Presentation
The patient presents with the typical symptoms of fever, malaise and night sweats. There is a positive TB contact.
Patient Data
Apparent multi-chamber cardiomegaly and no overt features to suggest cardiac decompensation. There are ill-defined reticular nodular opacities, multifocal, however predominantly upper and mid-zonal. There are no cavities, no effusions and no calcified lymph nodes.
Contrast-enhanced CT imaging of the chest with high-resolution lung windows demonstrates features consistent with post-primary pulmonary tuberculosis.
There is multifocal, ill-defined, patchy consolidation within the right upper lobe, left upper lobe and superior segment of the left lower lobe. Clustered parenchymal opacities with cavitation are evident within the upper lobes bilaterally. There is a coarse reticular nodular pattern, with areas of tree-in-bud appearance. There is no lobar collapse or lobar pneumonia.
There is associated ct significant and insignificant pretracheal, peri-carinal, subcarinal, bilateral hilar and aortopulmonary lymphadenopathy. There are no calcified nodes, no necrotic nodes and no nodal abscesses.
There is a significant simple pericardiac effusion with no pericardial or pleural calcification and no features of constrictive pericarditis.There are no pleural effusions.
Incidental hepatic steatosis, small type I hiatal hernia, Bosniak type I right midpole renal cyst. Importantly no hepatic or splenic micrabscesses, no upper abdominal ascites. There is no evidence of tuberculous spondylitis.
The galaxy sign is usually encountered in a minority of patients with sarcoidosis. It represents a coalescence of granulomata. It can occasionally be identified in pulmonary tuberculosis too and often with central cavitation as demonstrated above.
Case Discussion
A case of active post-primary tuberculosis was confirmed on sputum PCR testing. There is a large pericardial effusion without any calcified pericardial plaque, however, this may still occur in the future and predispose to constrictive pericarditis as a chronic sequela of prior tuberculous pericardial effusion. The lung changes are pathognomonic of post-primary tuberculosis and typically involve the posterior segments of the upper lobes and the superior segments of the lower lobes. The galaxy sign is well demonstrated in the upper lobes bilaterally. There is asymmetric left lower lobe involvement, likely due to aspirated contents and the consequent spread of infection.