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Radiology of Infectious Diseases 5 (2018) 131e134
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Case Report

Large pulmonary solitary mass caused by Mycobacterium tuberculosis

mimicking a malignant tumor in a child
Yingqian Chen, Youyou Yang, Lang Chen, Miao Fan*
Department of Radiology, First Affiliated Hospital of Sun Yat-Sen University, 58th, The Second Zhongshan Road, Guangzhou, China
Received 31 December 2017; revised 17 June 2018; accepted 6 August 2018
Available online 11 August 2018

Abstract

Tuberculoma, as a common characteristic of pulmonary tuberculosis (TB) in adults, is rarely seen in children. We report a very rare case of
large pulmonary solitary mass caused by Mycobacterium tuberculosis in a 7-year-old boy, which was misdiagnosed for malignant lung tumor
before the biopsy. Pathology and the following test proved it to be active TB. We also review the CT characteristics of TB and common thoracic
neoplasms in children for differential diagnosis. We call for the awareness of the atypical imaging characteristics of TB in children.
© 2018 Beijing You’an Hospital affiliated to Capital Medical University. Production and hosting by Elsevier B.V. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Tuberculoma; Mycobacterium tuberculosis; Pediatric; Computed tomography imaging

1. Introduction smear or culture. Moreover, children get infected more easily

Though the morbidity of Mycobacterium tuberculosis
(Mtb) infection is decreasing, there are around one third of the
world's population which are still infected with it [1]. Mtb
causes a substantial health burden in the world, especially in
developing countries. In the most current national tuberculosis
epidemiological survey in China in 2010, the prevalence of
active and smear positive prevalence of pulmonary tubercu-
losis (TB) were 459/100 000 and 66/100 000 respectively,
mostly attributed by rural area [2].
Pulmonary TB occurs relatively less in children. In 2016,
children under 15 years old accounted for 6.9% of the new TB
cases globally [1]. But it is hard to diagnose Mtb infection in
children, since their symptoms vary from those in adults, and
it is usually hard to get their sputum for acid-fast bacilli (AFB)
with Mtb from other children and adults with active tubercu-
losis, which may cause a localized outbreak. Hence the im-
aging examinations, especially the chest radiograph and chest
multi spiral computed tomography (CT) plays a critical role in
the diagnosis and treatment of active pulmonary TB in
children.
Unlike the imaging appearances in adult, lymphadenopathy
is the most common imaging manifestation in pediatric pa-
tients [3], follow by consolidation and pleural effusion [4].
While pulmonary solitary mass or nodule, which is also
termed as tuberculoma in adult patients, is rarely seen in pe-
diatric patients. Herein we report a case of pathology proved
pulmonary TB with the imaging appearance of solitary mass
which was misdiagnosed as malignant tumor before the
biopsy.

* Corresponding author. Department of Radiology, First Affiliated Hospital 2. Case report

of Sun Yat-Sen University, 58th, The Second Zhongshan Road, Guanzhou,
510080, China.
E-mail addresses: chenyx288@mail.sysu.edu.cn (Y. Chen), fanmiao@
mail.sysu.edu.cn (M. Fan).
Peer review under responsibility of Beijing You'an Hospital affiliated to
Capital Medical University.
A 7-year-old boy was referred to our hospital with a 6-
month history of cough. The boy was healthy ever before
and no obvious predisposing cause was found. He had no
expectoration, fever, chest pain, night sweat or weight loss.

https://doi.org/10.1016/j.jrid.2018.08.002
2352-6211/© 2018 Beijing You’an Hospital affiliated to Capital Medical University. Production and hosting by Elsevier B.V. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
132 Y. Chen et al. / Radiology of Infectious Diseases 5 (2018) 131e134
The laboratory test showed a higher platelet count (377  109/
L) and higher serum lactate dehydrogenase (LDH) level
(300U/L, normal 114e240U/L). But other indexes of the
whole blood cell test and other blood biochemical indexes
were within the normal ranges (white blood cell: 7.10  109/L,
neutrophils: 3.90  109/L, eosinophils: 0.22  109/L). The
posterior-anterior and lateral chest radiographs revealed a
mass with clear margin in his left upper lobe (Fig. 1AeB).
Then chest CT imaging was recommended for a further ex-
amination. In the non-enhanced chest CT images, an oval,
sharply marginated, shallow lobulated mass with a size of
47 mm  37 mm  33 mm was found in the apicoposterior
segment of the left upper lobe. The mass appeared as a ho-
mogeneous attenuation, which both nodular hypoattenuation
areas and annular hyperattenuation inside (Fig. 2AeC). After
contrast enhancement, the hypoattenuation areas showed no
enhancement (Fig. 2D). Lymph nodes enlargement in the
hilum or mediastinal were absent. According to these mani-
festations, a tentative diagnosis by radiologist of pulmonary
malignant tumor was made. After that, more tests of serum
tumor markers were done. The level of alpha fetoprotein
(AFP), neuron-specific enolase (NSE), carcino-embryonic
antigen (CEA) and CYFRA21-1 of the serum were all
within the normal ranges. And the HIV antibody primary
screening was also negative. What was more, to exclude
metastasis, a 18F-fluorodeoxyglucose positron emission
tomography-CT (18F FDG-PET/CT) was done. The pulmo-
nary mass appeared as high FDG consumption, with the
highest standardized uptake value (SUVmax) to be 4.1, which
remind the radiologist to consider the possibility of malignant
tumor. However, no other area of abnormal high FDG uptake
was found (Fig. 3AeB). Base on the image examinations, a
preoperative diagnosis of malignant lung tumor was made. In
order to make a definite diagnosis, the patient received a
pulmonary needle biopsy after consultation. After H-E stain-
ing, large amount of caseous necrosis with focal accumulation
Fig. 1. AeB: The anterior-posterior and lateral chest radiography shows a mass with clear margin located in the left upper lobe (arrow). And the other lung field is
clear.
of lymphocytes could be seen inside the tissue (Fig. 3C).
Tumor cell or abnormal mitoses were absent in the mass. Base
on these findings, pathology diagnosis of inflammation
(possibly TB) was made. Then the boy was transferred to the
infectious disease hospital for further diagnoses and treat-
ments. There, a positive sputum AFB smear and positive
nucleic amplification test proved an active pulmonary TB. The
pulmonary mass shrank after half-a-year's antituberculosis
therapy with isoniazid, rifampicin, ethambutol and pyr-
azinamide. Regretfully, for many reasons, the clear CT images
after treatment were unobtainable.
3. Discussion and conclusion
Herein we reported a case of large pediatric pulmonary
tuberculoma. The boy was ever misdiagnosed as malignant
tumor by CT imaging and 18F FDG-PET/CT. The diagnosis of
pulmonary TB was not taken into account before the biopsy.
Hence the prevention measure of the medical worker and his
families to the active pulmonary TB was far from insufficient,
which might cause regionally spreading of Mtb. Luckily, no
medical workers or the families and classmates of the patient
was found infected in this case. Besides, tuberculoma is
considered as a late and severe complication of tuberculosis in
childhood, which need timely and effective treatment. This
experience calls for the vigilance to atypical imaging
appearance of pediatric tuberculosis.
The CT appearance of pulmonary tuberculosis in children is
different from that of adult. The most common form of active
pulmonary TB in children is primary disease. As the age in-
creases, the morbidity of primary disease decreases and the
postprimary TB increases. The primary TB in infants and
children were characterized by lymphadenopathy and paren-
chymal diseases. The parenchymal disease most frequently
shows as consolidation, followed by nodules of bronchogenic
spread. Besides, pleural involvement is also usually seen in the
 Y. Chen et al. / Radiology of Infectious Diseases 5 (2018) 131e134 133

Fig. 2. AeB: The axial and coronal CT images show a solitary mass located in the apicoposterior segment of the left upper lobe. The mass has sharply margin,
swallow lobulation and homogenous intensity. CeD: In the soft tissue window of non-enhanced and contrast-enhanced CT images, the non-enhanced nodular
hypoattenuation areas (arrow) and annular hyperattenuation can be seen inside the tumor.

Fig. 3. AeB:18F FDG-PET scan of the boy. Maximum intensity projection image and the axial scan of integrated PET/CT image shows the high 18F FDG uptake
of the mass (arrow), especially in the peripheral area. The hypoattenuation areas in CT image shows low uptake of 18F FDG. C: Pathologic image (HE, original
magnification  200) reveal the red-stained caseous necrosis inside the mass. Focal accumulation of lymphocytes can also be seen in the peripheral area (long
arrow).

children with TB [5,6]. While tuberculoma, as a very common
manifestation in adult with TB, is rarely seen in children.
There are a few cases of pulmonary TB manifested as solid
pulmonary nodule or mass in children published in articles. In
2014, Ushiki A et al. published a case of a 14-year-old girl
with a solid pulmonary nodule in posterior segment of right
lower lobe and reported that the tuberculoma is an infrequent
form of TB in children [7]. Toma P et al. reviewed 217 chil-
dren with pulmonary TB and none of them manifested as
tuberculoma [5]. This could be explained by that the immune
system is not so mature in children, and the tuberculoma is a
kind of outcome by the immune system against the Mtb.
The pulmonary tuberculoma is characterized by the
following:
1) Mostly locating in the apicoposterior lung segments or the
apical segments of the lower lobes.
2) Nodular caseous necrosis manifesting as non-enhanced
hypoattenuation areas.
3) Annular or patchy calcification around the necrosis areas [8].
Nonetheless, the tuberculoma in our case was manifested
with typical CT characteristic, which calls for the alertness
that typical tuberculoma may also exist in children.
Moreover, though solid pulmonary nodule or mass can be
secondary to a varies of different cause, it is rarely found in
children. The differential diagnosis may include metastatic
tumor and primary pulmonary neoplasms like pleuro-
pulmonary blastoma (PPB) and pulmonary hamartoma [9].
Metastatic tumor can be differentiated by medical history and
the primary cancer focus. Moreover, metastatic tumor usually
manifests as multiple nodules rather than solitary pulmonary
mass. PPB is the most common malignant pediatric primary
lung parenchymal neoplasm. It can appear as both cystic and
solitary masses on CT, according to its pathologic feature [10].
The absence of chest wall invasion, presence of pleural fluid
and heterogeneous low attenuation are the CT characteristics
of PPB. But calcification is rarely seen in PPB [11]. Pulmo-
nary hamartoma in children appears as a smooth or lobulated
peripheral mass with the classic popcorn calcification and fat
on CT, just like its appearance in adult. Besides, the Kaposi
sarcoma should be taken into account if the children has im-
mune deficiency [9].
In our case, the mass showed high FDG uptake on 18F-
FDG-PET imaging. To some extent, it made the diagnosis to
be more complicated. 18F-FDG-PET can be used to detect the
glucose uptake of the mass, which is usually capable to
differentiate the malignant form the benign mass. But for
many infection diseases, the inflammation process can also
consume glucose, which may cause the high uptake of 18F-
FDG. In this case, as a nonspecific tracer,18F-FDG cannot
reliably distinguish tuberculomas from malignant lung lesions
[12]. On the other hand, many studies have proved that 18F-
FDG-PET can be used in Mtb infection for detection of active
lesion, assessing the disease activity and monitoring the
response to therapy as a non-invasive method, for the level of
18
F-FDG uptake can reveal the activity level of TB lesion in
some degree [13]. As in our case, the level of 18F-FDG uptake
is high of the mass, which is consistent with the hyperactivity
of the TB lesion. Regretfully, limited by the condition of the
local hospital, 18F-FDG PET haven't been used during the
follow-up examinations in this case.
134 Y. Chen et al. / Radiology of Infectious Diseases 5 (2018) 131e134
Sputum culture plays a critical role in the diagnosis of
active pulmonary TB, which has the highest specificity of
98%. But it takes too long (2e8 weeks) to get the result, which
also has a high false negative rate, especially in children.
While AFB smear and polymerase chain reaction (PCR) are
hard to detect Mtb in children due to the poor bacteriologic
specimen. QuantiFERON-TB (QFT) test for detection of
interferon gamma (IFN-g) concentration together with tuber-
culin skin test (TST) seems more reliable and exercisable in
the TB detection of children [14,15]. In developed countries,
contact history to patient with active Mtb infection is a critical
rule to the suspective of TB. However, the rate to contact with
a patient with infectious TB are relatively high in China,
especially in rural area. In this case, every patient suspective of
TB by clinical manifestation, imaging examination or other
laboratory tests should receive a primarily screen of TB.
In conclusion, the report of our case reveals that the tuber-
culoma may also be seen in children. The clinical manifesta-
tions combine with the typical CT characteristic should call for
the awareness of Mtb infection and the necessary protective
measures should be taken to reduce the risk of infection.
Ethics statement
The study was approved by the Research Ethics Committee
of Sun Yat-sen University, China and the written informed
consent was obtained from the subject.
Financial disclosure
This research did not receive any specific grant from
funding agencies in the public, commercial, or not-for-profit
sectors.
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