Presentation
Headache. MRI of the brain showed a left cerebral space-occupying lesion, likely metastatic.
Patient Data
Brain: FDG avid left basal ganglia enhancing space-occupying lesion SUVmax 10.9 and measures 5.2x4 cm. It's surrounded by vasogenic edema and mass effect.
Lungs:
- Increased FDG uptake by bilateral upper lobar and apical lower lobar small consolidative patches showing internal cavitations, associated with extensive tree-in-bud and nodular densities, and mosaic attenuation with hyperlucent areas, secondary to small airway involvement.
- Increased FDG uptake by retrocaval and posterior mediastinal nodes, with SUV max 3.5.
Abdomen and pelvis
- Adnexa: increased FDG uptake by bilateral adnexal lesions with SUVmax 9.9 in left side
- Peritoneum: increased FDG uptake by omental nodular thickening underneath the anterior abdominal wall, with SUVmax 7
Opinion:
- metabolically active pulmonary changes are highly suggestive of inflammatory process (active TB)
- metabolically active cerebral, bilateral adnexal solid lesions and omental thickening likely representing granulomatous (TB) spread
Omental excision biopsy revealed inflammatory fibrotic lesion. No malignancy.
Case Discussion
This patient initially presented with headache for which MRI was requested. It revealed left basal ganglia enhancing space occupying lesion, and suggested a metastatic lesion. PET-CT was made to demonstrate to identify any primary neoplasms.
PET-CT revealed the hypermetabolic left basal ganglia space occupying lesion. Bilateral pulmonary tree-in-bud densities, small confluent apical opacities with central cavitation and mediastinal lymphadenopathy indicative of active TB. Abdominal cuts showed diffuse nodular omental thickening with hypermetabolic heterogeneous bulky adnexa.
The cerebral and abdominal lesions were highly suggestive of TB spread.
Omental biopsy revealed inflammatory fibrotic lesion. No malignancy.
Active TB was confirmed by positive laboratory work up.