Presentation
One-month history of prolonged cough, intermittent hemoptysis and unintentional of excessive weight loss.
Patient Data
Diffuse reticulonodular interstitial opacities throughout both lungs, predominantly affecting both upper lung zones. A few cavitating lung lesions in both upper lung zones.
Asymmetrical enlargement of the left hilum noted.
Left pneumothorax without flattening of left hemidiaphragm and contralateral mediastinal shift to suggest tension component.
Diffuse small lung nodules which are randomly distributed seen scattered throughout both lungs, with predominance affecting bilateral upper lobes.
These lung nodules have "tree-in-bud" appearance.
Multiple thick-walled cavitating lesions at both upper lobes and left lower lobe. The largest cavitating lung lesion at the superior segment of the left lower lobe is fluid-filled with central hyperdensity and may indicate hematoma. No suspicious adjacent aneurysm or active contrast extravasation to suggest significant active bleeding.
Multiple areas of pulmonary consolidations are seen, notably in the left lower lung lobe.
Small left pneumothorax.
Mediastinal lymphadenopathy.
Case Discussion
Overall CT findings are highly suspicious of active pulmonary tuberculosis. The presence of tree-in-bud appearance of randomly distributed lung nodules are usually associated with endobronchial spread of pulmonary tuberculosis, though they are not specific signs.
For tuberculosis patient who presents with hemoptysis and multiple lung cavities, the possibility of Rasmussen aneurysm should be suspected. CT pulmonary angiography is the investigation of choice. It will appear as focal dilatation of one of the pulmonary segmentary arteries adjacent to tuberculous parenchymal change or a tuberculous cavity.