Tuberculous lymphadenitis presenting with extensive internal jugular, subclavian, and brachiocephalic vein thrombosis: a case report

Tuberculous lymphadenitis is the most common form of extrapulmonary tuberculosis; however, associated major venous thrombosis is uncommon and may delay diagnosis because of its atypical presentation. Internal jugular vein thrombosis associated with tuberculosis remains rarely reported. We report the case of a 45-year-old Indian man who presented with a 5-day history of fever, productive cough, and painful left-sided neck swelling. Clinical examination revealed a tender swelling along the anterior border of the sternocleidomastoid muscle. Laboratory evaluation showed leukocytosis and elevated inflammatory markers, while the initial infectious and coagulation workup was inconclusive. Ultrasound of the neck demonstrated complete luminal obstruction of the left internal jugular vein by thrombus, which was further confirmed by computed tomography venography showing extensive thrombosis involving the left internal jugular, subclavian, and brachiocephalic veins. Echocardiography excluded intracardiac thrombus and vegetations. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of a necrotic mediastinal lymph node showed no granulomatous inflammation or malignant cells, and ZiehlNeelsen staining was negative; however, GeneXpert performed on the EBUS-TBNA aspirate detected Mycobacterium tuberculosis at a low level without rifampicin resistance, supporting the diagnosis of tuberculous lymphadenitis. The patient was treated with anti-tubercular therapy and anticoagulation, with clinical improvement and discharge in stable condition. This case highlights the potential association between tuberculous lymphadenitis and extensive cervical and central venous thrombosis and emphasizes the importance of considering tuberculosis in unexplained internal jugular vein thrombosis, particularly in tuberculosis-endemic regions. Microbiological testing may support the diagnosis even when cytological examination and ZiehlNeelsen staining are negative. Early imaging and appropriate microbiological evaluation are important for timely diagnosis and management.