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Weekly Chest CasesArchive of Old Cases

Case No : 574 Date 2008-10-27

  • Courtesy of Kook Seon Kim, MD, Eil Seong Lee, MD. / Hallym University College of Medicine, Korea.
  • Age/Sex 67 / M
  • Chief ComplaintCough 10 days ago
  • Figure 1
  • Figure 2
  • Figure 3

Diagnosis With Brief Discussion

Diagnosis
Tuberculoma
Radiologic Findings
Figs 1. Chest PA shows mass with eccentric cavity in the right upper lung.
Fig 2-1 & 2-2. Mediastinal window setting of the chest CT scan shows low attenuated mass with peripheral rim enhancement. Small cavities and peripheral air bubbles seen in the mass.
Figs 3-1 & 3-2. Lung window setting of the chest CT shows a CT halo sign (halo of ground-glass attenuation surrounding the nodule).

Tissue from lung, right upper lobe, aspiration cytology;
Atypical squamous cells embedded in inflammatory background; the latter is mainly polymorphonuclear leukocytes, lymphocytes and epitheloid histiocytes;
tuberculoma is the most probable diagnosis.
Brief Review
Tuberculoma is a round or oval granuloma caused by acid-fast bacilli, encapsulated by connective tissue [1]. The pathogenesis of tuberculomas is controversial. They may result from a bronchial infection that has been localized and sealed off. A healed, filled-in cavity and a rounded-off,contracted healing tuberculous lesion are the reported possible mechanisms of tuberculoma formation [1,2].

The tuberculomas on CT scans are usually regular and smooth in outline but may have a rough edge. Cavitation in the lesion or surrounding satellite nodule(s) can be seen on CT scans. The lesions are usually low in attenuation and show no or minimal enhancement with administration of contrast medium [3]. Calcification in the tuberculomas is found in 20-30% of the lesions and is usually nodular and diffuse [4]. Rarely, tuberculoma appears with a CT halo sign (halo of ground-glass attenuation surrounding the nodule) in patients with hemoptysis [5].

In recent report about HRCT findings in patients with pulmonary tuberculosis correlating with the degree of smear positivity, a significant difference was found for scores of GGO between smear-positive and smear-negative PTB patients [6]. They also found that a significant correlation between GGO score and the degree of smear positivity, which is compatible with previous studies [7]. GGO in PTB might reflect nonspecific inflammatory change adjacent to an area of consolidation. Even though, this finding may be considered as a significant indicator of tuberculous activity, some reports suggest that GGO might be seen as a sign of insufficient treatment [8].
References
1. Sochocky S. Tuberculoma ofthe lung. Am Rev Tubercle 1958;78:403-410
2. Bleyer JM, Marks JH. Tuberculomas and hamartomas of the lung. AJR 1957;77:101 3-1 022
3. Lee KS, Song KS, Lim TH, Kim PN, Kim IV, Lee BH. Adult-onset pulmonary tuberculosis: findings on chest radiographs and CT scans. AJR 1993;160:753-758
4. Lee KS, Kim HT, Cho WS, Kim PN, Bae WK, Kim IV. Active solitary tuberculoma of the lung: CT and clinical findings. J Korean Radiol Soc 1993;29:1200-1207 (Korean)
5. Gaeta M, Volta 5, Stroscio 5, Romeo P, Pandolfo I. CT 밾alo sign?in pulmonary tuberculoma. J Comput Assist Tomogr 1992;16:827-828
6. Ors F, Deniz O, Bozlar U, Gumus S et al. High-resolution CT Findings in patients with pulmonary tuberculosis: correlation with the degree of smear positivity. JTI 2007;22:154-159
7. Kosaka N, Sakai T, Uematsu H, Kimura H, et al. Specific high-resolution computed tomography findings associated with sputum smear-positive pulmonary tuberculosis. J Comput Assist Tomogr 2005;29:801-804
8. Poey C, Verhaegen F, Giron J, et al. High resolution chest CT in tuberculosis: evolutive patterns and signs of activity. J Comput Assist Tomogr.1997;21:601?07.
Keywords
Lung, Infection, Bacterial infection, Tuberculosis,

No. of Applicants : 84

▶ Correct Answer : 7/84,  8.3%
  • - Soonchunhyang university hospital, Bucheon , Korea (South) Hyelin Kim
  • - HOSPITAL SOTIRIA , Greece AIKATERINI DELAVERI
  • - Shinsegye Rad Clinic, Daegu , Korea (South) Gi Beom Kim
  • - McGill University Health Center , Canada Alexandre Semionov
  • - Gimpo Woori Hospital , Korea (South) Son Youl Lee
  • - Armed Forces Chun-Cheon Hospital , Korea (South) ChaeHun Lim
  • - Stroger hospital , United States ky yoo
▶ Correct Answer as Differential Diagnosis : 38/84,  45.2%
  • - China Medical University,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - Shiga University of Medical Science , Japan Norihisa Nitta
  • - MD PG Resident, PIMS,LONI, MAHARASHTRA, INDIA , India Sushant Bhadane
  • - chest hospital , Egypt assaad assaad
  • - McGill University Health Centre , Canada Amr Ajlan
  • - OSWAL CANCER HOSP. , India VISHAL GARG
  • - Changhua Christian Hospital , Taiwan Chia-Fu Tsai
  • - POPOVO HOSPITAL , Bulgaria VLADISLAV RUSINOV
  • - john h stroger hsp , United States dheeraj reddy gopireddy
  • - The Armed Forces HamPyeong Hospital , Korea (South) Bae Geun Oh
  • - EHIRC , India Aakash Mahajan
  • - Cheongshim international medical center , Korea (South) Hae Jum Yang
  • - Marien Hospital, Hamm , Germany Davis Chiramel
  • - IRSA La Rochelle France , France Denis Chabassiere
  • - Vitalife Clinics , Pune , India. , India Rahul Deshmukh
  • - McGill university , Canada Makki Almuntashri
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - SPS APOLLO HOSPITALS , India LOVKESH MITTAL
  • - kims,narkatpally , India k bhaskar
  • - hospital Sao Paulo , Brazil israel missrie
  • - INRAD , Brazil fabricio feltrin
  • - EKH-Berlin , Germany Michael Weber
  • - IRSA LA ROCHELLE FRANCE , France jean-luc BIGOT
  • - Ondokuz Mayis University , Turkey Cetin Celenk
  • - chp st martin , France Mariotte benoit
  • - Regional Imaging Ltd. - Riverina, NSW, Australia , Australia Rashid Hashmi
  • - Homs National Hospital , Syria Rami Abou Zalaf
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - Hospital Sotiria, Athens, Greece , Greece Vasilios Tzilas
  • - Kashan University of Medical Sciences, kashan , Iran Ebrahim Razi
  • - Dongguk University International Hospital , Korea (South) Hee Seok Choi
  • - National Taiwan University Hospital , Taiwan Chin-Chung Shu
  • - Trakya University School of Medicine , Turkey Umut Ugur
  • - Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - CHU Grenoble , France Fabrice Bing
  • - radiology department ANNECY , France gilles GENIN
  • - All India Institute of medical sciences , India Justin Moses
▶ Semi-Correct Answer : 37/84,  44.0%
  • - Mackay Memorial Hospital , Taiwan Shen ShengYeh
  • - Kasturba Medical College Manipal , India Paresh Desai
  • - IRCCS S.Luca Hosp. , Italy filippo casolo
  • - Royal Oldham Hospital , United Kingdom Rajesh Annamalaisamy
  • - Retd. Prof Thoracic Surgery B.J.MEDIDCAL COLLEGE Punr India , India Bankim Amin
  • - Kosin University , Korea (South) Woonha Lee
  • - Hanmaeum Hospital , Korea (South) Kwon Hyoung Kim
  • - Osaka University , Japan Osamu Honda
  • - Samsung Medical Center , Korea (South) Eun Kim
  • - wonju christial hospital , Korea (South) daekeon Lim
  • - Samsung Medical Center , Korea (South) Dae Kun Oh
  • - Trakya Univercity School of Medicine , Turkey Armagan Sarac
  • - BATRA HOSPITAL NEW DELH , India MONIKA AGARWAL
  • - Seoul National University Hospital , Korea (South) Sang Min Lee
  • - alex scan , Egypt abeer abouelela
  • - Chungnam National University hospital , Korea (South) Kyoung Jin Oh
  • - K.J.SOMAIYA HOSPITAL AND RESEARCH CENTRE. , India vipul jethwa
  • - BHMRC, NEW DELHI , India NIDHI GOYAL
  • - Father Muller Medical College , Mangalore , India nabil mahmood
  • - CHRU lille , France manuel toledano
  • - UCLA , United States Fereidoun Abtin
  • - Univ. of Miami/Jackson Memorial , United States mantosh rattan
  • - Konkuk university hospital , Korea (South) Jeong Geun Yi
  • - Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
  • - tantia general hospital , India gurpreet khalsa
  • - Aarthi scan, chennai , India Sanjeeb Agrawal
  • - ROHINI Scans (P) Ltd. , India UMAPATHI MAHESH
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - Lilavati hospital and Research center , India vivek gupta
  • - Lilavati Hospital & Research Centre , India Mahavir Swami
  • - Louisiana State University - Shreveport , United States Carlos Previgliano
  • - Central Queensland Medical Imaging , Australia Sandeep Joshi
  • - Arora Neuro Centre,Ludhiana , India Devendra Kumar
  • - Vital Imaging Centre, Mumbai,India , India Ganesh Agrawal
  • - Soonchunhyang University Cheonan Hospital , Korea (South) Park Sang Hyun
  • - All India Institute of Medical Sciences , India Ashish Gupta
  • - E-DA Hospital / I-Shou University , Taiwan Yu-Feng Wei
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