SUBMITTED 21 NOV 22 1 REVISIONS REQ. 18 JAN & 23 FEB 23; REVISIONS RECD. 31 JAN & 28 FEB 23 2 ACCEPTED 1 MAR 23 3 ONLINE-FIRST: MARCH 2023 4 DOI: https://doi.org/10.18295/squmj.3.2023.016 5 6 Pleural Pseudo-tumor Tuberculosis 7 Mouaad Amraoui,1 Massine El Hammoumi,1 Mohamed Oukabli,2 8 *El Hassane Kabiri1,3 9 10 1Departments of Thoracic Surgery and 2Pathology, Mohamed V Military Teaching Hospital, 11 Rabat, Morocco; 3Faculty of Medicine & Pharmacy, Mohamed V University, Rabat, 12 Morocco. 13 *Corresponding Author’s e-mail: hassankabiri@yahoo.com 14 15 The pseudotumoral form of bronchopulmonary tuberculosis is rare. It can manifestas a 16 bronchial, pulmonary, or pleural lesion, suggesting neoplasia, which makes the diagnosis 17 difficult. A 23-year-old female patient was referred to our department for management of a 18 right thoracic mass incidentally found on a chest Computed Tomography (CT). She reported 19 intermittent right-sided chest pain and fever. Clinical examination was normal. Chest CT 20 showed a well-defined, homogenous right low pleuro-parietal mass measured 50x50x24 mm 21 with a peripheral enhancement of contrast without bone invasion, pleural effusion, 22 parenchymal lesion, or mediastinal lymph nodes (figure 1 A, B, C). Routine blood tests were 23 normal except for a high erythrocyte sedimentation rate (ESR) at 32 mm/hr. Bacteriological 24 testing for acid-fast bacilli and GeneXpert were negative in sputum. Bronchoscopy and 25 percutaneous CT-guided needle-aspiration didn’t allow a pathological diagnosis. The patient 26 underwent an elective right posterolateral thoracotomy. Pre-operative findings noted 27 capsulated fluids mass with the presence of caseous necrosis after the accidental opening of 28 the lesion (figure 2), the mass was resected completely. Bacteriology revealed Bacillus of 29 Koch in caseous liquid culture and pathological exams revealed the presence of areas of 30 caseous necrosis with epithelioid granulomas, which were consistent with tuberculosis 31 infection. The patient received anti-tuberculous chemotherapy (2RHZ + 4RH) with a good 32 clinical and radiological resolution (figure 3). Patient consent was obtained for publication 33 purposes. 34 35 Comment 36 The incidence of pulmonary pseudotumor tuberculosis varies from 2 to 4%.1-3 Clinical and 37 radiological manifestations are not specific and may suggest malignancy, bronchoscopic 38 explorations can be negative. The differential diagnosis is lung cancer; metastasis, localized 39 mesothelioma, or benign disease like inflammatory myofibroblastic tumors. Surgical removal 40 of the mass through thoracoscopic or conventional approach is the best approach when we fail 41 to establish a definite diagnosis and for management of complications like heamoptysis.4-5 42 43 Authors’ Contribution 44 MA conceptualized and drafted the manuscript. ME interpreted the data in the manuscript. 45 MO interpreted the pathological data. EHK contributed to drafting and revising the 46 manuscript. All authors approved the final version of the manuscript. 47 48 References 49 1. Arul P, Varghese RG, Ramdas A. Pleural tuberculosis mimicking inflammatory 50 pseudotumour. J Clin DiagnRes2013; 7(4):709-11. DOI: 10.7860/JCDR/2013/4382.2888 51 2. Le Guillou F, Hubscher P, Cuvelier A, Quieffin J, Guyonnaud CD, El Haite A et al. 52 Bilateral pleural thickening pseudo-tumour due to tuberculosis. Rev Mal Respir 2002; 53 19(4):515-7. PMID: 12417867 54 3. Chaouch N, Saad S, Zarrouk M, Racil H, Cheikh Rouhou S et al. Diagnostic difficulty in 55 bronchopulmonary tuberculous pseudotumor. Rev Mal Respir 2011; 28(1):9-13. DOI: 56 10.1016/j.rmr.2010.05.014 57 4. Schweigert M, Dubecz A, Beron M, Ofner D, Stein HJ. Pulmonary infections imitating 58 lung cancer: clinical presentation and therapeutical approach.Ir J Med Sci. 2013; 182(1):73-59 80. DOI: 10.1007/s11845-012-0831-8 60 5. Ishida T, Yokoyama H, Kaneko S, Sugio K, Sugimachi K, Hara N. Pulmonary tuberculoma 61 and indications for surgery: radiographic and clinicopathological analysis. Respir Med 1992; 62 86:431-6. DOI: 10.1016/s0954-6111(06)80011-9 63 64 65 https://pubmed.ncbi.nlm.nih.gov/23730653/ https://pubmed.ncbi.nlm.nih.gov/23730653/ https://doi.org/10.7860/jcdr/2013/4382.2888 https://pubmed.ncbi.nlm.nih.gov/12417867/ https://pubmed.ncbi.nlm.nih.gov/21277469/ https://pubmed.ncbi.nlm.nih.gov/21277469/ https://doi.org/10.1016/j.rmr.2010.05.014 https://pubmed.ncbi.nlm.nih.gov/22592566/ https://pubmed.ncbi.nlm.nih.gov/22592566/ https://doi.org/10.1007/s11845-012-0831-8 https://doi.org/10.1016/s0954-6111(06)80011-9 66 Figure 1: CT scan of the thorax showing (A: axial B: frontal, C: coronal) pleural right 67 based mass lesion with calcification and irregular margins. 68 69 70 Figure 2: Operative view showing caseous necrosis after opening of the basal mass. 71 72 73 Figure 3: CT scan of the thorax 2 years later showing (A: axial, B: frontal, C: coronal) no 74 signs of recurrence or remaining infection. 75