Ann Thorac Surg 2003;76:1733-1735
© 2003 The Society of Thoracic Surgeons
Case report
Tuberculosis presenting as pancoast tumor
Morris Beshay, MDa,
Thierry Roth, MDa,
Robert M. Stein, MD,
Ralph A. Schmid, MD*a
a Division of General Thoracic Surgery, University Hospital Berne, Berne, Switzerland
Accepted for publication March 25, 2003.
* Address reprint requests to Dr Schmid, Division of General Thoracic Surgery, University Hospital Berne, Berne 3010, Switzerland
e-mail: ralph.schmid{at}insel.ch
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Abstract
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A 48-year-old man presented with pain in his left shoulder radiating to the left scapula and a tingling sensation of the left arm with involvement of the fourth and fifth finger. Based on the clinical and radiologic findings, the diagnosis of Pancoast tumor of the left lung was made. Computed tomographic guided fine needle biopsy was not conclusive. A video-assisted thoracoscopic surgery was performed to obtain a biopsy. The histologic and microbiologic examinations established the diagnosis of tuberculosis (TB).
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Introduction
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Tuberculosis remains a worldwide, serious health problem and it has been reemerging in economically well-developed countries since 1985. This could be caused by an increasing number of immigrants or a higher number of immune-compromised patients mainly because of HIV infection or emergence of drug-resistant strains [1–3]. In addition, the clinical and radiologic presentations of TB seem to switch to more unusual manifestations.
A 49-year-old man from Cameroon, living in Switzerland since 4 years, presented to his family doctor with progressive pain in his left shoulder radiating to the left scapular region. A few days later he started to complain of paresthesia of the left upper arm with involvement of the fourth and the fifth finger. The patient has a positive serology for hepatitis A, B, and C, and he is under treatment for essential arterial hypertension. He did not have alcohol or nicotine abuse. General and local examinations revealed no abnormalities except reduced sensibility of the fourth and fifth finger of the left hand. In particular, there were no signs of Horner’s syndrome. Laboratory investigations showed no abnormal results, but a tuberculin test was positive. A chest roentgenogram was performed that showed a slight opacity at the apex of the left lung (Fig 1).
Thoracic computed tomographic scan confirmed the presence of a left paravertebral mass measuring 2 x 2.5 cm in diameter at the apex of the left lung (Fig 2).
Neck and chest magnetic resonance imaging showed that the tumor had infiltrated the seventh cervical and first thoracic vertebral bodies, the lower roots of the brachial plexus, and the apex of the left pleura (Fig 3).
Bone scintigraphy revealed no metastases. Bronchoscopic examination showed no endobronchial pathologic findings and the bronchial lavage cytology revealed no malignant cells. Based on the clinical and radiologic findings, the diagnosis of an upper sulcus tumor (Pancoast tumor) was made. A computer tomographic guided biopsy showed no malignant cells.
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Fig 2. Chest computed tomographic scan showing the paravertebral lesion on the left side at the apex of the lung (arrow).
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Fig 3. Magnetic resonance image showing the lesion (arrow) with infiltration of the pleura, the seventh cervical, and the first thoracic vertebral bodies.
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Histologic diagnosis was mandatory to plan further treatment. To obtain tissue for histologic diagnosis, video-assisted thoracoscopic surgery was performed on the patient. Intraoperative exploration showed that the lesion was extrathoracic with infiltration of the parietal pleura at the apex. After opening the pleura, further dissection showed a mass (2 cm in diameter) slightly whitish in color, soft in consistency, and positioned adherent to the seventh cervical root. On taking biopsies for frozen section and microbiologic examination, whitish creamy caseating materials were evacuated from the lesion. All biopsies showed no malignant cells, but granulomatous tissue with chronic inflammatory and epithelioid cells as well as Langhans giant cells were present. There was no lymphatic tissue around the lesion. Polymerase chain reaction as well as microbiologic examinations confirmed the diagnosis of mycobacterium tuberculosis.
The patient was given triple antituberculous chemotherapy medications, consisting of a combination of Rifampicin (Rimactan [600 mg/d]; Novartis, Basel Switzerland), Levofloxacin (Tavanic [500 mg/d]; Aventis Pharma, Strasbourg, France), and Pyrazinamid (Pyrazinnamid [2 gm/d]; Lederle, Zug, Switzerland) for 9 months.
The postoperative course of the patient was uneventful, and he was discharged on the fourth postoperative day. A few weeks later the patient was symptom free. At the 2-year follow-up, the patient showed no clinical or radiologic abnormal findings.
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Comment
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Pancoast syndrome arises in nearly all cases of malignant tumors, mainly superior sulcus tumors (Pancoast tumors), which represents a subset of bronchial carcinomas that occur in the apex of the lung and frequently invade the first two or three ribs, the nearby vertebral bodies, the lower part of the brachial plexus, the subclavian vessels, and the stellate ganglion. However, infection as a cause for Pancoast syndrome is extremely rare [4]. These tumors present by radiography as small homogeneous shadows of the extreme apex with local rib destruction and vertebral infiltration [5].
The presentation of tuberculosis seems to be changing to a more unusual clinical and radiographic finding. Therefore, determining the diagnosis of tuberculosis is often difficult. In our patient, the magnetic resonance imaging examination was helpful because it showed the changes in both the bones and the surrounding soft tissues, as well as the presence of the compression of the brachial plexus [6].
Thoracoscopy was first used by Jacobaeus in 1910 to release pleural adhesions under local anesthesia to facilitate the collapse therapy for pulmonary TB [7]. In recent years, video-assisted thoracoscopic surgery has become the method of choice for diagnosis und treatment of thoracic pathologies. In the literature, one patient with thoracic spinal TB is described, which was diagnosed by video-assisted thoracoscopic surgery [8].
Preoperative tissue diagnosis is mandatory to confirm the diagnosis before neoadjuvant therapy is started in these patients. We performed video-assisted thoracoscopic surgery to obtain material for a bacteriologic culture and to ensure an adequate surgical biopsy to confirm the histologic diagnosis, especially because the patient was a nonsmoker. The origin of this paravertebral TB lesion may have been a localized tuberculous spondylitis of the seventh cervical vertebra and the paravertebral tissue. However, even though no remaining lymphatic tissue was found in the biopsy, it is more likely to be a manifestation of lymphatic TB. We believe this is the first case report of extrapulmonary tuberculosis presenting with this type of clinical manifestation. In addition, this case report demonstrates that tuberculosis should be kept in mind as a differential diagnosis of thoracic lesions and that malignant tumors always have to be confirmed by histologic examination.
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References
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- Narian JP, Raviglone MC, Kochi A. HIV-associated tuberculosis in developing countries. Epidemiology and strategies for prevention. WHO/TB 1992;164:Geneva, WHO
- Treasure R.L., Seaworth B.J. Current role of surgery in Mycobacterium tuberculosis. Ann Thorac Surg 1995;59:1405-1408.[Abstract/Free Full Text]
- Selwyn P.A., Sckell B.M., Alcabes P., Friedland G.H., Klein R.S., Schoenbaum E.E. High risk of active tuberculosis in HIV-infected drug users. JAMA 1992;268:504-509.[Abstract/Free Full Text]
- Attar S., Krasna M., Sonett J., Hankins J., Salwson R., et al. Superior sucus (Pancoast) tumors. Experience with 105 patients. Ann Thor Surg 1998;66:193-198.[Abstract/Free Full Text]
- Pancoast H.K. Superior pulmonary sulcus tumors. JAMA 1932;99:1391-1396.[Abstract/Free Full Text]
- Sharif H.S., Morgan J.L., Al Shahied M.S. The role of CT and MR imaging in the management of tuberculous spondylitis. Radiol Clin North Am 1995;33:787-804.[Medline]
- Braimbridge M.V. The history of thoracoscopic surgery. Ann Thorac Surg 1993;65:610-612.
- Dusmet M, Halkic N, Carpataux JM. Video-assisted thoracic surgery, diagnosis of thoracic spinal tuberculosis. Chest 1999:1471–2
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Abstract
Introduction
