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CASE REPORTS

Pulmonary pseudotumoral tuberculosis in an old man:

A rare presentation
Anna Campobasso∗1 , Antonio Perrone1 , Alessia D’Introno1 , Viera Boccuti1 , Moris Sangineto1 , Leonardo Resta2 , Carlo
Sabbà1
1
Departement of Interdisciplinary Medicine “C. Frugoni”, University of Bari Aldo Moro, Bari, Italy
2
Department of Pathological Anatomy, University of Bari Aldo Moro, Bari, Italy

Received: August 31, 2016 Accepted: October 31, 2016 Online Published: February 12, 2017
DOI: 10.5430/crim.v4n1p78 URL: https://doi.org/10.5430/crim.v4n1p78

A BSTRACT
The pseudotumoral form of tuberculosis is very rare in healthy immunocompetent subjects and can simulates lung carcinoma
causing diagnosis dilemma or lead to abusive surgical resection. Here we report a case of pulmonary tuberculosis in its
pseudotumoral form in an immunocompetent old men who presented with cough, fatigue and fever. A computerized tomography
of the chest indicated a dishomogeneous mass that compressed and deformed the left main bronchus that was referable to a
primary tumor. The hystopatological exam from the bioptic samples obtained by bronchoscopy was negative for neoplasia.
Moreover, an abdomen CT scan showed hypodense solid lesions of the liver likely to be considered as metastasis; the histological
analysis of these hepatic lesions was negative for neoplasia. It was necessary to perform a second CT scan of the chest and another
bronchoscopy with biopsy and histopathological examination before establishing the diagnosis of the pulmonary pseudotumoral
form. The case report confirm, as previously described, the difficulties in the diagnosis of this rare form of tuberculosis that
lead to a delay in therapy, and suggest that the pseudotumor has to be included as different diagnosis of pulmonary mass also in
healthy immunocompetent subjects.

Key Words: Pulmonary tubercolosis, Pseudotumoral form, Lung cancer, Biopsy

1. I NTRODUCTION resection.[2, 3] Here we describe a case of pulmonary tuber-

culosis in its pseudotumoral form in an immunocompetent
Tuberculosis is an infectious disease that can affect any organ
old men.
and system, being the lung is the most prevalent site. Pul-
monary tuberculosis is characterized by different radiological
and clinical expressions and it can present as a distinct en- 2. C ASE PRESENTATION
tity called mycobacterial pseudotumor. The pseudotumoral A 83-year-old man was admitted to our Clinical Unit with
form of tuberculosis affects more often immunosuppressed one month history of non productive cough, fatigue and fever.
patients with or without AIDS and is very rare in healthy im- He was non smoker and never treated for tuberculosis, with
munocompetent subjects.[1] It can simulates lung carcinoma no notion of contagious tuberculosis. In 1994 he underwent
on imaging studies or bronchoscopic examination and there- to a partial prostatectomy because of an adenoma and in
fore causes diagnosis dilemma or lead to abusive surgical 2007 he was diagnosed to have prostatic cancer and treated
∗ Correspondence: Anna Campobasso, MD; Email: [email protected]; Adress: Departement of Interdisciplinary Medicine “C.

Frugoni”, University of Bari Aldo Moro, Piazza G. Cesare 11, Bari 70124, Italy.

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with radiotherapy. On clinical examination the patient was scan, and a volume increase of the dishomogeneous mass
found eupneic and afebrile with general good conditions. compressed the left main bronchus. Therefore another bron-
Abdominal, cardiac, pulmonary and neurological examina- choscopy with biopsy was performed; the histopathological
tions were normal. Laboratory data showed an increased examination revealed a granulomatous chronic inflammatory
erythrocyte sedimentation rate (ESR) of 111 mm/h and a C process with caseous necrosis, along with type giant multin-
reactive protein (CRP) of 90 mg/dl; AST, ALT, renal func- ucleated cells (see Figure 3), and the RT-PCR for detection
tion, electrolytes, glycaemia, blood coagulation tests, tumor mycobacterium tuberculosis on bioptic sample showed pos-
markers were within normal levels. The patient was immuno- itive results. A Quantiferon Gold showed positive results.
competent and non-reactive for human immunodeficiency Based on these findings, a diagnosis of pseudotumoral tuber-
virus. Computerized tomography of the chest indicated a culosis was made and a therapeutic regimen composed of
dishomogeneous mass that compressed and deformed the rifampicin and isoniazid for 24 weeks, and ethambutol asso-
left main bronchus (see Figure 1) and strictly adhered to hilar ciated with pyrazinamide for 2 months was prescribed with
and subcarinal adenopathies; it was considered referable to a clinical, biological, and radiological surveillance. In patient’s
primary tumor. follow-up, general condition was good and no problem was
reported.

Figure 1. Lung CT scan showing the dishomogeneous

mass that compressed and deformed the left main bronchus Figure 2. Abdominal CT scan showing an hypodense solid
lesion in the liver
Multiple adenopathies were also observed within the right
hilum and the tracheo-bronchial areas with infiltration of the
pulmonary artery window. At the same time abdominal CT
scan showed hypodense solid lesions in segments II, IV, V e
VII of the liver likely to be considered as metastasis (see Fig-
ure 2). Bronchoscopy with biopsy was performed. The bron-
choscopy showed mucosal swelling in the left main bronchus
and partial occlusion in its inferior part; the histopathological
exam was negative for neoplasia and revealed a nonspecific
granulomatous inflammation, even if the biopsy sample was
not totally adequate and representative. After one week a
biopsy of the liver lesion was also performed and the histolog-
ical analysis was negative for neoplasia and granulomatous
lesions. Because of the hystopatological results and the per-
sistence of the symptoms, a second CT of the chest was
performed and revealed the presence of tiny bilateral paratra- Figure 3. Histology: granulomatous chronic inflammatory
cheal adenopathies that were not present in the previous CT process with caseous necrosis
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3. D ISCUSSION lustrated hepatic lesions that were considered as metastasis.

It was necessary to perform two bronchoscopies with biopsy
Pulmonary tuberculosis may present with myriad of mani- and histopathological examination before confirming the di-
festations and the pseudotumoral form is a very rare entity agnosis of the pulmonary pseudotumoral form. Despite to
especially in developing countries and healthy immunocom- the diagnostic difficulties, the therapy of the pseudotumoral
petent subjects. On the other hand, in developed countries form of tuberculosis is based on the common treatment of
lung cancer is among the most common adult neoplasms and the tuberculosis infection,[8] and the follow-up is generally
is increasing in incidence.[4] Since the pulmonary pseudo- favorable even if some complications as bronchial steno-
tumor has been reported to mimic both benign and malignant sis, bronchiectasis and bronchiolitis may occur. Data on
tumors and there are not specific symptoms and patognomic parenchymal pseudotumoral form tuberculosis are poor and
radiological pictures or endoscopic aspects,[5, 6] as illustrated just a few cases have been reported in literature.[9–12] Herein
by our case report, diagnostic error can be common and its di- in this case report showing a pulmonary pseudotumoral tu-
agnosis is often delayed.[3] Moreover, microscopic analysis berculosis in an old immunocompetent patient we stressed
of the sputum is generally negative, because the pseudotumor the rarity of the disease and the difficulties in the diagnosis
lesions are poorly oxygenated solid caseous lesions.[3, 4] The that leaded to a delay in therapy. This case report underlines
histological exam is therefore necessary to clarify diagnostic that pulmonary tuberculosis can present like mass lesion
dilemma and confirm or reject the diagnosis of pseudotu- mimicking bronchogenic carcinoma. However biopsy from
mor,[7] and avoid unnecessary surgical resections. In our the lesion can clinch the diagnosis.
patient who had positive history for prostatic cancer, both
the CT of the chest revealed a dishomogeneous mass that C ONFLICTS OF I NTEREST D ISCLOSURE
was referable to a primary tumor and abdomen CT scan il- The authors have no competing interests to declare.

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