mediastinal lymph nodes into the left main bronchus in a 26-year - old woman with tuberculosis lymphadenitis . 
 bronchial obstruction due to paradoxical reactions , especially in the late phase of treatment , has not been described in adults before . 
INTRODUCTION
CASE REPORT
DISCUSSION