A 40 year-old Moroccan woman presented with a one-month history of dyspnoea, cough and right chest pain.

She had not had fever or any other general symptoms.

Physical examination showed a right pleural effusion and hepatomegaly 3 cm below the costal margin.

Analytical studies showed an increased C reactive protein of 25 mg/dl; haemoglobin 12 g/dL; white blood cells 10,000/mm3; AST (GOT) 34 IU/dL; ALT (GPT) 41 IU/dL.

The chest X-ray showed a right pleural effusion (see image).

Mantoux test was positive; Quantiferon test and sputum smear for acid fast bacilli (x3) were negative. The pleural effusion contained wbc 1500/mm3 (80 % lymphocytes), proteins 2.5 g/mL and glucose 56 mg/dL.

Treatment with isoniazid, rifampicin, pyrazinamide and ethambutol was initiated while awaiting mycobacterial cultures.

A month later, due to the persistence of clinical symptoms, a CT scan was performed (see image).

What abnormalities do you see in the CT scan? What is your diagnosis and what procedure would you recommend to confirm it?

The CT scan shows a right pleural effusion with parenchymal consolidation and collapse of the right lower lobe of the lung. There are bilateral micronodular pulmonary lesions. A hypoattenuated hepatic lesion of 52 x 39 mm with irregular borders and small satellite nodules can be seen.

To confirm the diagnosis a biopsy of the hepatic lesion was performed and it showed a biliary adenocarcinoma.

The initial suspicion was of pleural tuberculosis. Its incidence is high in migrants and is related to poor living conditions in the country of destination and high prevalence of infection.

Mantoux test can be positive in other mycobacterial infections and after BCG vaccination.

Interferon-–release assays (IGRAs) from sensitized T-cells activated with M. tuberculosis antigens can avoid these false positive Mantoux tests. There are currently two commercially available IGRAs: Quantiferon-TB Gold (Cellestis, Australia) and T-Spot.TB (Oxford Immunotec, UK).

More information about IGRAs at www.igrasymposium.com