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Medical recordPatients, male, 57 years old, continued to the afternoon due to low thermal expansion with a sense of Cullen Ma 5 months, in November 2008 admitted to hospital.
The end of May 2008, afternoon fever patients, with the waist, Cullen Ma inflation. Antipyretics no relief from the service, check local hospital after a week suggest pleurisy chest syndrome, no relief to be anti-inflammatory treatment, tuberculin purified protein derivative (PPD) test (). History of tuberculous pleurisy with consideration, for diagnostic anti-tuberculosis treatment, the symptoms were not relieved. In order to further diagnosis and treatment of patients, to a Shanghai hospital. A sputum acid-fast bacilli (AFB) (), diagnosed as tuberculosis, continue to anti-tuberculosis treatment for 5 months. But patients still afternoon fever, abdominal symptoms. 5 months to decrease body weight 10 kg.
Patients had long been engaged in metallurgical work, occupational exposure to asbestos. Mother has a history of pulmonary tuberculosis.Figure 1 Initial chest X-ray prompt, right pleural thickening, a small amount of pleural effusion. Figure 2 Chest CT suggested that changes in both lungs with a small interstitial nodules, pleural reaction on both sides, oblique fissure thickening, increased multiple mediastinal lymph nodes, both sides of the pleural, pericardial effusion. Figure 3,4 abdominal CT prompt, peritoneum, omentum and mesentery density increased.Admission examination body temperature


37.2 , the next day afternoon temperature rose to 38.5 . Body weight loss, mild anemia appearance, the body about inadequate superficial lymph nodes. Thoracic symmetry, clear breath sounds in both lungs and less obvious wet and dry rales. More rigid abdominal palpation, the abdominal light - moderate tenderness. Palpation of the liver and spleen are not satisfied. Shifting dullness (-), bowel sounds 4 to 5 times / min.
Laboratories and auxiliary examination before anti-tuberculosis treatment chest X-ray showed right pleural thickening, a small amount of pleural effusion. PPD test (), sputum (single) AFB (), tuberculosis antibody (TB-Ab) (). Biochemistry was exudative pleural effusion, adenosine deaminase (ADA) 20U / L, pleural fluid tumor markers NSE 52.72 ng / ml, CY211 129.61 ng / ml, SCCA 10.12 ng / ml. Trachea microscopy (-). Pleural fluid cytology shows atypical cells degeneration. Lung methoxy isobutyl isonitrile (MIBI )(-) Chest CT showed small bilateral lung nodules with interstitial changes, pleural reaction on both sides, oblique fissure thickening, multiple enlarged mediastinal lymph nodes. Both sides of the pleural, pericardial effusion. Colonoscopy showed multiple polyps. Hypochromic blood prompted small-cell anemia, mononucleosis, abnormal increase of platelet (697 109 / L, were prompted by several replatelets significantly increased). Liver function tests showed pre-albumin 67 mg / L, albumin 17 g / L, C-reactive protein (CRP) 24.6 mg / dl, ESR 120 mm / h. Tumor markers were normal, abdominal CT showed peritoneum, omentum and mesentery density increased, retroperitoneal lymph nodes. See attached bilateral pleural thickening, tuberculosis pleurisy (suspected), right lower pulmonary tuberculosis (suspect), right ventricular septal corner of enlarged lymph nodes.Treatment for patients with refractory fever in the outer court, chest X-ray prompt pleurisy symptoms, combined with PPD test was positive, anti-TB treatment to be of diagnostic symptoms are not relieved. Found in sputum AFB due to post-diagnosis of tuberculous pleurisy and continued anti-tuberculosis treatment. In addition, patients who had received a thoracentesis, pleural fluid drainage out of the dark red 300 ml. Abdominal symptoms worsened after our hospital. We first consider the risk of tuberculous peritonitis are possible, but because of its no ascites, ascites can not be relatively large number of specimens for laboratory examination, it is recommended to assist in its laparoscopic diagnosis. Laparoscopic examination showed a huge liver microscope, flat leaves about navel, smooth surface, normal color, no nodular changes; clear fluid within the abdominal cavity, omentum and mesentery root see the size of a small amount of about 0.1 cm white miliary-like Results section; intestinal adhesion significantly, pelvic no obvious abnormalities. Diagnosis of peritoneal nodules of unknown origin (abdominal tuberculosis), nodules and omental biopsy. Pathological examination revealed visceral peritoneum clear table cover cell proliferation, given obvious proliferation of mesothelial cells, some showed infiltrative growth tendency of malignant peritoneal mesothelioma. Immunohistochemical results consistent with the characteristics of malignant mesothelioma.
The patient is middle-aged men, past history of asbestos exposure have long-term, continuing the afternoon due to low thermal expansion with a sense of treatment Cullen Ma. Consider the first diagnosis of tuberculous pleurisy and the etiology of sputum obtained evidence, due to poor treatment, abdominal symptoms worsened further treatment, according to laparoscopic access to pathology with malignant peritoneal mesothelioma. We should be the judge of malignant peritoneal mesothelioma with tuberculous pleurisy, a disease that can be used or abdominal film to explain malignant mesothelioma? Malignant mesothelioma is from diffuse malignant mesothelioma of all primary tumors can be divided into two kinds of localized and diffuse types. The most common malignant mesothelioma is pleural primary site, followed by peritoneal, pericardial, and reproductive systems, foreign reports more common in the peritoneum. 50% to 80% of patients with malignant mesothelioma and asbestos exposure related causes. The typical chest film malignant mesothelioma symptoms and signs of respiratory difficulty, chest pain, abdominal pain, bloating, vomiting, weight loss, pleural effusion, with or without abdominal mass and ascites. Typical symptoms are easily misdiagnosed as tuberculous pleurisy, peritonitis, or pleural metastasis of lung cancer.
of the above questions, we invite experienced physician radiologist films (including anti-tuberculosis treatment before and after treatment chest X-ray chest and abdomen CT), the advice is both to support breast imaging diagnosis of pleural mesothelioma, but also do not rule out the possibility of tuberculous pleurisy. Imaging of pleural mesothelioma showed typical pleural effusion and pleural thickening, but also with tuberculous pleurisy have such performance. It seems just from the imaging point of can not provide too much information.
In patients with definite diagnosis of peritoneal malignant mesothelioma, we give them pemetrexed 750 mg intravenous infusion of 1 day, cisplatin 40 mg intravenous infusion of 3 days for a course of chemotherapy. 3 weeks for a course of treatment. Examination of patients admitted to hospital the second time the body temperature normal, no significant changes over the previous rest. Relateral chest film showed two markings are more disorders, inflammatory changes affect the lower lobe of both lungs, both lungs may see multiple small nodules; pleural thickening and adhesion on both sides, both sides of the pleural effusion. Chest high resolution CT (HRCT) showed bilateral pleural thickening with mediastinal pleura and pleural effusion on both sides, both lungs scattered in the fiber of the cable video and multiple nodules. Routine blood test showed platelet 280 109 / L (significantly decreased than before.)
Patients with body temperature returned to normal after chemotherapy, thrombocytopenia, mediastinal lymph nodes disappeared, pericardial effusion disappeared, suggesting that efficacy can still be.Symptoms and chest, the contradiction between the treatment
According to reported in China, the incidence of malignant peritoneal mesothelioma usually male 0.21 cases / 10 people, women 0.13 cases / 10 people. The patient was initially diagnosed as a result of afternoon heating tuberculosis, especially in a sputum AFB () will post more as the first diagnosis of TB and received anti-tuberculosis treatment. But in the course of 5 months of treatment, the patient's main symptoms have not been alleviated. Although the chest X-ray absorption suggest signs of disease had improved, but the abdominal symptoms had Ruoyouruowu seems worse.
We can not help but question: theory Why is not effective treatment to improve symptoms? chest X-ray results and why the contradiction between the symptoms? For the former, we get the revelation is not valid when the disease treatment, especially anti-tuberculosis treatment for 2 to 3 weeks after the symptoms were not relieved and the emergence of disease progression, really should reconsider the original diagnosis is correct and look for other possible causes. For the latter, the possible explanation is that patients who have received the drainage of pleural effusion, which may cause a false impression of improvement (reducing the absorption of pleural effusion).
Thoracic tuberculosis, peritonitis and abdominal mesothelioma in the differential membrane
Tuberculous chest, peritonitis and abdominal mesothelioma is difficult to identify membrane, it is difficult from non-invasive examination to obtain more specific tips.
The incidence of tuberculous pleurisy is due to TB and more primary syndrome from the hilar lymph nodes through lymphatic vessels to reach the pleura, or from direct spto the pleura under the pleural tuberculosis or hematogenous spto the pleura. However, the patient's chest radiograph and chest CT lung itself does not suggest a clear focus, and always prompt pleural abnormalities and pleural effusion. By inference, pleural disease itself should be placed in tuberculous pleurisy before being taken into account. Similarly, tuberculous peritonitis is often associated with mesenteric lymph nodes, gastrointestinal tract, female pelvis, urinary tract tuberculosis. The patient underwent total colonoscopy has been ruled out intestinal tuberculosis, abdominal CT did not provide much evidence. A typical CT of tuberculous peritonitis and peritoneal mesothelioma diffuse CT performance is very close. When the lack of circumstantial evidence, while not obvious ascites (paracentesis cytology is difficult to obtain evidence), the clinical or should be considered to obtain direct evidence that the pathological diagnosis.
Current abdominal symptoms according to the patients, which have been diagnosed as malignant peritoneal mesothelioma. However, under very difficult circumstances to make the chest pleural mesothelioma, pleural mesothelioma, tuberculous pleurisy or the identification of tuberculosis combined. Re-examine the patients chest, imaging physicians still believe that ambiguity. Of course, there are some pleural fluid test results support the evidence of the tumor. When asked again, when the occupational history of patients, but also increased the basis of malignant mesothelioma. It seems that this is a typical case of malignant mesothelioma patients, but the doctor had been fooled by a clot of phlegm.
Only by tuberculosis and malignant mesothelioma symptoms, laboratory tests, imaging findings more difficult to make a differential diagnosis. Pathological diagnosis is the gold standard, pathological conditions are or should be based. Therefore, we find contradictions in the treatment, they should consider re-diagnosis.



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