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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 6  |  Issue : 2  |  Page : 61-64

Cannonballs in the Lung—A Rare Presentation


Department of General Medicine, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India

Date of Web Publication10-Jul-2018

Correspondence Address:
Jijin Satheesh
Department of General Medicine, Sri Ramachandra Medical College, Porur, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacp.jacp_33_17

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  Abstract 

Pulmonary tuberculosis is one of the most prevalent and rampant communicable infectious diseases in the Southeast Asian region. Often the disease has an unusual presentation that diverts our attention toward other diseases. We describe such a case, wherein a 54-year-old male, chronic smoker and a known patient of chronic obstructive airway disease presented with fever, weight loss, and radiographic evidence showing well-circumscribed lesions resembling cannonballs. This was suggestive of secondaries in the lung, which on further diagnosis was determined to be disseminated tuberculosis. The patient was treated with antituberculous medication, following which his symptoms resolved, as evidenced by a radiological examination of his primary disease.

Keywords: Cannonballs, lung, tuberculosis


How to cite this article:
Satheesh J, Vangipuram DR, Madhavan K. Cannonballs in the Lung—A Rare Presentation. J Assoc Chest Physicians 2018;6:61-4

How to cite this URL:
Satheesh J, Vangipuram DR, Madhavan K. Cannonballs in the Lung—A Rare Presentation. J Assoc Chest Physicians [serial online] 2018 [cited 2018 Sep 24];6:61-4. Available from: http://www.jacpjournal.org/text.asp?2018/6/2/61/233810


  Introduction Top


Pulmonary tuberculosis is still the most prevalent communicable disease in Southeast Asia, with an estimated 4.9 million prevalent cases in the region. One-third of these cases are from the Indian subcontinent.[1] The increasing prevalence of immunocompromised states, for example, because of human immunodeficiency virus (HIV), has particularly added to this burden in the past decade. As such, we now encounter more severe and unusual presentations of tuberculosis, which prove to be a diagnostic and therapeutic challenge to the primary care physician. The radiological appearance of tuberculosis is generally as a cavitatory lesion, although other forms such as associated fibrosis, lobar consolidation, bilateral lung involvement, and even lesions resembling acute respiratory distress have been frequently described. Cannonballs in the lung have been classically reported in patients with secondaries in the lung, but such a presentation in patients with tuberculosis has been rarely reported.


  Case Report Top


A 54-year-old male, a carpenter by profession, presented to our clinic with a 2-month history of low-grade fever, a significant weight loss of 15 kg in the past 3 months, and night sweats. The patient was diabetic, being treated with metformin and glipizide for the past 5 years. In addition, he had chronic obstructive airway disease, for which he was not on any regular therapy. He was a smoker consuming 20–40 cigarettes daily for the past 20 years. On clinical examination, the patient was febrile with palpable, firm lymph nodes in the right upper jugulodigastric, axillary, and supraclavicular nodes, grade 3 clubbing, bilateral wheeze on lung auscultation, tender hepatomegaly with a liver span of 16 cm, and splenomegaly. All investigations were conducted showing erythrocyte sedimentation rate (ESR) level at 105 mm, aspartate transaminase (AST) at 91 (<40 U/L), and alanine transaminase (ALT) at 108 (<56 U/L). HIV and HbsAg tests were negative. Sputum Acid fast Bacilli (AFB) test was performed on four samples—two at the Government Hospital of Chest Sciences, Tambaram, Chennai and two samples at our hospital. The results of this test were all negative. We ran a sputum polymerase chain reaction (PCR) for Mycobacterium tuberculosis (GeneXpert) prospectively in the course of diagnosis, which also could not detect mycobaterium tuberculosis (MTB). Chest X-ray performed showed multiple well-circumscribed homogenous lesions of varying sizes with mildly irregular margins present throughout the bilateral lung fields resembling cannonball metastasis [Figure 1]. With a provisional diagnosis of probable malignancy, computed tomography (CT) thorax [Figure 2] and whole abdomen [Figure 3] scan with contrast were performed, which showed multiple well-defined contrast-enhancing lesions in both the lobes of the liver, with the largest measuring 4.1 cm × 3.2 cm. In addition, an enlarged spleen measuring 18 cm without any focal lesions, multiple heterogeneous nodular and soft tissue lesions with irregular margins in the bilateral lung fields, and enlarged mediastinal and abdominal lymph nodes—suggestive of metastasis or lymphoma—were noted. With the aforementioned findings, biopsies were obtained from multiple sites, and pathological analysis was performed. Cervical lymph node biopsy showed reactive lymphadenitis. Liver lesion biopsy showed fibrocollagenous tissue with ill-defined granulomatous process, which stained negative for AFB/PAS/PAS-D stains. Lung lesion biopsy showed necrotizing granulomas with CD45-positive lymphoid cells suggestive of necrotizing granulomas with reactive lymphoid process and no evidence of dysplasia or malignancy. AFB and fungal staining were also negative. Therefore, further investigation was conducted for the evaluation of disseminated granulomatous diseases. The testing of sputum for M. tuberculosis by both AFB staining and PCR techniques showed negative results. Bronchial alveolar lavage was negative for AFB and fungal elements by microscopy, PCR for MTB was negative and bronchial wash was negative for malignant cells. Serum calcium level was 9.3 g/dl, and angiotensin-converting enzyme levels were normal. Culture reports obtained prospectively were also negative for tuberculosis and fungus. cANCA and pANCA were negative. During the course of hospital stay, the patient complained of breathlessness. Further evaluation revealed that the patient had developed significant bilateral pleural effusion (left > right). Hence, the pleural fluid was analyzed, which showed a white blood cells (WBC) count of 350 cells, which were lymphocyte predominant, low sugars, elevated lactate dehydrogenase (LDH) and protein, and an adenosine deaminase level (ADA) of 77 (<32 U/L). Considering all investigations, the patient was initiated on antituberculous therapy. The patient showed significant improvement symptomatically within 2 weeks. Because the prevalence of M. tuberculosis is common in our country and the patient showed significant response to antitubercular therapy, other investigations to rule out atypical mycobacteria were not conducted. Chest X-ray performed one month after antituberculous therapy showed the disappearance of all the cannonball lesions with decrease in bilateral pleural effusion [Figure 4].
Figure 1: Chest X-ray showing multiple well-circumscribed homogenous lesions of varied sizes with mildly irregular margins present throughout the bilateral lung fields resembling cannonball metastases

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Figure 2: CT thorax showing multiple heterogeneous nodular and soft tissue lesions with irregular margins in the bilateral lung fields and enlarged mediastinal and abdominal lymph nodes—suggestive of metastasis or lymphoma

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Figure 3: CT whole abdomen with contrast showing multiple well-defined contrast-enhancing lesions in both the lobes of the liver, with the largest measuring 4.1 cm × 3.2 cm; an enlarged spleen of 18 cm without any focal lesions

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Figure 4: Chest X-ray performed one month after antituberculous therapy showing the disappearance of all the cannonball lesions with decrease in bilateral pleural effusion

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  Discussion Top


This case highlights the difficulty in diagnosing tuberculosis despite its high prevalence among our populations. Despite all the clinical features and radiological findings pointing toward a primary malignancy with metastasis, ultimately, it required a combination of histopathological evaluations to identify it as a disseminated granulomatous disease. These lesions were well-circumscribed with fairly regular margins. They may be labeled as atypical cannonball lesions. It may also be noted that the relative sparing of the upper lobes would be atypical of tuberculosis. Even then, it was difficult to exact the cause, and only the pleural fluid analysis was definitive toward diagnosing tuberculosis. Cannonball metastases[2] are majorly associated with malignancies; hence, it is quite rare to see tuberculosis masquerading as one. With a background history of smoking and a nonspecific history of fever with weight loss, it is almost a straightforward diagnosis that these characteristic cannonball lesions are associated with malignancy. Although tuberculosis has not been classically described in major textbooks as the cause for clubbing, significant positive correlation has been demonstrated in independent studies.[3],[4] The classical radiological features associated with tuberculosis is generally consolidation, cavitation, pleural effusion, miliary mottling, tuberculomas, and rarely as acute respiratory distress syndrome,[5] broncholithiasis, isolated hilar lymphadenopathy, and cannonballs.[6],[7]Differentials[8] for disseminated granulomatous diseases to be considered in this case are as follows:
  1. Infections: Fungi: blastomyces, aspergillus, and histoplasma; Protozoa: toxoplasma, leishmania, and spirochaetes; Bacteria: brucella and yersinia.
  2. Vasculitis: Wegener’s granulomatosis, necrotizing sarcoid granulomatosis, Churg-Strauss syndrome, and giant cell arteritis.
  3. Immunological aberrations: Sarcoidosis, Langerhans granulomatosis and Crohn’s disease.
  4. Leucocyte oxidase defects: Chronic granulomatous disease during childhood and adulthood.
  5. Hypersensitivity pneumonitis: Farmers’ lung and bagassosis.
  6. Chemicals: Beryllium, silica, and talc.
  7. Miscellaneous infections: Whipple’s disease, cat scratch, and Kikuchi disease.


It is also important to note that although biopsy and pleural fluid analysis were the imperative tools for diagnosis, the response to antituberculous therapy should also be considered as an additional and critical tool toward diagnostic accuracy, especially in areas that are endemic for tuberculosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgements

I thank my professor Dr. K. Madhavan and my assistant Dr. Vangipuram Deepak Rajkumar for their active contribution toward this case report. I also extend my wholehearted gratitude to the entire cardiology department for playing an active role for a favorable outcome in the patient’s prognosis. In addition, most importantly, my deepest thanks to the patient for his cooperation that helped fulfill our goal toward furthering education and knowledge.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Bulletin of the World Health Organization, vol. 88; 2010. p. 164.  Back to cited text no. 1
    
2.
Crow J, Slavin G, Kreel L. Pulmonary metastasis: A pathologic and radiologic study. Cancer 1981;47:2595-602.  Back to cited text no. 2
    
3.
Banyai AL, Cadden AV. Changes in the finger nails in pulmonary tuberculosis. Arch Derm Syphilol 1943;48:306-9.  Back to cited text no. 3
    
4.
Ddungu H, Johnson JL, Smieja M, Mayanja-Kizza H. Digital clubbing in tuberculosis—Relationship to HIV infection, extent of disease and hypoalbuminemia. BMC Infect Dis 2006;6:45.  Back to cited text no. 4
    
5.
Abi-Fadel F, Gupta K. Acute respiratory distress syndrome with miliary tuberculosis: A fatal combination. J Thorac Dis 2013;5:E1-4.  Back to cited text no. 5
    
6.
Kshatriya R, Patel V, Chaudhari S, Patel P, Prajapati D, Khara N et al. Cannon ball appearance on radiology in a middle-aged diabetic female. Lung India 2016;33:562-8.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Kumar S, Parkash P, Patnaik S. Pulmonary tuberculosis presenting with cannon-ball opacities. Indian J Chest Dis Allied Sci 2001;43:223-5.  Back to cited text no. 7
    
8.
James DG. A clinicopathological classification of granulomatous disorders. Postgrad Med J 2000;76:457-65.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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