‘Stepladder Lung Cavities’ with ‘Starry Sky Pattern’ in HRCT Thorax with Constitutional Symptoms: A Strong Predictor of Active Pulmonary Tuberculosis

Abstract

Pulmonary Tuberculosis is most common diseases in India with significant mortality and morbidity. Tuberculosis can cause diverse thoracic presentations ranging from nodules, consolidations & cavitation, mediastinal adenopathy, pleural effusion to diffuse endobronchial disease presenting like bronchial asthma. In this case report, 29- year male, presented with constitutional symptoms for 4 months duration with partial response to medical treatment received according to their knowledge and experience towards bronchial asthma, enteric fever and jaundice. Radiological investigations documented only prominent hilum left side of thorax which was underestimated due to presence of wheeze. Recurrent, progressive and partially responding constitutional symptoms was the reason for referral to our center. We have also noted prominent hilum with inhomogeneous infiltrates left lung field and localized wheeze and crepitations on left side of thoracic cavity in mammary and interscapular region. We have further evaluated with HRCT thorax and observed thick-walled cavities in left upper lobe posterior segment. ‘Stepladder Lung Cavities’ in HRCT is defined as multiple cavities adjacent with each other partially communicating to noncommunicating of variable size and shape unilaterally or bilaterally in stepladder fashion. ‘Starry sky pattern’ in HRCT Thorax is defined as randomly placed nodular opacities presenting as discrete or conglomerated, interstitial and acinonodular opacities unilateral or bilateral adjacent to pulmonary cavities usually reported as satellite nodules. Satellite nodules are defined as nodular opacities adjacent to pulmonary primary caviatary lung disease and indicator lymphatic local spread and active pulmonary tuberculosis. We have done sputum examination and documented acid-fast bacilli in sputum smear and MTB genome with rifampicin sensitivity in cartridge based nucleic acid amplification test. Treatment initiated with anti-tuberculosis (ATT) and recorded near complete radiological resolution, bacteriological cure after six months with good compliance. High index of suspicion is must while managing these cases with constitutional symptoms with typical ‘Stepladder Lung Cavities’ with ‘starry sky pattern’ in HRCT Thorax to have successful treatment outcome.