Asymptomatic primary tuberculous pleurisy with intense 18-fluorodeoxyglucose uptake mimicking malignant mesothelioma

Our plain-English summary of Asymptomatic primary tuberculous pleurisy with intense 18-fluorodeoxyglucose uptake mimicking malignant mesothelioma, by T. Shinohara, N. Shiota, M. Kume, et al (BMC Infectious Diseases, 2013).

The study

• Authors: T. Shinohara, N. Shiota, M. Kume, N. Hamada, K. Naruse, F. Ogushi
• Journal: BMC Infectious Diseases
• Published: 2013;13:12
• Type of article: Case report
• Cited by: 15 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: The pathogenesis of primary tuberculous pleurisy is a delayed-type hypersensitivity immunogenic reaction to a few mycobacterial antigens entering the pleural space rather than direct tissue destruction by mycobacterial proliferation. Although it has been shown that pulmonary tuberculosis induces 18-fluorodeoxyglucose (FDG) uptake in active lesions, little is known about the application of FDG positron emission/computed tomography (FDG PET/CT) to the management of primary tuberculous pleurisy.

Case Presentation: We report a case of asymptomatic primary tuberculous pleurisy presenting with diffuse nodular pleural thickening without distinct pleural effusion and parenchymal lung lesions mimicking malignant mesothelioma. An initial FDG PET/CT scan demonstrated multiple lesions of intense FDG uptake in the right pleura and thoracoscopic biopsy of pleural tissue revealed caseous granulomatous inflammation. The patient received antituberculous therapy for 6 months, with clearly decreased positive signals on a repeated FDG PET/CT scan.

Conclusion: FDG PET/CT imaging may be useful for evaluating disease activity in tuberculous pleurisy patients with an unknown time of onset.

In plain English

This case report from Japan described one 26-year-old man with no symptoms whose chest X-ray, taken at a college health examination, showed a right-sided abnormality. CT showed diffuse nodular thickening of the right pleura (the lining around the lung), which the authors said mimicked malignant mesothelioma. He had no history of occupational exposure to asbestos, silica, or other fibrogenic substances. A PET/CT scan showed intense uptake of the tracer FDG in multiple lesions in the right pleura (SUVmax 10.9). A thoracoscopic biopsy showed caseous necrosis and granulomatous inflammation. No acid-fast bacilli were found and no culture was positive, but a QuantiFERON-TB test and a tuberculin skin test were both positive. The authors judged tuberculous pleurisy highly likely, and he received 6 months of tuberculosis treatment. A repeat PET/CT then showed clearly decreased uptake (SUVmax 5.7), and X-rays showed further improvement 6 months later. The authors concluded that FDG PET/CT may be useful for evaluating disease activity and monitoring treatment response in tuberculous pleurisy with an unknown time of onset. They also concluded that active tuberculosis should be considered in diffuse pleural thickening even without symptoms.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report
• Who was studied: One 26-year-old man in Japan with no symptoms, referred after an abnormality on the right side of his chest X-ray was found by chance at a college health examination
• Exposure: No asbestos exposure. The patient had no history of occupational exposure to asbestos, silica, or other fibrogenic substances. The condition studied was tuberculous pleurisy that mimicked malignant mesothelioma on imaging.
• Main results:
  • Imaging at presentation showed extensive nodular thickening of the right pleura with intense FDG uptake, without distinct pleural effusion or lung lesions
  • The initial FDG PET/CT showed multiple lesions of intense uptake in the right pleura, with a maximal standard uptake value (SUVmax) of 10.9
  • Pleural tissue from thoracoscopic biopsy showed caseous necrosis and granulomatous inflammation
  • No acid-fast bacilli were found in the biopsy specimens, and no positive culture was obtained
  • The QuantiFERON-TB second generation test (3.02 IU/ml) and the tuberculin skin test (10 mm induration) were both positive by Japanese criteria
  • The patient received antituberculous therapy for 6 months
  • Just after treatment, a repeat FDG PET/CT showed clearly decreased signals (SUVmax 5.7) with marked improvement in pleural thickening
  • A chest X-ray 6 months after the end of treatment showed further improvement
• The authors' conclusion: The authors concluded that active tuberculosis should be considered in the differential diagnosis of diffuse pleural thickening even without symptoms. They also concluded that FDG PET/CT may be useful for evaluating disease activity and monitoring treatment response in tuberculous pleurisy patients with an unknown time of onset.
• Limitations the authors state:
  • The diagnosis of tuberculous pleurisy was not confirmed by culture or by finding acid-fast bacilli. The authors described it as highly likely based on other clinical data.
  • The authors stated that the mechanisms causing high FDG uptake in the pleural thickening are unclear

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Tuberculous pleurisy, Mesothelioma, Pleural Thickening, Pleural Effusion, CT Scan, Pleura, Thoracoscopy, Inflammation.

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• Pseudomesotheliomatous lung cancer mimicking mesothelioma on ¹⁸F-FDG PET/CT images: report of 2 cases — T. Nakamori, S. Kosuda, et al. (2013)
• Clinical implications of 18F-fluorodeoxyglucose positron emission tomography/computed tomography at delayed phase for diagnosis and prognosis of malignant pleural mesothelioma — Y. Abe, K. Tamura, et al. (2012)
• ¹⁸F-fluorodeoxyglucose PET/CT findings in pleural effusions of patients with known cancer. A cytopathological correlation — I. Letovanec, G. Allenbach, et al. (2012)
• Prognostic value of 18F-FDG standard uptake value by integrated PET/CT in the staging of malignant pleural mesothelioma — G. Genestreti, A. Moretti, et al. (2012)
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