Atypical Pleuropulmonary Tuberculosis Mimicking a Malignant Disease
Authors: Henda Nèji, Mariem Affes, Monia Attia, Soumaya Ben Saad, Anissa Berraies, Ines Baccouche, Saoussen Hantous-Zannad, Khaoula Ben Milad-M’rad
Journal: Journal of Thoracic Oncology (2017)

Pseudotumoral tuberculosis is considered to be among the most important differential diagnoses of lung and pleural malignancies. This form of tuberculosis is rare and occurs in 3.5% to 4.5% of immunocompetent patients. It is more frequent in those with immunocompromised status and is diagnosed with a delay of 30 to 70 days.1Hantous-Zannad S. Zidi A. Néji H. Attia M. Baccouche I. Ben Miled-M'rad K. The role of imaging in thoracic tuberculosis.Rev Pneumol Clin. 2015; 71: 93-109Crossref PubMed Scopus (7) Google Scholar We report the case of a 47-year-old women with a history of diabetes who consulted for cough with purulent sputum, weakness, and fever. A plain chest radiograph showed multiple bilateral nodules and right hilar lymphadenopathies (Fig 1). An atypical pneumonia was suspected. Antibiotics were administered. However, the patient clinically worsened. Enhanced computed tomography was performed. It showed subcarinal as well as right hilar and bilateral bronchial lymph node enlargement. There were bilateral lung nodules—especially in the lower lobes. The pleura exhibited bilateral nodular enhanced thickening that was more obvious in the lower regions. Pleural effusion was absent (Fig. 2). Metastatic involvement of the lungs and pleura was suggested. Transbronchial biopsy and cytologic examination of the bronchial fluid showed inflammation with no signs of malignancy. Bronchoalveolar lavage fluid analysis showed no malignant cells. The results of screening for Mycobacterium tuberculosis in the sputum and bronchial fluid were negative.Figure 2Enhanced computed tomography scan before treatment with lung (A) and mediastinal (B) windowing showing bilateral pulmonary nodules (arrows) and bilateral nodular thickening of the pleura (thick arrows). Subcarinal, right hilar, and bilateral bronchial lymph node enlargement is also present (dashed arrows).View Large Image Figure ViewerDownload Hi-res image Download (PPT) The patient underwent a surgical pleural and parenchymal biopsy. Anatomopathological examination resulted in a diagnosis of caseofollicular tuberculosis. The patient received combined antibacillary medication. One month later, a second chest computed tomography scan showed improvement of the pulmonary and pleural lesions (Fig. 3). This case illustrates how confusing pseudotumoral tuberculosis can be. Generally, typical features of postprimary pulmonary tuberculosis include centrilobular branching 2- to 4-mm nodules with a tree-in-bud appearance, acinar nodules, and consolidations. Lesion cavitation is a hallmark finding leading to endobronchial spread.1Hantous-Zannad S. Zidi A. Néji H. Attia M. Baccouche I. Ben Miled-M'rad K. The role of imaging in thoracic tuberculosis.Rev Pneumol Clin. 2015; 71: 93-109Crossref PubMed Scopus (7) Google Scholar There are two forms of pseudotumoral tuberculosis: bronchial and parenchymal.2Chaouch N. Saad S. Zarrouk M. et al.Diagnostic difficulty in bronchopulmonary tuberculous pseudotumor.Rev Mal Respir. 2011; 28: 9-13Crossref PubMed Scopus (11) Google Scholar In these cases, location in the upper lobes and upper segments of the lower lobes in association with parenchymal tuberculous activity signs may suggest the diagnosis. Their confirmation is by histological examination of bronchial and computed tomography-guided biopsies samples.1Hantous-Zannad S. Zidi A. Néji H. Attia M. Baccouche I. Ben Miled-M'rad K. The role of imaging in thoracic tuberculosis.Rev Pneumol Clin. 2015; 71: 93-109Crossref PubMed Scopus (7) Google Scholar Location in the lung bases is also rare and confusing.3Ben Miled-M’rad K. Kara M. Hantous-Zannad S. Zidi A. Mestiri I. Tuberculosis of the lung bases.Rev Mal Respir. 2002; 19: 161-165PubMed Google Scholar Pleura involvement has many features. Pleuritis is one among the most frequent forms of extrapulmonary tuberculosis. M. tuberculosis is often absent in the effusion fluid. The pleura is generally thin. In contrast, empyema results from a highly bacilliferous process; the pleura is thick and regular.1Hantous-Zannad S. Zidi A. Néji H. Attia M. Baccouche I. Ben Miled-M'rad K. The role of imaging in thoracic tuberculosis.Rev Pneumol Clin. 2015; 71: 93-109Crossref PubMed Scopus (7) Google Scholar Pleural involvement results from hematogenous spread of the infection or from subpleural parenchymal foci rupture. In our patient, nodular thickening of the pleura and absence of effusion were atypical and are considered to be very rare tuberculous features.4Ariyürek O.M. Cil B.E. Atypical presentation of pleural tuberculosis: CT findings.Br J Radiol. 2000; 73: 209-210Crossref PubMed Scopus (15) Google Scholar Absence of typical parenchymal involvement made the diagnosis more difficult. Mesothelioma and pleural metastases are the principal differential diagnoses. On computed tomography some signs, despite the fact that they are nonspecific, may suggest tuberculosis. They include central necrosis, peripheral rim enhancement, and association with necrotic lymph nodes.5Hwang S.M. Rho J.Y. Yoo S.M. Jung H.K. Cho S.H. Atypical pleural tuberculosis presenting as an isolated pleural tuberculoma.Acta Radiol. 2012; 53: 49-52Crossref PubMed Scopus (6) Google Scholar In conclusion, pseudotumoral lung and pleural tuberculosis should be suspected every time there are lesions that mimic malignant disease, especially in countries where this infection is endemic and particularly when they are associated with signs of parenchymal activity.