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Image Diagnosis: Endobronchial Tuberculosis Masquerading as an Endobronchial Tumor with Presentation as Middle Lobe Syndrome.

CASE REPORT A 70-year-old woman, a never-smoker, presented to our hospital with a dry cough, breathlessness, temperature increase in the evening, and 2 months of loss of appetite and weight loss. Her physical examination was unremarkable. Her chest radiograph posterior-anterior view showed an ill-defined patchy opacity in the right lower zone with loss of cardiac silhouette (Figure 1A). Chest radiograph right lateral view showed a wedge-shaped density extending anteriorly and inferiorly from the lung hilum and loss of lung volume (Figure 1B), suggestive of middle lobe syndrome (MLS). On high-resolution computed tomography of the patient’s thorax (Figures 2A and 2B), consecutive axial images revealed the abrupt truncation of the right middle lobe bronchus (bronchial cut-off sign) and a trapezoidal opacity with its base toward the hilum, confirming the presence of MLS. Mantoux test using 1 TU elicited an induration of 15 mm after 48 hours. Fiberoptic bronchoscopy revealed a mass lesion covered with caseous material, which completely occluded the right middle lobe bronchus (Figure 3) and extended into the intermediate bronchus (Figures 4A and 4B). Multiple endobronchial biopsy (EBB) samples were taken from this lesion and sent to the laboratory for histopathology and Mycobacterial tuberculosis culture. Bronchial aspirate was negative for acid-fast bacilli, and histopathologic examination of EBB samples was inconclusive, but Mycobacterium tuberculosis was cultured in the EBB sample. A diagnosis of tumorous-type endobronchial tuberculosis (EBTB) presenting as MLS was made on the basis of the following: 1) on bronchoscopy, a mass lesion covered with caseous material was found occluding the middle lobe bronchus, suggesting a tumorous-type lesion of EBTB (Figure 3, Figure 4A and 4B); 2) isolation of Mycobacterium tuberculosis from the EBB sample; and 3) characteristic radiologic presentation suggestive of MLS. The patient was started on antituberculous treatment and showed clinical improvement after 2 weeks.