The case series are summarized in Table 1. The figure 1 shows the radiologic features of these cases.
Case 1
An 81-year-old male visited the emergency room with a 3-day history of anorexia, fever, cough, and phlegm. He was a non-smoker and was taking anti-hypertensive drugs (losartan). Examination at the time of the visit revealed the following: blood pressure (BP), 137/62 mmHg; pulse rate (PR), 103 beats/min; respiratory rate (RR), 20 breaths/min; body temperature (BT), 37.7℃, and peripheral saturation, 95% on room air. Chest X ray (CXR) and computed tomography (CT) revealed lobar consolidation in both upper lung fields (Figure 1A), focal consolidation in right middle and right lower lobes, and bilateral pleural effusion. A complete blood count revealed the leukocyte number to be 7400/uL (neutrophils, 81.9%). Other laboratory values were as follows: hemoglobin (Hb), 9.8 g/dL; erythrocyte sedimentation rate (ESR), 20 mm/hr (normal range, 0–10 mm/hr); C-reactive protein (CRP), 45.5 mg/L (normal, < 5 mg/L); procalcitonin, 0.14 ng/mL (normal < 0.5 ng/mL); pro-B-type natriuretic peptide (pro-BNP), 1271 pg/mL (normal range, 17.5–158.2 pg/mL); Na, 130 mEq/L; blood urea nitrogen (BUN), 5.9 mg/dL; creatinine (Cr), 0.7 mg/dL; and albumin, 1.6 g/dL. An anti-HIV antibody screening test was negative. After starting antibiotic treatment for community acquired pneumonia, a sputum AFB smear was negative, but the sputum MTB PCR was positive. Therefore, he received a diagnosis of pulmonary tuberculosis and was treated with isoniazid, rifampin, ethambutol, and pyrazinamide. After 2 weeks, no improvement in the lung lesions was seen on follow-up chest CT; therefore, it was judged that the dense consolidation was not typical of tuberculosis. To exclude other diseases, we performed transbronchial lung biopsy (TBLB) and bronchial washing under radial probe endobronchial ultrasonography (R-EBUS). The biopsy revealed OP with small granuloma. Anti-tuberculosis treatment was continued due to a positive AFB stain and MTB PCR of the bronchial wash fluid. Subsequent AFB culture confirmed M. tuberculosis, which was sensitive to all anti-tuberculosis drugs. No steroid was used. A further follow-up CXR showed an improvement in his condition.
Case 2
A 72-year-old male visited the hospital with a recent history of cough and phlegm. He was taking medication for hypertension. He had neurofibromatosis (Von Recklinghausen disease) and a history of pulmonary tuberculosis. He was a non-smoker. A CXR revealed focal increased opacity in left lower lung field (LLLF); therefore, he received antibiotics to treat community acquired pneumonia. However, he was admitted to hospital upon the finding of LLLF on follow-up CXR. On admission, BP was 120/70 mmHg, PR was 90/min, RR was 20/min, and BT was 36.6℃. Chest CT showed consolidation in the LLLF (Figure 1B). The leukocyte count was 4700/uL (neutrophils, 58%), Hb was 12.6 g/dL, ESR was 26 mm/hr, CRP was 5.3 mg/L, procalcitonin was 0.03 ng/mL, Na was 139 mEq/L, BUN was 15.1 mg/dL, Cr was 0.8 mg/dL, and albumin was 2.8 g/dL. An anti-HIV antibody screening test was negative. To confirm the cause of pneumonia, TBLB and bronchoalveolar lavage (BAL) were performed under R-EBUS. The BAL results were as follows: macrophages, 11%; lymphocytes, 11%; neutrophils, 61%; and eosinophils, 0%. The lung biopsy results suggested OP. AFB stain of bronchial wash fluid was negative, but the MTB PCR was positive. Since the biopsy and radiologic examination results did not show findings appropriate for TB, the MTB PCR result was determined to be a false-positive. Therefore, he received corticosteroid treatment while maintaining antibiotic treatment. CXR showed that LLLF infiltration improved after steroids, but 3 weeks later M. tuberculosis was confirmed on AFB culture of BAL fluid. Therefore, the steroid was discontinued and anti-tuberculosis treatment (isoniazid, rifampin, ethambutol and pyrazinamide) was started. The microbe was sensitive to all anti-tuberculosis drugs and CXR revealed that all lesions improved thereafter.
Case 3
A 54-year-old female patient was transferred to the clinic due to identification of a speculated mass measuring 3.2 × 2.8 cm in right upper lobe (RUL) on CXR and chest CT (Figure 1C), accompanied by a fever lasting 4 days. She also had diabetes and hyperlipidemia, and was a non-smoker. Upon hospitalization, BP was 120/70 mmHg, PR was 78/min, RR was 20 /min, and BT was 36.9℃. The leukocyte count was 7500/uL (neutrophils, 51.9%), Hb was 15.3 g/dL, ESR was 6 mm/hr, CRP was 1.4 mg/L, Na was 142 mEq/L, BUN was 16 mg/dL, Cr was 0.6 mg/dL, and albumin was 4.7 g/dL. No anti-HIV antibody screening test was performed. Antibiotic treatment was based on a diagnosis of pneumonia, and TBLB and bronchial washing were performed under R-EBUS to exclude malignancy. The biopsy result revealed OP. AFB stain of the bronchial wash fluid was negative, but MTB PCR was positive. Therefore, we made a diagnosis of pulmonary tuberculosis and began anti-tuberculosis treatment (isoniazid, rifampin, ethambutol and pyrazinamide). An AFB culture test confirmed M. tuberculosis, which was sensitive to all drugs. No steroids were used. After 6 months of anti-tuberculosis treatment, chest CT revealed that the mass lesions on the RUL had improved.
Case 4
A 57-year-old male patient visited the emergency room with a 3-week history of generalized weakness. He was a non-smoker and had no known underlying diseases. At the time of the visit his BP was 134/72 mmHg, his PR was 118/min, his RR was 20/min, his BT was 36.1℃, and room air oxygen saturation was 90%. Chest CT revealed multiple micronodules distributed randomly in both lungs, accompanied by cavitary nodules, irregular linear opacity, and patchy consolidation in both apices. He was diagnosed with miliary tuberculosis with active pulmonary tuberculosis. The leukocyte count was 4500/uL (neutrophils, 93.2%), Hb was 14.5 g/dL, ESR was 8 mm/hr, CRP was 213 mg/L, procalcitonin was 17.65 ng/mL, Na was 114 mEq/L, BUN was 81.2 mg/dL, Cr was 2 mg/dL, and albumin was 2.9 g/dL. An anti-HIV antibody screening test was negative. Sputum AFB stain was negative, but MTB PCR was positive; therefore, he received anti-tuberculosis drugs (isoniazid, rifampin, ethambutol and pyrazinamide). Follow-up chest CT revealed increased diffuse consolidation and ground glass opacity (GGO) in both lungs (Figure 1D). Mechanical ventilator treatment began on the 22nd day of hospitalization due to hypoxia. To confirm the cause of the exacerbation we performed a blind TBLB and BAL. The BAL results were as follows: macrophages, 17%; lymphocytes, 55%; and neutrophils, 11%. The BAL AFB stain was negative, and the MTB PCR results were positive. The biopsy results confirmed OP and so he received corticosteroids while continuing anti-tuberculosis treatment. Subsequently, as hypoxia and CXR improved, the patient was extubated on the 12th day of ventilator treatment. M. tuberculosis was cultured in sputum and was confirmed to be sensitive to all drugs. The steroid was tapered for a total of 6 months and although anti-tuberculosis drug treatment continued, rifampin was stopped due to leukopenia and ethambutol was stopped due to impaired vision. The patient received anti-tuberculosis treatment (isoniazid, pyrazinamide, and levofloxacin) for 18 months. After treatment was completed, CXR showed that all lesions had improved.
Case 5
A 78-year-old male was admitted to the emergency room due to fainting and near drowning while sitting in a bathtub. He was taking medication for back pain. He was a non-smoker. At the time of the visit, his BP was 100/60 mmHg, his PR was 126/min, his RR was 23/min, his BT was 37.8℃, and his peripheral saturation was 83% on nasal O2 (4 L/min). Chest CT revealed suspected pulmonary edema with diffuse patchy consolidations and GGO with a crazy paving pattern in both lungs. The leukocyte count was 5400/uL (neutrophils, 61.3%), Hb was 11.3 g/dL, ESR was 6 mm/hr, CRP was 0.6 mg/L, procalcitonin was 13.16 ng/mL, BNP was 253 pg/mL, Na was 131 mEq/L, BUN was 13.1 mg/dL, and Cr was 0.9 mg/dL. The anti-HIV antibody screening test was negative. The patient's medical history and imaging findings suggested a high probability of pulmonary edema, but procalcitonin was high and a mild fever of > 37.8℃ persisted. Therefore, antibiotic treatment was started for suspected pneumonia, along with diuretics. Chest CT (Figure 1E) was followed up on the 10th day of hospitalization, and the lesions appeared to be reduced; however, new diffuse centrilobular nodules with multifocal conglomerated nodules were observed in both lungs. TBLB and BAL were performed under R-EBUS to identify the cause. The BAL results were as follows: 29% macrophages, 29% lymphocytes, 6% neutrophils, and 1% eosinophils. AFB stain of the BAL fluid was negative, but the MTB PCR was positive; therefore, anti-tuberculosis drugs (isoniazid, rifampin, ethambutol and pyrazinamide) were started. The biopsy confirmed OP, but no steroids were given. M. tuberculosis was identified on BAL AFB culture, which was sensitive to all drugs. Anti-tuberculosis drugs were used for 2 months. CXR tracking confirmed that the lesions improved. However, due to side effects, all drugs were discontinued after 2 months. The patient is being followed up.
Case 6
A 70-year-old male visited the clinic due to identification of a 2.7 cm solitary pulmonary nodule on CXR and CT (Figure 1F). He was a non-smoker and had no known underlying diseases. At the time of the visit, his BP was 121/74 mmHg, his PR was 62/min, his RR was 20/min, and his BT was 36.4℃. The leukocyte count was 6200/uL (neutrophils, 57.8%), Hb was 12.1 g/dL, Na was 134 mEq/L, BUN was 9.7 mg/dL, Cr was 0.8 mg/dL, and albumin was 4.4 g/dL. No anti-HIV antibody screening test was performed. No antibiotics were used. TBLB and bronchial washing were performed under R-EBUS; the biopsy confirmed OP. AFB staining of the bronchial washing fluid was negative, but the MTB PCR was positive, so anti-tuberculosis treatment (isoniazid, rifampin, ethambutol and pyrazinamide) was started due to a diagnosis of pulmonary tuberculosis. M. tuberculosis was confirmed by AFB culture and was sensitive to all drugs. Steroids were not used. After 6 months of anti-tuberculosis treatment, CXR revealed that the RUL nodular lesion had improved.