From the Department of Radiology (J.Y.H., G.Y.) and Department of Radiology, Division of Cardiothoracic Imaging (G.Y.), University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213; and Department of Radiology, Bundang Seoul National University Hospital, Seoul, South Korea (K.H.L.).
Radiology. 2023 Oct;309(1):e223089. doi: 10.1148/radiol.223089.
An 81-year-old man living in South Korea was referred to the pulmonology clinic because of abnormal findings at routine surveillance CT (Fig 1A, 1B). His past medical history included right radical nephroureterectomy for ureteral cancer in 2016, transurethral resection of a bladder tumor in 2015, and tuberculous pleurisy in his third decade of life that was complicated by a chronic calcified empyema (Fig 1C). He had been doing well clinically until 6 months prior, when he presented to an outside hospital with progressive right-sided chest pain and dyspnea and was found to have active tuberculosis. During that hospitalization, he underwent chest CT and CT-guided biopsy of an incidentally found thoracic lesion (Fig 2), which revealed chronic active inflammation. His symptoms improved after initiation of antituberculous medication, and he was discharged home to complete treatment. Because of interval growth of this lesion noted on a subsequent surveillance CT scan, he was referred to pulmonology for further evaluation. Laboratory tests obtained during his visit revealed mild leukocytosis (1258 cells × 10/L; normal range, 4000-10 000 cells × 10/L) with neutrophilic predominance (82% neutrophils; normal range, 50%-75% neutrophils), and a mildly elevated C-reactive protein level (3.17 mg/dL; normal range, 0-0.5 mg/dL). A sputum culture was negative for tuberculosis. The patient reported mild chest discomfort and dyspnea. Liver MRI was performed to further evaluate an abnormal lesion seen at CT (Fig 3). Given the patient's recent nonspecific biopsy results and tuberculosis treatment, no further work-up was pursued. Contrast-enhanced chest CT was performed 6 months later because the patient developed worsening chest pain and dyspnea (Fig 4). He remained afebrile, with persistent leukocytosis (1485 cells × 10/L) and an elevated C-reactive protein level (3.56 mg/dL). On the basis of the imaging findings, repeat CT-guided biopsy and PET/CT were performed (Fig 5), thereby enabling confirmation of the diagnosis, and appropriate treatment was initiated.
一位 81 岁的韩国男性因常规监测 CT 发现异常而被转至呼吸科门诊（图 1A、1B）。他的既往病史包括 2016 年因输尿管癌行右侧根治性肾输尿管切除术、2015 年行经尿道膀胱肿瘤切除术，以及 30 多岁时并发慢性钙化性脓胸的结核性胸膜炎（图 1C）。在那之后，他的临床情况一直良好，直到 6 个月前，他因进行性右侧胸痛和呼吸困难到一家外院就诊，被诊断为活动性肺结核。在那次住院期间，他接受了胸部 CT 和 CT 引导下偶然发现的胸部病变活检（图 2），结果显示为慢性活动性炎症。他在开始抗结核治疗后症状改善，并出院回家完成治疗。由于随后的监测 CT 扫描发现该病变有间隔生长，他被转至呼吸科进一步评估。就诊时的实验室检查结果显示轻度白细胞增多（1258 个细胞×10/L；正常范围为 4000-10000 个细胞×10/L），中性粒细胞占优势（82%中性粒细胞；正常范围为 50%-75%中性粒细胞），C 反应蛋白水平轻度升高（3.17 mg/dL；正常范围为 0-0.5 mg/dL）。痰培养结果为结核阴性。患者自述有轻度胸痛和呼吸困难。为进一步评估 CT 上发现的异常病变，进行了肝脏 MRI（图 3）。鉴于患者近期非特异性活检结果和结核病治疗，未进行进一步检查。6 个月后因患者出现胸痛和呼吸困难加重行增强胸部 CT（图 4）。患者仍无发热，持续白细胞增多（1485 个细胞×10/L）和 C 反应蛋白水平升高（3.56 mg/dL）。根据影像学表现，再次进行 CT 引导下活检和 PET/CT（图 5），从而确诊，并开始了适当的治疗。
