Presentation
Cough of 3 months duration, treated with over-the-counter antitussives. Then developed bilateral ankle edema at which point she sought medical attention. Abdomen ultrasound was performed and showed ascites, subsequently, abdomen CT was performed for further evaluation.
Patient Data
Hyperattenuating ascites relative to urine within the bladder.
Thick enhancing peritoneal reflections.
An enlarged hypoattenuating porta hepatis lymph node with rim enhancement.
Hyperattenuating mild pericardial effusion/thickening.
Right middle lobe lateral segmental consolidation/collapse with ipsilateral hilar, precarinal, and paratracheal lymph nodes.
The lymph nodes have a hypoattenuating center with rim enhancement.
Endobronchial lesion severely narrowing the right middle lobe bronchus.
Bilateral pulmonary nodules.
Severe loss of height of T5 vertebral body resulting in mild kyphosis (Gibbus deformity).
The patient had a seizure. A CT brain was performed.
There is a right parietal lesion based at the grey-white matter junction with moderate perifocal vasogenic edema. There is a suspicion of subtle intralesional punctate calcifications.
The right parietal lesion shows no evidence of diffusion restriction, appeared hypointense on T2W images and iso to slightly hyperintense on T1W images with marginal enhancement.
Case Discussion
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 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 thoracic 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.
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