Abbreviations:

DST- drug sensitivity test,M.Tb-   Mycobacterium tuberculosis ,ATT- Anti tubercular treatment, CTVS- cardio thoracic vascular surgery, Opd- Out patient department

Case Presentation

A 65 year old male presented in Emergency Department of a multi-specialty hospital with complaints of cough with muco-purulent expectoration, occasional mild hemoptysis, fever intermittently low grade, minimal dyspnea with exertion (mMrc grade 1) since one month with no history of weight loss.

He is a daily wager, with addiction of tobacco chewing and no significant past history. On examination vitals were within normal limits except he was febrile, no tachypnea, no clubbing/edema/icterus/lymph node, pallor was visible. On auscultation crepitations were heard in right infra scapular region.

His first chest x-ray showed right lower lobe density surrounded by consolidation. Blood test showed neutrophilia and mild anemia. He was asked to do sputum for AFB and culture sensitivity, was prescribed oral antibiotics and asked for an Opd review after 10 days.

In the subsequent visit, his cough was persisted though fever subsided. His repeat Chest X-ray showed similar right lower lobe dense opacity resembling mass lesion, whereas his sputum reports were negative for M.Tb and sputum culture showed pseudomonas. In suspicion of lung mass, non-contrast CT thorax scan was done and it was found lateral part of ascending thoracic aorta protruded in right lower lobe as aneurysmal sac and surrounded by necrotising consolidation. His sputum was repeated for CBNAAT test and this time found positive for M.Tb, he was started for drug-sensitive Tb regimen and sputum sample sent for M.Tb culture and DST

Fig 1: 1^st Chest X-ray

Fig 2: 2^nd Chest X-ray after 10 days

Fig 3: CT – Thorax Mediastinal Window

Fig 4: CT – Thorax Lung Window

Fig 5: CT – Thorax Coronal

He was referred to CTVS surgeon for opinion and ATT was advised to continue till further follow up.

Tuberculous aortic aneurysm is a high risk condition due to possibility of sudden rupture. It often involves small vessels of meninges and cavities but involment of aorta can be because of direct extension of adjacent lesion. Para-mediastinal and para-aortic lymph nodes are more involved.

Early diagnosis, medical management along with appropriate endovascular surgical intervention is required for proper treatment.