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Multimacronodular pulmonary tuberculosis (bacteriologically negative) confirmed histologically

Ianoși Edith Simona MD, PhD

 

Abstract: 

Background: Pulmonary tuberculosis can be confirmed by positive bacteriology of sputum, bronchial aspirate or by biopsies (microscopy and/ or culture) or by histopathological examination highlighting specific tuberculous granulomas. When microscopy is repeatedly negative during noninvasive methods, lung biopsy by thoracoscopy is needed for confirmation and differential diagnosis. Case presentation: A 40-year-old female patient (nonsmoker, diabetic, with previous exposure to chemicals) was admitted to the hospital for weight loss, dry cough, loss of appetite, pallor, and fatigue. Chest-X-ray and thoracic CT revealed multiple irregular macronodules with various shapes, randomly spread across the lungs. Bacteriology for acid fast bacilli (AFB) from six spontaneous sputum was negative. Bronchoscopy showed an acute bronchitis. Bronchial aspirate was negative for tumor cells and AFB. Several biopsies from bronchial wall showed unspecific changes. The molecular biology tests for specific nucleic acids detection (Polymerase Chain Reaction) or positron-emission-tomography (to differentiate benign nodules from malign ones) were not accessible. Multiple biopsies from lung parenchyma and pleura were obtained using thoracoscopy. Histopathology
revealed multiple specific tuberculous granulomas. The complex antituberculous treatment (9 months) has led to the total cure of the disease and resorption of the nodules. The patient’s last visit (after 2 years) showed no clinical/imagistic or bacteriologic relapse of the disease.

Conclusion: Tuberculosis may present in the form of multiple macronodules spread randomly across the lung parenchyma. Thoracoscopy coupled with multiple large lung biopsies are recommended for diagnosis of multinodular lung lesions, especially when common bacteriology/cytology from bronchoscopic aspiration failed to achieve diagnosis. Histological exam from thoracoscopic biopsies allows differential diagnosis between entities that have macronodular features: tuberculosis, primitive lung cancer, lymphomas, metastatic disease or invasive fungal disease.
 

Keywords: 
tuberculosis, macronodular lesions, tuberculous caseous granuloma

Introduction Pulmonary tuberculosis (TB) can be confirmed by positive bacteriology of sputum, bronchial aspirate or tissue biopsy (Ziehl Neelson acid fast bacilli stain and/or culture
on Löwenstein Jensen) or by histopathological examination highlighting specific TB granulomas. Accurate bacteriological assessment of pulmonary TB consists in 3 probes of sputum collected during a 24 hour period, on different days. The use of “induced sputum” technique in 3 different days, is indicated in patients who do not cough (1,2,3) . When microscopy is repeatedly negative, bronchoscopy with aspirate or bronchoalveolar lavage offer a targeted sampling (3).

 

References: 
  1. World Health Organization, Global Laboratory Initiative. Roadmap for TB laboratory strengthening. Geneva,2010. Available at: http://www.stoptb. org/wg/gli and http://www.who.int/tb/laboratory/policy_statements /en/index.html.
  2. Programul Național de Control al Tuberculozei 2013-2017, http://www.marius-nasta.ro/Programu -Național-de-Prevenire-Supraveghere-și-Control-al-Tuberculozei-148.htm;
  3. Jimborean G, Ianoși ES. Tuberculoza, micobacteriozele atipice, elemente de diagnostic și tratament, Ed. Univ. Petru Maior, 2004, pag 30 – 52.

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