A Case Report: Coexistent Pulmonary Tuberculosis and Lung

Cancer Diagnosed from the Same Specimen

Rispan Pratama

, Bintang Yinke Magdalena Sinaga

Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Sumatera Utara

H.Adam Malik General Hospital, Medan, Indonesia.

Keywords: Pulmonary Tuberculosis, Lung Cancer

Abstract: Pulmonary tuberculosis and cancer are common causes of morbidity, mortality and major public health

problem worldwide, Tuberculosis can coexist with lung malignancy making the underlying disorder leading

to delay in diagnosis and management. Here we present an interesting case of a 58-year-old woman who on

initial presentation was diagnosed with tuberculosis but did not a response to antituberculosis therapy.

Further investigation revealed underlying lung cancer. The patient was then treated according to the latest

guideline.

1 INTRODUCTION

Cancer and tuberculosis are common causes of

morbidity and mortality, and a major public health

problem worldwide. The interaction between lung

cancer and active tuberculosis is known for many

years. The first description of ‘cancerous phthisis’

was reported by Bayle in 1815. Tuberculosis is an

important risk factor for cancer. The dormant bacilli

may activate due to disturbed defense mechanisms.

Pulmonary cancer mortality was higher in people

with tuberculosis than in those without. Diagnosis

may be a delay and the patient's survival may be

shorter (Beyhan, Aydin, 2018, p 33-37).

One-third of the world population is infected

with Mycobacterium Tuberculosis bacillus.

According to the WHO 2016 global tuberculosis

report, tuberculosis affects more than 9 million

people and caused death in 1.8 million people,

especially in developing countries (WHO, 2017).

Worldwide, there were approximately 14 million

new cancer cases, 8.2 million death-related cancer

and 32.6 million people living with cancer in 2012.

Among men, the three most common cancer are

lung, prostate, and colorectal cancer, and among

women, breast, colorectal and lung cancer as the

three most common causes (WHO, 2016).

Pulmonary tuberculosis and lung malignancy are

a common disease, especially in endemic areas

including Indonesia, This often requires special

attention to enforce the diagnosis. Clinicians often

find difficulties to identify due to similar symptoms,

which result in one disease or the other to be a delay

to be treated.

In this case report, there was a coexist pulmonary

tuberculosis and lung malignancy in one sample

diagnosed from Bronchoalveolar lavage (BAL) from

bronchoscopy procedure.

2 CASE

A 58-year-old female came to Adam Malik

General Hospital on 29 December 2018 with

complaints of shortness of breath since the previous

two months, which had gotten worse in the previous

one month. It became worse when she performed an

exercise. Cough occurred since the previous month

with whitish sputum production. Left chest pain

also occurred for a month before admission, and

worsened on a deep breath in and heavy coughing.

Hoarseness occurred for a month. Loss of body

weight for about 3 kgs was observed in the last 2

months. The patient was a farmer for 20 years.

History of biomass exposure was found with

pesticide and mosquito coils. The patient was

diagnosed with Diabetes Mellitus in the previous

year.

Before admitted to Adam Malik General

Hospital, patients were treated in another hospital in

Pratama, R. and Sinaga, B.

A Case Report: Coexistent Pulmonary Tuberculosis and Lung Cancer Diagnosed from the Same Specimen.

DOI: 10.5220/0009864402530256

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 253-256

ISBN: 978-989-758-469-5

253

November 2018, and had pleural fluid an amount of

3000 ml aspirated from the left pleura. The patient

was started on category I Anti Tuberculosis Therapy

(ATT) in November 2018. The patient also received

medication from a pulmonologist, based on chest X-

ray and clinical presentation.

On examination on 14 January 2019, the patient

was alert, blood pressure was 110/80 mmHg, pulse

rate was 104 times/minute, respiratory rate was 24

times/minute, the temperature was 36,5Ԩ, and SpO2

was 97% at room air,

On chest examination, there was an

asymmetrical chest movement, delayed movement

on the left hemithorax, decreased of the tactile

fremitus on the left hemithorax, dullness on the left

hemithorax and diminished breath sound on the left

hemithorax without additional sound. Enlargement

of the liver was found, tenderness of the liver was

found.

Laboratory findings on 29 February 2019

showed haemoglobin 14.0 g/dl, leukocyte 21.910 x

/mm

, erythrocyte 4.98 x 10

/mm

, hematocrite

39.1%, platelet 323.000 /mm

, ad random blood

glucose 400 mg/dL, natrium 131 meq/ml, kalium 2.8

meq/ml, chloride 93 meq/ml, and nonreactive Elisa

Test for HIV.

Radiological finding from 14 January 2019

showed homogenous consolidation appearance.

Thorax CT-Scan on 8 January 2019 showed left lung

tumor, enlarged perihilar lymph node, left pleural

effusion T2aN3M1b (liver) (Figure 1).

Bronchoscopy finding showed infiltrative

stenosis in lingula and left lower lobe. Biopsy results

were in line with the image of adenocarcinoma,

cytology with a malignant smear (C5). Results from

cytology of BAL revealed an impression of

adenocarcinoma, with a malignant smear (C5).

Similar findings were also shown in pleural fluid

cytology with C3 atypic smears but tend to be clear

on the impression of reactive mesothel.

GeneXpert analysis of bronchoalveolar lavage

showed Mycobacterium tuberculosis susceptible to

rifampicin. Epidermal Growth Factor Receptor

(EGFR) analysis on 17 January 2019 showed no

mutation detected.

2.1 Working Diagnose

We diagnosed this patient with left lung

adenocarcinoma T4N3M1c (pleura, hear) stage IVb

PS I with a new case of pulmonary tuberculosis, and

diabetes mellitus.

2.2 Treatment

Tuberculosis treatment consisted of two months of

RHZE (R: rifampicin, H: isoniazide E: ethambutol,

Z: pyrazinamide) plus 7 months of RH daily until

complete TB treatment. The evaluation was

performed two months after the initiation of

treatment including clinical and physical

examinations, chest x-ray, and AFB smear.

The patient also received chemotherapy with

platinum-based therapy such as carboplatin and

paclitaxel. Chemotherapy was planned for 6 cycles

and would be evaluated every 2 cycles.

Fig 1: Radiological findings. (A) shows homogenous

consolidation, large pleural effusion, (B) after insertion of

water sealed drainage (WSD) in Adam Malik Hospital.

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Figure 2: Bronchoscopy Finding

3 DISCUSSION

The relationship between pulmonary tuberculosis

and lung cancer has been known for years.

Pulmonary tuberculosis and lung cancer are able to

mimic each other, often on clinical symptoms and

radiological features. The common symptoms are

fever, night sweats, loss of appetite, weight loss,

fatigue, and chest pain. Cancer cells invasion in

healed tuberculosis lesions might also lead to

tuberculosis reactivation by weakening the local

immunity. Two diseases may be located in the

ipsilateral lung, contralateral lung or same lobe

location. Tuberculosis bacilli may live at a dormant

status in granulomas and induce tuberculosis

sensitivity (WHO, 2016). When the local immunity

deteriorates, reactivation of latent TB, primary

mycobacterial infection, the new exogenous

infection may cause tuberculosis infection. Chronic

inflammation like pulmonary tuberculosis process

may also lead to carcinogenesis of the lung tissue

which can lead to DNA damage by nitric oxide

synthase from the infected macrophage. Thus,

chronic inflammation and scarring due to

tuberculosis can lead to the development of cancer.

An occurrence of lung cancer at the site of the scars

of old tuberculosis lesions has been shown in other

studies (Jacobs, Gu, Chachoua, 2015). According to

Harikrishna et al., the possible association between

cancer and tuberculosis is a coincidence without any

apparent relation, can be a simultaneous

development of both tuberculosis and cancer, a

metastatic carcinoma developed in an old

tuberculosis scar, or a secondary TB infection in

cancer (Harikrishna, Sukaveni, Kumar, 2012). The

discordant organ involvement may be by chance

without any apparent relation. Smoking is an

important risk factor for lung cancer. Chemotherapy,

immune dysfunction, radiotherapy, severe

malnutrition may lead to immune suppression.

Radiotherapy might lead to deregulation of

granulomas microenvironment, allowing

tuberculosis mycobacteria to proliferate

(Wu, et al,

2011). Kurasawa et al. showed that coexistence of

lung cancer and pulmonary tuberculosis occurred in

about 2 to 4% of lung cancer cases and in about 1 to

2% of tuberculosis cases. Histopathology analysis of

lung cancer revealed a more periphery origin and a

squamous cell carcinoma. As previously reported

(Kurasawa, et al, 1998), the authors concluded that

in this case report, lung cancer is comorbid that is

most likely to be a risk factor for the decrease in

endurance, hence patient became susceptible to

tuberculosis.

4 CONCLUSION

In this case report, a patient was diagnosed with

pulmonary malignancy and tuberculosis infection.

The patient was planned to be continuously observed

to evaluate the response of therapy. Although with

the worst prognosis, it was expected that appropriate

therapy would improve the quality of life. As a

clinician, we should be able to make this case report

as a reference to be more active in looking the

possible risks of tuberculosis and lung cancer to

occur together so that treatment of either disease will

not be delayed.

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