Multiple tuberculous nodules with metachronous changes: a case report
© Fukusumi et al.; licensee BioMed Central Ltd. 2013
Received: 23 April 2013
Accepted: 8 August 2013
Published: 12 August 2013
Spontaneous regression of lesions occurs in non-infectious benign diseases, such as sarcoidosis, as well as in infectious diseases, such as tuberculosis. Lung cancer and malignant lymphoma, on the other hand, rarely follow a similar course. We report a rare case of lung tuberculosis that presented with multiple nodules with metachronous changes in size.
We describe the case of a 50-year-old immunocompetent Japanese man with pulmonary tuberculosis in the form of multifocal nodules. He came to our hospital because of a chest X-ray abnormality. During the course of observation, some nodules reduced while others enlarged in size. Two years after the first visit, fever and pleural effusion appeared. The sputum examination turned out to be positive for tuberculosis. A course of anti-tubercular agents resolved the pleural effusion and multifocal nodules.
Differences in the manner of granuloma formation suggest that the local immune response can be different even in the same lung field.
Spontaneous regression of lesions occurs in non-infectious benign diseases, such as sarcoidosis, as well as in infectious diseases, such as tuberculosis. Lung cancer and malignant lymphoma, on the other hand, rarely follow a similar course[2, 3]. Local immune response and granuloma formation are the main factors contributing to spontaneous regression of the lesions. Here, we report a Japanese man who suffered from tuberculosis of the lung in the form of multiple nodules that showed metachronous changes in size.
452 × 104/μl
36.4 × 104/μl
Fecal occult blood
Prior to the introduction of chemotherapy for tuberculosis, spontaneous regression of lesions had been regarded as one aspect of a disease’s natural course. Spontaneous regression of lung tuberculosis was reported from the 1950s to 1970s[4–7]. Spontaneous regression of extrapulmonary tuberculosis, in the form of a tuberculous psoas abscess with calcification and intracranial tuberculoma, were also reported in the 1990s[8, 9].
In our case, there were two possible mechanisms for the disappearance of the initial nodules prior to the exacerbation of new ones. First is a partial decrease in the immune response in the enlarged lesions. Chronic lung diseases, such as organizing pneumonia (OP) and non-tuberculous Mycobacterium infection (NTM), or even an acute infection, such as atypical pneumonia, sometimes present with translocation of the infiltrates or simultaneous occurrence of partial improvement and partial worsening of the infiltration. These phenomena suggest that immune responses may differ in strength, process and phase within a wide lung field. Although our patient presented with nodular shadows, our case may share similar mechanisms of movement of infiltrates as in OP or NTM infection. Second, the local confines of granuloma formation may be broken down only in the lesions, which communicated with an airway, resulting in better oxygen supply for the TB bacilli, and consequent growth of the lesions.
In conclusion, we report a rare case of pulmonary tuberculosis presenting as multifocal nodules that showed metachronous changes in size, which suggest that the local immune response might be different even in different parts of the same lung field.
Written informed consent was obtained from our patient for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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