Tuberculosis - multisystem

This case presented to our center carrying the differential diagnoses of lymphoma, disseminated malignancy or tuberculosis (TB).

Two biopsies were obtained - the first one from the mediastinal lymph nodes that showed necrotizing lymphadenitis and a second from the endobronchial lesion at the the right middle lobe bronchus which showed caseating granulomas, both biopsies were negative for Ziehl-Neelsen stain.

The radiological appearances though collectively are classical for TB; the chest showing the manifistations of primary TB as a consolidation with lower predominance (right middle lobe in this case) with multiple ipsilateral hilar and paratracheal lymph node enlargement with central hypoattenuation reflecting caseation and rim enhancement.

The dorsal spine shows the classic gibbus deformity secondary to TB spondylitis involving T5 vertebra (Potts disease).

The pericardial thickening and hyperattenuating effusion raises the possibility of pericardial involvement though resolved on subsequent imaging as seen on chest CT. 

In the abdomen, there is TB peritonitis which is classically hyperattenuating due to high protein content and enhancing peritoneal reflections consistent with the wet peritonitis associated with TB, the enlarged porta hepatis lymph node again with a hypoattenuating center and enhancing rim reflecting central caseation.

Lastly at the brain, there is a classic appearance of a tuberculoma, which appears hyperattenuating on CT with subtle calcifications, the MRI confirms this by showing the hypointense signal on T2 which reflects caseation and differentiate it from the rare TB abscess.