Tuberculosis: not all cavitating lung lesions are malignancies

This case report presents the clinical journey of an 81-year-old male who was initially investigated for a left upper lobe opacity in 2019, but was later diagnosed with tuberculosis.  Despite recurrent chest infections and progressive computed tomography scan of the chest findings involving a left lobe lesion and mediastinal lymphadenopathy, the patient declined further investigations due to his role as the sole caregiver for his wife.

He was referred to the palliative team for suspected lung cancer. His health continued to decline over the years with notable weight loss.

The patient was readmitted with symptoms of a chest infection, prompting additional investigations. His computed tomography scan of the chest (Fig A) showed worsening of a large left upper lobe cavitating lesion and mediastinal lymphadenopathy, further investigations were carried out to look for reversible causes like tuberculosis, fungal infection and ANCA related vasculitis.

Could it be tuberculosis?

The Mycobacterium Tuberculosis complex was isolated from his sputum leading to the diagnosis of pulmonary tuberculosis. He was referred to the respiratory team for further management.

Fig A -There is a large left upper lobe cavitating lesion, extending to the apical segment of the left lower lobe and mediastinal lymphadenopathy, with patchy bilateral irregular peripheral opacities.

Epidemiology data revealed 3,628 notifications of tuberculosis in the first three quarters of 2023 and showed an 8.1% increase compared with the same period in 2022.¹

The sputum culture remains the gold standard test for the diagnosis of pulmonary tuberculosis.² The usual presentation includes a progressive history of cough, dyspnoea, low grade fever, night’s sweats, weight loss.³ less specific symptoms like dyspnoea, lethargy and poor appetite were more common in older patients than in younger patients.⁴

This case highlights the challenges of diagnosing tuberculosis in older individuals with complex medical histories and emphasises the importance of considering infectious aetiologies, even in the presence of suspicious radiological findings.

The delayed diagnosis in this case underscores the need for heightened clinical suspicion, especially in patients with recurrent respiratory symptoms and atypical disease presentations.

Learning points

• Diagnosing tuberculosis in elderly individuals with complex medical comorbidities remains a challenge
• The sputum culture remains the gold standard test for the diagnosis of pulmonary tuberculosis
• The delayed diagnosis especially in patients with recurrent respiratory symptoms and atypical disease presentations, underscores the need for heightened clinical suspicion.

Kelum Ruwanpura, Specialty Registrar, Conquest hospital, St Leonards on Sea

Mishma Mehzabeen, Foundation Year 2 trainee, Conquest hospital, St Leonards on Sea

Kobazoglu Sercan, Internal Medicine trainee, Conquest hospital, St Leonards on Sea

Sanidhya Khanna – Internal Medicine trainee, Conquest hospital, St Leonards on Sea

Muhammad JH Rahmani, Consultant Physician, Conquest hospital, St Leonards on Sea

References

1. National quarterly report of tuberculosis in England: Quarter 3, 2023 provisional data
2. Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children. Clin Infect Dis. 2017 Jan 15;64(2): e1-e33. [PubMed] [Reference list]
3. Davies PDO. Tuberculosis in the elderly. J. Antimicrob. Chemother. 1994;34((Suppl. A)):93–100. doi: 10.1093/jac/34.suppl_A.93.
4. Abbara A, Collin SM, Kon OM, et al. Time to diagnosis of tuberculosis is greater in older patients: A retrospective cohort review. ERJ Open Res. 2019; 5:00228–02018. doi: 10.1183/23120541.00228-2018