KeywordsMiliary shadows/pattern · Miliary tuberculosis · Adenocarcinoma · Intrapulmonary metastases. AbstractMiliary shadows on chest imaging have wide differential diagnoses. The most common etiology is infectious, such as miliary tuberculosis (TB) and histoplasmosis, but miliary shadows can be the presentation of sarcoidosis, pneumoconiosis, and secondary metastasis to the lungs from primary cancers of the thyroid, kidney, and trophoblasts as well as sarcomas. Here we present the case of a 35-year-old Indian male who presented with a 2-month history of dry cough and shortness of breath. Chest imaging showed diffuse bilateral miliary nodules. The initial impression was that of miliary pulmonary TB. Subsequent bronchoscopy with a transbronchial biopsy confirmed the diagnosis of pulmonary mucinous adenocarcinoma with brain metastasis, which is a rare and unusual presentation of primary lung cancer. The tumor was positive for ALK5A4 and PD-L1, and the patient was started on tyrosine kinase inhibitor immunotherapy, with a favorable response.chial brushings, and fluoroscopy-guided transbronchial biopsies of the right-sided mass were conducted.The bronchioalveolar lavage was negative for malignant cells, and histopathology showed pulmonary mucinous adenocarcinoma (Fig. 4-6). Immunohistochemical analysis revealed that the tumor cells were positive for napsin A (Fig. 7) and anaplastic lymphoma kinase

No abstract

Black pleural effusion is a rare entity and may be a diagnostic dilemma. This interactive case discusses the various steps involved to reach the diagnosis.

Tuberculous spondylitis (Pott’s disease) is among the frequent extra-pulmonary presentations of tuberculosis (TB). The global incidence of lung adenocarcinoma is on the rise, and it is a rare differential diagnosis of miliary shadows on chest imaging. It has a predilection to metastasize to ribs and spine in particular. There is a very close clinical and radiological resemblance in the presentation of spinal metastasis of lung cancer and Potts’s disease. It poses a diagnostic challenge to clinicians particularly in TB endemic areas to arrive at an accurate diagnosis, leading to disease progression and poor outcome. We report a 54-year-old female patient presented with constitutional symptoms of on and off fever and back pain. Her chest X-ray revealed miliary shadows, and acid-fast bacilli (AFB) sputum smear and TB polymerase chain reaction (PCR) test came negative; radiological diagnosis of tuberculous spondylitis was done on computerized tomography (CT) chest and magnetic resonance imaging (MRI) spine. Subsequent bronchoscopy and bronchoalveolar lavage (BAL) cytology showed malignant cells and CT-guided lung biopsy confirmed lung adenocarcinoma with spinal and brain metastasis. Despite being started on chemo-immunotherapy and radiotherapy her outcome was poor due to advanced metastatic disease. This case highlights the significance of considering metastatic adenocarcinoma of the lung a rare but ominous possibility in the differential diagnosis of miliary shadows on chest imaging. Early bronchoscopy and biopsy must be considered in all patients presenting with miliary pulmonary lesions and spinal lesions to make a correct diagnosis, preventing an unnecessary delay in starting proper treatment and poor outcome. It also emphasizes the importance of better understanding the different radiographic features of the two common mimics, spinal tuberculosis, and metastatic spinal tumors.

Las sombras miliares en imágenes del tórax tienen diagnósticos diferenciales muy diversos. La etiología más común es infecciosa, como la tuberculosis (TB) miliar y la histoplasmosis, pero las sombras miliares pueden ser la presentación de la sarcoidosis, neumoconiosis y metástasis secundaria al pulmón de cánceres primarios de tiroides, riñón y trofoblastos, así como del sarcoma. Presentamos el caso de un paciente indio, masculino, quien refirió una historia de dos meses con tos seca y dificultad respiratoria. Imágenes del tórax mostraron nódulos miliares bilaterales, difusos. La impresión inicial fue TB pulmonar miliar. Una posterior broncoscopía con biopsia transbronquial confirmó el diagnóstico de adenocarcinoma mucinoso pulmonar con metástasis al cerebro, una presentación rara e inusual de cáncer de pulmón primario. El tumor fue positivo para ALK5A4 y PD-L1, y se inició inmunoterapia con un inhibidor de tirosina quinasa, con respuesta favorable.