대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

Pulmonary tuberculosis granuloma as a paradoxical worsening of tuberculous pleural effusion

Radiologic Findings

Serial chest radiographs show complete resolution of bilateral pleural effusion. No lung lesions are noted on chest radiographs taken before May, 1995. Lateral chest radiograph and chest CT taken in May 1995 shows a newly developed peripheral lung lesion abutted to the thickened pleura. The lung lesion shows inhomogeneous enhancement.
Hospital course:

Percutaneous needle aspiration of the lung lesion showed caseating granulomas consistent with tuberculosis. The lung lesion disappeared 5 months later under the same treatment regimen.

Brief Review

Paradoxical response refers to enlargement of old lesions or unexpected appearance of new lesions during apparently adequate antituberculous therapy. Various types of paradoxical response have been reported, including increase in size of lymph nodes and areas of pulmonary infiltration in pediatric patients with primary tuberculosis, development of new lymph nodes or enlargement of original nodes in patients with tuberculous lymphadenitis, development of new pulmonary infiltrates in patients with extrapulmonary tuberculosis, and development of tuberculous pleural effusion and progression of pulmonary infiltrates in patients with pulmonary tuberculosis. In patients with tuberculous pleural effusion, development of contralateral pleural effusion, increase in the amount of effusion, and development of new pulmonary lesions as in this case have also been reported. Paradoxical response generally occurs 3?2 weeks after the beginning of antituberculous therapy that includes rapid bactericidal drugs like isoniazid and rifampin, and it usually regresses without a change of the initial drug regimen

According to our study (1), paradoxical response to antituberculous chemotherapy for non뺸IDS-related tuberculous pleural effusion was manifested as single or multiple nodules developing after resolution of pleural effusion. Some patients experienced two episodes of paradoxical response, appearing at an interval of up to 6 months. The paradoxical response was observed in 16 of 141 patients (11%) with tuberculous effusion. CT revealed that all of these new lesions were peripheral pulmonary nodules or masses that mostly abutted the normal or thickened pleura. They usually evolved within 3 months after an initiation of antituberculous medication. When the same medication was continued, they subsequently decreased in size, finally disappearing or leaving some residual lesions 3?8 months later.

References

1. Yo Won Choi, Seok Chol Jeon, Heung Seok Seo, Choong Ki Park, Sung Soo Park, Chang Kok Hahm, Kyung Bin Joo. Tuberculous Pleural Effusion: New Pulmonary Lesions During Treatment. Radiology 2002;224:493-502

Keywords

Lung, Infection, Bacterial infection, Tuberculosis,