CTICasesPleural Tuberculosis Mimicking Malignant Pleural Spread over Several Years
Imaging findings
A patient followed over roughly four years for an outside left upper lobe abnormality progressed from subtle reticular opacities, calcified nodules, and a cluster of ill-defined coalescing nodules with a "galaxy sign" appearance to a more expansive, PET-avid, asymmetric area that eventually was accompanied by a new left pleural effusion with nodular pleural thickening along the medial pleural surface, raising strong concern for a lung malignancy with pleural spread. VATS pleural biopsy ultimately revealed tuberculosis (Mycobacterium tuberculosis) with pleural seeding, and the earlier galaxy-sign appearance in retrospect reflected coalescing granulomas.
Key takeaways
Nodular pleural thickening with an underlying galaxy-sign pulmonary opacity can closely mimic malignant pleural spread (including mesothelioma-like appearances) and should prompt consideration of tuberculosis, particularly when the process has evolved slowly over years in a patient without a prior diagnosis or treatment; recognizing this pattern before attempting pleurodesis is important since pleurodesis would be inappropriate (and was appropriately avoided here) once tuberculosis was identified as the cause.
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