Presentation
Chronic shortness of breath with a history of tuberculosis infection and treatment.
Patient Data
Chest radiograph shows significant leftward shift of the mediastinum with subsequent opacification of the left hemithorax. Compensatory hyperinflation of the right lung is seen in addition to diffuse reticular opacities and increased right apical opacity likely due to fibrosis. No evidence of pneumothorax is seen.
Chest CT with IV contrast reveals significant volume loss in the left hemithorax with leftwards deviation of the heart and mediastinum. There is extensive bronchiectasis of the left lung with additional bronchiectasis and volume loss of the right lower lobe. A cavitary lesion in the posterior segment of the right upper lobe can be seen, likely representing a mycetoma. Additional nodules in the right lung base can also be visualized.
Case Discussion
Considering the radiographic and CT findings of marked volume loss and mediastinal shift in a patient who has a positive history of tuberculosis (TB) infection, these findings likely represent a sequela of unilateral tuberculous lung destruction (UTLD) demonstrating cicatrization collapse of the left lung.
UTLD is an irreversible complication of TB that most commonly demonstrates left lung predominance. This can occur in TB patients as a result of reduced lung expansion due to sustaining chronic fibrosis and scarring and is thought to occur in the late phases of the disease. An abnormal healing process is thought to be a primary contributor to the significant and permanent changes in lung structure after TB infection. Such changes have been linked to fibrogenic cytokines such as TNF-α, TGF-β, and IL-1β in addition to matrix metalloproteinase-induced lung injury.
Radiographic findings on both chest x-ray and CT typically include loss of lung volume and ipsilateral mediastinal shift. PA chest x-ray can show opacification of the entire hemithorax and/or coarse linear opacities representative of fibrotic changes. CT chest can be used to delineate whether residual cystic bronchiectasis is present or not and to rule out additional complications. Other findings on CT include a decreased diameter of the pulmonary vasculature, herniation of the contralateral lung, and/or increased extrapleural fat.
Case courtesy of Dr. Michael Apushkin - John H. Stroger Jr. Hospital of Cook County