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TB with BHL — RACP Adult Medicine MCQ

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ModerateInfectious DiseasesTB with BHLRACP Adult Medicine

A 35-year-old man recently arrived from sub-Saharan Africa presents with BHL on CXR, chronic cough, weight loss, and night sweats for 3 months. He is HIV positive (CD4 250 cells/μL). Mantoux test is 18 mm. Sputum AFB smear is positive. CT shows bilateral hilar lymphadenopathy with necrotising mediastinal lymph nodes. What is the most likely diagnosis?

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Correct answer: A — Tuberculosis

BHL with constitutional symptoms, HIV co-infection, positive Mantoux, and AFB-positive sputum is pulmonary TB with hilar lymphadenopathy. TB lymphadenopathy is more common in HIV (immune reconstitution may cause paradoxical lymph node enlargement). Necrotising (low-density) lymph nodes on CT are characteristic of TB. Treatment: standard 4-drug TB therapy (2RHZE/4RH) + ART initiation (within 2 weeks if CD4 <50, within 8 weeks if CD4 >50).

Reference: eTG Antibiotic – 2025 – TB; WHO 2024