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Tuberculous Pleural Effusion: New Pulmonary Lesions during Treatment¹

¹ From the Departments of Radiology (Y.W.C., S.C.J., H.S.S., C.K.H., K.B.J.) and Internal Medicine (S.S.P.), Hanyang University Seoul Hospital, 17 Haengdang-dong, Sungdong-ku, Seoul 133-792, South Korea; and Department of Radiology, Hanyang University Kuri Hospital, Kuri, Kyungki-do, South Korea (C.K.P.). Received July 26, 2001; revision requested September 24; revision received December 20; accepted January 22, 2002. Address correspondence to Y.W.C. (e-mail: ywchoi@hanyang.ac.kr).

View larger version (131K): [in a new window]   Figure 1a. Patient 6. Paradoxical response to antituberculous medication for tuberculous pleural effusion in a 23-year-old man. (a) Transverse contrast-enhanced chest CT scan (10-mm collimation) obtained through the right lower lobe a month after initial detection of pleural effusion shows loculated pleural fluid and well-enhancing parietal pleura (arrowheads) in the right side. Also note peripheral homogeneously enhancing consolidations (arrows), which appear to be passive atelectasis due to pleural effusion. (b) Magnified frontal chest radiograph showing the right lower lung, obtained 20 days after a, demonstrates a pleural abnormality obliterating the right costophrenic angle. Note an area of focal consolidation (arrow) abutting the pleural abnormality; the consolidation may represent atelectasis or an incipient lesion of a subsequent lung nodule (arrow in c). (c) Magnified frontal chest radiograph showing the right lower lung, obtained 2 months after b, demonstrates a peripheral pulmonary nodule (arrow) in the same area in which focal consolidation was noted before (arrow in b). However, this lesion is far larger than the one in b. Note an acute angle between the lesion and the pleura, suggesting its peripheral pulmonary origin. (d) Transverse contrast-enhanced chest CT scan (1.5-mm collimation) obtained at the same level as a, 10 days after c, shows that a well-enhancing peripheral lung nodule (arrow) with central low attenuation is responsible for the nodule in c. It abuts the thickened pleura, which also enhances. The nodule disappeared 14 months later with use of the same medication (image not shown).

View larger version (122K): [in a new window]   Figure 1b. Patient 6. Paradoxical response to antituberculous medication for tuberculous pleural effusion in a 23-year-old man. (a) Transverse contrast-enhanced chest CT scan (10-mm collimation) obtained through the right lower lobe a month after initial detection of pleural effusion shows loculated pleural fluid and well-enhancing parietal pleura (arrowheads) in the right side. Also note peripheral homogeneously enhancing consolidations (arrows), which appear to be passive atelectasis due to pleural effusion. (b) Magnified frontal chest radiograph showing the right lower lung, obtained 20 days after a, demonstrates a pleural abnormality obliterating the right costophrenic angle. Note an area of focal consolidation (arrow) abutting the pleural abnormality; the consolidation may represent atelectasis or an incipient lesion of a subsequent lung nodule (arrow in c). (c) Magnified frontal chest radiograph showing the right lower lung, obtained 2 months after b, demonstrates a peripheral pulmonary nodule (arrow) in the same area in which focal consolidation was noted before (arrow in b). However, this lesion is far larger than the one in b. Note an acute angle between the lesion and the pleura, suggesting its peripheral pulmonary origin. (d) Transverse contrast-enhanced chest CT scan (1.5-mm collimation) obtained at the same level as a, 10 days after c, shows that a well-enhancing peripheral lung nodule (arrow) with central low attenuation is responsible for the nodule in c. It abuts the thickened pleura, which also enhances. The nodule disappeared 14 months later with use of the same medication (image not shown).

View larger version (132K): [in a new window]   Figure 1c. Patient 6. Paradoxical response to antituberculous medication for tuberculous pleural effusion in a 23-year-old man. (a) Transverse contrast-enhanced chest CT scan (10-mm collimation) obtained through the right lower lobe a month after initial detection of pleural effusion shows loculated pleural fluid and well-enhancing parietal pleura (arrowheads) in the right side. Also note peripheral homogeneously enhancing consolidations (arrows), which appear to be passive atelectasis due to pleural effusion. (b) Magnified frontal chest radiograph showing the right lower lung, obtained 20 days after a, demonstrates a pleural abnormality obliterating the right costophrenic angle. Note an area of focal consolidation (arrow) abutting the pleural abnormality; the consolidation may represent atelectasis or an incipient lesion of a subsequent lung nodule (arrow in c). (c) Magnified frontal chest radiograph showing the right lower lung, obtained 2 months after b, demonstrates a peripheral pulmonary nodule (arrow) in the same area in which focal consolidation was noted before (arrow in b). However, this lesion is far larger than the one in b. Note an acute angle between the lesion and the pleura, suggesting its peripheral pulmonary origin. (d) Transverse contrast-enhanced chest CT scan (1.5-mm collimation) obtained at the same level as a, 10 days after c, shows that a well-enhancing peripheral lung nodule (arrow) with central low attenuation is responsible for the nodule in c. It abuts the thickened pleura, which also enhances. The nodule disappeared 14 months later with use of the same medication (image not shown).

View larger version (115K): [in a new window]   Figure 1d. Patient 6. Paradoxical response to antituberculous medication for tuberculous pleural effusion in a 23-year-old man. (a) Transverse contrast-enhanced chest CT scan (10-mm collimation) obtained through the right lower lobe a month after initial detection of pleural effusion shows loculated pleural fluid and well-enhancing parietal pleura (arrowheads) in the right side. Also note peripheral homogeneously enhancing consolidations (arrows), which appear to be passive atelectasis due to pleural effusion. (b) Magnified frontal chest radiograph showing the right lower lung, obtained 20 days after a, demonstrates a pleural abnormality obliterating the right costophrenic angle. Note an area of focal consolidation (arrow) abutting the pleural abnormality; the consolidation may represent atelectasis or an incipient lesion of a subsequent lung nodule (arrow in c). (c) Magnified frontal chest radiograph showing the right lower lung, obtained 2 months after b, demonstrates a peripheral pulmonary nodule (arrow) in the same area in which focal consolidation was noted before (arrow in b). However, this lesion is far larger than the one in b. Note an acute angle between the lesion and the pleura, suggesting its peripheral pulmonary origin. (d) Transverse contrast-enhanced chest CT scan (1.5-mm collimation) obtained at the same level as a, 10 days after c, shows that a well-enhancing peripheral lung nodule (arrow) with central low attenuation is responsible for the nodule in c. It abuts the thickened pleura, which also enhances. The nodule disappeared 14 months later with use of the same medication (image not shown).

View larger version (129K): [in a new window]   Figure 2a. Patient 1. Paradoxical response to antituberculous medication for tuberculous pleural effusion in a 29-year-old man. (a) Magnified frontal chest radiograph obtained a month after detection of right pleural effusion shows that the pleural fluid has disappeared. No lung nodule or mass is evident in the right lower lung. (b) Magnified frontal chest radiograph obtained 8 months after a shows an ill-defined mass (arrow) above the right side of the diaphragm, which is not evident in a. The lesion was classified as uncertain in origin radiographically. (c) Transverse contrast-enhanced chest CT scan (5-mm collimation) obtained through the right half of the diaphragm at the same time as b shows that the mass in b results from an inhomogeneously enhancing pulmonary lesion (arrow) abutting the pleura. The mass disappeared 9 months later with use of antituberculous medication.

View larger version (132K): [in a new window]   Figure 2b. Patient 1. Paradoxical response to antituberculous medication for tuberculous pleural effusion in a 29-year-old man. (a) Magnified frontal chest radiograph obtained a month after detection of right pleural effusion shows that the pleural fluid has disappeared. No lung nodule or mass is evident in the right lower lung. (b) Magnified frontal chest radiograph obtained 8 months after a shows an ill-defined mass (arrow) above the right side of the diaphragm, which is not evident in a. The lesion was classified as uncertain in origin radiographically. (c) Transverse contrast-enhanced chest CT scan (5-mm collimation) obtained through the right half of the diaphragm at the same time as b shows that the mass in b results from an inhomogeneously enhancing pulmonary lesion (arrow) abutting the pleura. The mass disappeared 9 months later with use of antituberculous medication.

View larger version (150K): [in a new window]   Figure 2c. Patient 1. Paradoxical response to antituberculous medication for tuberculous pleural effusion in a 29-year-old man. (a) Magnified frontal chest radiograph obtained a month after detection of right pleural effusion shows that the pleural fluid has disappeared. No lung nodule or mass is evident in the right lower lung. (b) Magnified frontal chest radiograph obtained 8 months after a shows an ill-defined mass (arrow) above the right side of the diaphragm, which is not evident in a. The lesion was classified as uncertain in origin radiographically. (c) Transverse contrast-enhanced chest CT scan (5-mm collimation) obtained through the right half of the diaphragm at the same time as b shows that the mass in b results from an inhomogeneously enhancing pulmonary lesion (arrow) abutting the pleura. The mass disappeared 9 months later with use of antituberculous medication.

View larger version (151K): [in a new window]   Figure 3a. Patient 15. Paradoxical response to antituberculous medication for tuberculous pleural effusion in a 32-year-old man. (a) Frontal chest radiograph obtained a week after the initial detection of right pleural effusion shows a mild pleural abnormality on the right. Also note multiple ill-defined nodules (arrows) in both upper lungs, which are consistent with tuberculosis. (b) Frontal chest radiograph obtained 2 months after a shows a lobulated mass (arrow) in the right lower lobe that abuts the thickened pleura. (c) Frontal chest radiograph obtained 4 months after b shows that the right lung mass seen in b has disappeared, but multiple new lung lesions (long and short arrows) have developed in the right lower and both middle lungs. All lesions are ill-defined, and some of them show the incomplete border sign, suggesting their peripheral location within the lung. The lesion in the left middle lung (short arrow) is ill defined, and its relative location within the lung is difficult to determine. When compared with that in a, the pulmonary lesion in the right upper lobe (arrowhead) appears to be improved. (d, e) Transverse contrast-enhanced chest CT scans (1.5-mm collimation) obtained at the same time as c at the level of the left upper lobe bronchus (d) and the right lower lobe (e) show multiple inhomogeneously enhancing nodules (arrows) in both lungs. Note that all lesions, including the left pulmonary lesion that appeared undetermined in relative location within the lung (short arrow in c), are located peripherally. The pleura adjacent to the lung lesions appears to be normal (arrowheads in d) or thickened (arrowheads in e). All lesions disappeared 7 months later with use of antituberculous medication.

View larger version (147K): [in a new window]   Figure 3b. Patient 15. Paradoxical response to antituberculous medication for tuberculous pleural effusion in a 32-year-old man. (a) Frontal chest radiograph obtained a week after the initial detection of right pleural effusion shows a mild pleural abnormality on the right. Also note multiple ill-defined nodules (arrows) in both upper lungs, which are consistent with tuberculosis. (b) Frontal chest radiograph obtained 2 months after a shows a lobulated mass (arrow) in the right lower lobe that abuts the thickened pleura. (c) Frontal chest radiograph obtained 4 months after b shows that the right lung mass seen in b has disappeared, but multiple new lung lesions (long and short arrows) have developed in the right lower and both middle lungs. All lesions are ill-defined, and some of them show the incomplete border sign, suggesting their peripheral location within the lung. The lesion in the left middle lung (short arrow) is ill defined, and its relative location within the lung is difficult to determine. When compared with that in a, the pulmonary lesion in the right upper lobe (arrowhead) appears to be improved. (d, e) Transverse contrast-enhanced chest CT scans (1.5-mm collimation) obtained at the same time as c at the level of the left upper lobe bronchus (d) and the right lower lobe (e) show multiple inhomogeneously enhancing nodules (arrows) in both lungs. Note that all lesions, including the left pulmonary lesion that appeared undetermined in relative location within the lung (short arrow in c), are located peripherally. The pleura adjacent to the lung lesions appears to be normal (arrowheads in d) or thickened (arrowheads in e). All lesions disappeared 7 months later with use of antituberculous medication.

View larger version (146K): [in a new window]   Figure 3c. Patient 15. Paradoxical response to antituberculous medication for tuberculous pleural effusion in a 32-year-old man. (a) Frontal chest radiograph obtained a week after the initial detection of right pleural effusion shows a mild pleural abnormality on the right. Also note multiple ill-defined nodules (arrows) in both upper lungs, which are consistent with tuberculosis. (b) Frontal chest radiograph obtained 2 months after a shows a lobulated mass (arrow) in the right lower lobe that abuts the thickened pleura. (c) Frontal chest radiograph obtained 4 months after b shows that the right lung mass seen in b has disappeared, but multiple new lung lesions (long and short arrows) have developed in the right lower and both middle lungs. All lesions are ill-defined, and some of them show the incomplete border sign, suggesting their peripheral location within the lung. The lesion in the left middle lung (short arrow) is ill defined, and its relative location within the lung is difficult to determine. When compared with that in a, the pulmonary lesion in the right upper lobe (arrowhead) appears to be improved. (d, e) Transverse contrast-enhanced chest CT scans (1.5-mm collimation) obtained at the same time as c at the level of the left upper lobe bronchus (d) and the right lower lobe (e) show multiple inhomogeneously enhancing nodules (arrows) in both lungs. Note that all lesions, including the left pulmonary lesion that appeared undetermined in relative location within the lung (short arrow in c), are located peripherally. The pleura adjacent to the lung lesions appears to be normal (arrowheads in d) or thickened (arrowheads in e). All lesions disappeared 7 months later with use of antituberculous medication.

View larger version (88K): [in a new window]   Figure 3d. Patient 15. Paradoxical response to antituberculous medication for tuberculous pleural effusion in a 32-year-old man. (a) Frontal chest radiograph obtained a week after the initial detection of right pleural effusion shows a mild pleural abnormality on the right. Also note multiple ill-defined nodules (arrows) in both upper lungs, which are consistent with tuberculosis. (b) Frontal chest radiograph obtained 2 months after a shows a lobulated mass (arrow) in the right lower lobe that abuts the thickened pleura. (c) Frontal chest radiograph obtained 4 months after b shows that the right lung mass seen in b has disappeared, but multiple new lung lesions (long and short arrows) have developed in the right lower and both middle lungs. All lesions are ill-defined, and some of them show the incomplete border sign, suggesting their peripheral location within the lung. The lesion in the left middle lung (short arrow) is ill defined, and its relative location within the lung is difficult to determine. When compared with that in a, the pulmonary lesion in the right upper lobe (arrowhead) appears to be improved. (d, e) Transverse contrast-enhanced chest CT scans (1.5-mm collimation) obtained at the same time as c at the level of the left upper lobe bronchus (d) and the right lower lobe (e) show multiple inhomogeneously enhancing nodules (arrows) in both lungs. Note that all lesions, including the left pulmonary lesion that appeared undetermined in relative location within the lung (short arrow in c), are located peripherally. The pleura adjacent to the lung lesions appears to be normal (arrowheads in d) or thickened (arrowheads in e). All lesions disappeared 7 months later with use of antituberculous medication.

View larger version (113K): [in a new window]   Figure 3e. Patient 15. Paradoxical response to antituberculous medication for tuberculous pleural effusion in a 32-year-old man. (a) Frontal chest radiograph obtained a week after the initial detection of right pleural effusion shows a mild pleural abnormality on the right. Also note multiple ill-defined nodules (arrows) in both upper lungs, which are consistent with tuberculosis. (b) Frontal chest radiograph obtained 2 months after a shows a lobulated mass (arrow) in the right lower lobe that abuts the thickened pleura. (c) Frontal chest radiograph obtained 4 months after b shows that the right lung mass seen in b has disappeared, but multiple new lung lesions (long and short arrows) have developed in the right lower and both middle lungs. All lesions are ill-defined, and some of them show the incomplete border sign, suggesting their peripheral location within the lung. The lesion in the left middle lung (short arrow) is ill defined, and its relative location within the lung is difficult to determine. When compared with that in a, the pulmonary lesion in the right upper lobe (arrowhead) appears to be improved. (d, e) Transverse contrast-enhanced chest CT scans (1.5-mm collimation) obtained at the same time as c at the level of the left upper lobe bronchus (d) and the right lower lobe (e) show multiple inhomogeneously enhancing nodules (arrows) in both lungs. Note that all lesions, including the left pulmonary lesion that appeared undetermined in relative location within the lung (short arrow in c), are located peripherally. The pleura adjacent to the lung lesions appears to be normal (arrowheads in d) or thickened (arrowheads in e). All lesions disappeared 7 months later with use of antituberculous medication.