Weekly Chest CasesArchive of Old Cases

Case No : 925 Date 2015-07-20

  • Courtesy of So Youn Shin, Dong Wook Sung / KyungHee University Medical Center
  • Age/Sex 69 / F
  • Chief ComplaintChief Complaint: Known gastric diffuse large B Cell lymphoma patient, asymptomatic, routine follow up
  • Figure 1
  • Figure 2

Diagnosis With Brief Discussion

Diagnosis
Tuberculosis
Radiologic Findings
On routine follow up chest CT, newly developed subpleural mass in the right upper lobe (RUL) pleural/subpleural area causing osteolytic and osteoblastic change to the adjacent ribs was detected. There were no surrounding satellite nodules, other lung parenchymal changes, or enlarged mediastinal lymph nodes. On PET-CT, the lesion showed high FDG uptake (max. SUV: 7.8) and there were no other lesions showing significant uptake. Malignancies such as pleural metastasis or other primary malignancy was suggested. However, VATS pleural biopsy revealed that the lesion was a ‘Chronic granulomatous inflammation, consistent with tuberculosis’. Thus, the patient was started on TB medication and the mass finally disappeared.
Brief Review
Although pulmonary tuberculosis is usually accompanied by parenchymal abnormalities, pleural effusion or a pleural nodule/mass may be the sole imaging manifestation of tuberculosis (TB). Pleural TB may occur by extension from lymphatics.
In a previous study, experimental findings suggested the implication of interleukin (IL)10 in the reactivation of TB. Indeed, serum IL10 concentrations have been proven to be increased in NHL patients which could lead to compromised cell mediated immunity and reactivation of latent TB. Thereafter, several cases have been reported of pleural TB without parenchymal involvement or lymphadenopathy.
Although FDG is a cancer specific imaging agent, false positive results may be observed with benign disease and are commonly observed in areas of active inflammation or infection. Tuberculosis usually presents in the lungs, but in one third of cases, it may present in other organs such as lymph nodes, pulmonary pleura, the genitourinary system, skeletal system, pericardium, and the central nerveous system. Although a high SUV, greater than 2.5, is attributed to malignant lesions, people have encountered high values of peak SUV, even up to 21.0, in tuberculous lesions. Unlike 18F-FDG PET scans, 11C-choline PET scans can help differentiate between lung cancer and tuberculoma as the standard uptake value of tuberculoma is low in 11C-choline PET scans.
References
1. Jeong YJ, Lee KS. Pulmonary tuberculosis: Up-to-Date Imaging and Management. AJR 2008; 191:834-844.
2. Hara T, Kosaka N, Suzuki T, Kudo K, niino H. Uptake rates of 18F-fluorodeoxyglucose and 11C-choline in lung cancer and pulmonary tuberculosis: a positron emission tomography study. Chest 2003; 124:893–901.
3. Goo JM, Im JG, Do KH, et al. Pulmonary tuberculoma evaluated by means of FDG PET: findings in 10 cases. Radiology 2000; 216:117–121.
4. Turner J, Gonzalez-Juarrero M, Ellis DL, et al. In vivo IL-10 production reactivates chronic pulmonary tuberculosis in C57BL/6 mice. J Immunol 2002; 169:6343-51.
5. Fayad L, Keating MJ, Reuben JM, et al. Interleukin-6 and interleukin-10 levels in chronic lymphocytic leukemia: correlation with phenotypic characteristics and outcome. Blood 2001; 97:256-63.
6. Blunt SB, Harries MG. Discrete pleural masses without effusion in a young man. An unusual presentation of tuberculosis. Thorax 1989; 44:436-7.
7. Ariyurek OM, Cil BE. Atypical presentatation of pleural tuberculosis CT findings. Br J Radiol 2000; 73:209-10.
8. Ko JM, Park HJ, Kim CH. Pulmonary changes of pleural TB: Up-to-Date CT Imaging. Chest 2014; 146(6):1604-1611.
Please refer to
Case 408
Keywords
Pleura, Rib, Infection, Bacterial infection, Tuberculosis,

No. of Applicants : 73

▶ Correct Answer as Differential Diagnosis : 17/73,  23.3%
  • - Avrasya Hospital , Turkey Murat Ulusoy
  • - KUMS, kashan, Iran , Iran Ebrahim Razi
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - Niigata City General Hospital , Japan Takao Kiguchi
  • - Pneumologia Universitaria, Policlinico di Bari , Italy Mario Damiani
  • - Niigata University , Japan Atsushi Uehara
  • - CHU Poitiers , France Yannick DE LA TORRE
  • - Osaka Rosai Hospital , Japan Hiromitsu Sumikawa
  • - Asan Medical Center , Korea (South) , Korea (South) Han Na Lee
  • - Chonnam National University Hospital , Korea (South) So yeon Ki
  • - IRSA La Rochelle , France Denis Chabassiere
  • - The University of Tokyo Hospital , Japan Takeyuki Watadani
  • - ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou
  • - National Center hospital of Neurology and Psychiatry , Japan Kaoru Sumida
  • - Okinawa Kyodo Hospital , Japan Shoko Iraha
  • - Kizawa Memorial Hospital , Japan Shoji Okuda
  • - Nasaret Hospital , Korea (South) Hee Seok Choi
▶ Semi-Correct Answer : 1/73,  1.4%
  • - �stanbul , Turkey Ayhan Yilmaz
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