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Disorders of the Pleura |

Tuberculosis: A Common Misdiagnosis

Anshum Aneja, DTCD; Vivek Nangia*, MD; R. Chatterji, MD; Hemant Tewari, MD; Ak Singh, MD; M. Bhayana, MD
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Fortis Hospital, New Delhi, India


Chest. 2012;142(4_MeetingAbstracts):507A. doi:10.1378/chest.1388932
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Abstract

SESSION TYPE: Pleural Global Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Tuberculosis is the most common cause of an exudative lymphocyte predominant pleural effusion especially in countries where TB is rampant, but certainly not the only cause. The demonstration of tubercle bacilli in the pleural fluid or pleural biopsy and the confirmation of granulomas are confirmatory of tuberculosis. However , very often patients are given antitubercular drugs without any further confirmatory tests. Various other common causes of exudative lymphocytic predominant pleural effusions include mesotheliomas, lymphomas , connective tissue disorders and other chronic infections . Solitary Fibrous tumour of the pleura(SFTP)is a rare primary tumour arising from the mesenchymal cells and resulting in similar biochemical and radiological picture of pleural effusion. We report a case of a young female with an exudative lymphocyte predominant pleural effusion which was persistent despite anti tubercular treatment and would refill despite recurrent thoracocentesis.

CASE PRESENTATION: A 30 year old female presented with progressive cough, shortness of breath and generalized weakness for two years. She had been detected to have right sided pleural effusion of exudative lymphocyte predominance and initiated on antitubercular treatment. However pleural effusion continued to recur despite repeated thoracentesis .On admission she was grossly emaciated ,had evidence of right sided pleural effusion with contralateral mediastinal shift . CT chest revealed a large heterogenous mass occupying right upper , middle lobes and massive pleural effusion . Bronchoscopy showed extrinsic compression of right main bronchus reducing it to only a narrow slit through which the bronchoscope could not be maneuvered. Bronchial brushings and lavage were inconclusive .A medical thoracoscopy was performed and 2.5 litres of hemorrhagic pleural fluid evacuated. A large smooth surfaced pleural based mass (over which the thoracoscopic biopsy needle would slip )was seen completely occupying pleural cavity above 5 th rib . A CT guided Tru cut biopsy was then performed from the 3 rd and 4 th intercostal spaces.Histopathological examination revealed a tumour composed of bland spindle shaped cells with nuclear polymorphism. Tissue was sent for immunohistochemical study for CD34, CD99 and Cytokeratin . CD 34 was negative , suggesting a rare malignant form of spindle cell neoplasm while bcl-2 was positive confirming it to be malignant variant of solitary fibrous tumour of pleura(SFTP)

DISCUSSION: SFTP is a rare pleural tumour. Only about 800 cases have been reported in the literature of which the malignant form still remains enigmatic. The tumors behave unpredictably and do not always correlate with histologic findings . SFTP usually appear as a well defined, rounded mass on chest radiograph . Rarely, a pleural effusion is associated with malignant SFTP. Heterogeneity may be observed because of myxoid degeneration or necrosis. Most are encapsulated however firm adhesions may be present between visceral and parietal pleura at the surface of the tumor .Immunohistochemistry is extremely useful to differentiate SFTP from mesotheliomas and other sarcomas . SFTP is vimentin positive and keratin negative. In addition, CD34, bcl-2 is positive in most benign and malignant SFTP, whereas it remains negative for most other pulmonary tumors. Occasionally, malignant SFTP may be CD34 negative .The main differentials include mesothelioma, neurogenic sarcoma, synovial sarcoma, fibrosarcoma, and malignant fibrous histiocytoma. Treatment is mainly directed at complete en bloc surgical removal with or without concomitant chest wall resection .The role of adjuvant and neoadjuvant therapy in SFTP is limited

CONCLUSIONS: Tuberculosis is a commonly misdiagnosed entity among pleural effusions. Definitive diagnostic procedures like pleural biopsies are important in suspicious cases .Rare tumours such as Solitary fibrous tumors of the pleura may be uncommonly detected. These neoplasms are fortunately benign 80% of the time and readily curable with complete resections however Malignant variety has higher recurrence rate and mortality

1) Robinson LA.Solitary fibrous tumor of the pleura. Cancer Control. 2006 Oct;13(4):264-9

2) de Perrot M, Fischer S, Brundler MA, et al. Solitary fibrous tumors of the pleura. Ann Thorac Surg. 2002;74:285-293.

3) Chan JKC. Solitary fibrous tumour—everywhere, and a diagnosis in vogue. Histopathology 1997;31:568-76

DISCLOSURE: The following authors have nothing to disclose: Anshum Aneja, Vivek Nangia, R. Chatterji, Hemant Tewari, Ak Singh, M. Bhayana

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