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\begin{document}

\title{Pulmonary Adenocarcinoma Mimicking Miliary Tuberculosis in a 20-year-old
Male; a Clinical Case Report}



\author[1]{Arash Seifi}%
\author[1]{Nahid Shafiee}%
\author[2]{Maryam Moradi}%
\affil[1]{Imam Khomeini Hospital Complex}%
\affil[2]{Iran University of Medical Sciences}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\selectlanguage{english}
\begin{abstract}
Lung adenocarcinoma (LA) is the most common subtype of lung cancer with
non-significant manifestations. Some benign conditions can mimic LA in
symptoms and even chest imaging. In this case report, we are discussing
a young man without any significant past medical history with metastatic
LA, initially presumed military TB.%
\end{abstract}%



\sloppy


\textbf{Pulmonary Adenocarcinoma Mimicking Miliary Tuberculosis in a
20-year-old Male; a Clinical Case Report}

Arash Seifi\textsuperscript{1}, Nahid Shafiee\textsuperscript{1}, Maryam
Moradi\textsuperscript{2*}

\textsuperscript{1}Department of infectious diseases, Imam Khomeini
Hospital, Tehran University of Medical Sciences, Tehran, Iran

\textsuperscript{2*}Iran University of Medical Sciences, Tehran, Iran

*Co-responding Author: Maryam Moradi

Iran University of Medical Sciences, Tehran, Iran

E-mail: m.moradi3051375@gmail.com

Phone: 00989362805838

\textbf{Consent Statement:} Written informed consent was obtained from
the patient to publish this report in accordance with the journal's
patient consent policy.

\textbf{Abstract}

Lung adenocarcinoma (LA) is the most common subtype of lung cancer with
non-significant manifestations. Some benign conditions can mimic LA in
symptoms and even chest imaging.

In this case report, we are discussing a young man without any
significant past medical history with metastatic LA, initially presumed
military TB.

\textbf{Keywords} : Lung adenocarcinoma, Miliary tuberculosis, Miliary
nodule, Lung cancer.

\textbf{Background}

Lung adenocarcinoma (LA) is the most frequent histological subtype of
lung cancer worldwide. This condition is categorized from preinvasive
lesions to metastatic adenocarcinoma (1, 2). Smoking is the most common
responsible risk factor for LA so far along with a family history of
lung cancer, occupational exposure, and genetic mutations. In the early
stages, LA can be asymptomatic while in late stages, non-specific
symptoms such as coughing, weight loss, and hemoptysis can occur (3).

Miliary tuberculosis (TB) is the wide-spreading dissemination of
Mycobacterium tuberculosis through the bloodstream. It can affect single
or several organs and through a hematogenous way to the brain (4).
Miliary TB can present with non-specific manifestations including fever,
weight loss, sweats, and anorexia mimicking other diseases especially
primary and secondary lung cancers. Immune suppression due to cancer,
HIV infection, malnutrition, diabetes, transplantation, and end-stage
renal disease are risk factors for this condition (5).

The miliary pattern in lung imaging can present in miliary TB,
occupational lung diseases, different fungal infections, sarcoidosis,
and metastatic diseases from primary or secondary lung cancers;
therefore, diagnosis cannot be distinguished by CT imaging alone.
Further investigations such as serological and pathological tests are
necessary for diagnosis (6, 7).

In the current article, we are presenting a young man with no prior
medical history or risk factor with metastatic lung adenocarcinoma
mimicking miliary TB in imaging.

\textbf{Case presentation}

A 20-year-old male with no significant past medical history visited a
tertiary referral collegiate hospital in Tehran on 5 June 2022, with
severe headache (frontal, non-positional, pulsatile without any
photophobia, phonophobia, and visual disturbances), nausea, vomiting,
malaise, non-bloody sputum for 2 weeks and significant weight loss of
about 15 kg in recent two months. His familial history was negative for
TB or lung malignancies. At admission, his vital signs were in the
normal range. In physical examination, his conjunctiva was pale along
with cervical and supraclavicular lymphadenopathies. Other neurological
and non-neurological examinations were normal.

Due to the severe headache which last for 30 minutes each time and
repeat every 3 hours neurological consultation was done. In MRI,
multiple hyperdense lesions were seen (Figure 1).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

\textbf{Figure 1: Patient's Brain Magnetic Resonance Image.}

To rule out endocarditis, echocardiography was done which detected
severe pericardial effusion of about 750 CCs, and pericardiocentesis
along with a myocardial biopsy and pericardial smear and culture has
been done.

In abdominal and chest spiral CT scans, lesions suspected of miliary TB
including adrenal involvement, multiple pulmonary small nodules, and
mediastinal lymphadenopathies were seen (Figure 2). In infectious
disease consultation sputum smear and culture for mycobacterium
tuberculosis, blood and sputum MTB-PCR, cytology MTB-PCR,
technetium-99m-ethambutol (Tc-EMB) scintigraphy, and IGRA were sent.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image5/image5}

\end{center}
\end{figure}

\textbf{Figure 2: Patient's Lung Computed Tomography.}

Sputum smear and culture, blood, and sputum MTB-PCR were negative but
Tc-EMB scintigraphy was positive. According to the patient's clinical
condition and positive scintigraphy, it was decided to prescribe an
anti-TB regimen including isoniazid, rifampin, pyrazinamide, and
ethambutol along with dexamethasone.

Following the results of the pericardial and myocardial biopsy, the
patient was diagnosed with lung adenocarcinoma with massive intra-lung
and remote metastasis. According to the new diagnosis, the anti-TB
regimen was stopped and chemotherapy was started for the patient. Due to
the rarity of the diagnosis in our young patient without any prior risk
factor, an immunological study was done which was all negative. The
patient's clinical condition starts to improve after the chemotherapy
and he is alive at the moment of writing this article.

\textbf{Discussion}

Lung cancer is the most common cancer diagnosis worldwide with a high
rate of mortality. Lung adenocarcinoma a non-small cell lung cancer is
the most common histological subtype with non-specific symptoms and
outcomes. Early diagnosis and treatment are critical in patients'
outcomes and survival (8).

Miliary TB is a lethal state of tuberculosis in immunosuppressed
patients with widespread dissemination of Mycobacterium even in the
brain. Various symptoms can be present due to the site of involvement.
Diagnosis is complicated due to the non-specific radiograph findings
(9).

Chest CT scan is a critical tool in LA diagnosis while it can appear
differently, mimicking non-malignant and infectious diseases (10).
Miliary shadows on imaging can appear in different diagnoses, especially
in infectious diseases such as miliary TB and histoplasmosis. Metastatic
primary and secondary lung cancers can also present as miliary nodules
(11).

In TB endemic areas such as our country, it is always critical to treat
patients with non-specific symptoms and miliary shadows on chest imaging
as miliary TB cases while further evaluations are necessary for the
proper diagnosis. Miliary nodules in chest imaging are a rare finding in
LA, while probable. We have to consider LA as an important differential
diagnosis in those with miliary shadows because it has a bad prognosis
in late diagnosis. Like our patient, several cases have been reported to
be LA, while their initial diagnosis was miliary TB (7, 11, 12).

\textbf{Conclusion}

Various conditions can present a miliary view in chest imaging,
including benign conditions such as bacterial and fungal infections and
occupational disorders. More severe cases can appear the same, such as
miliary TB and metastatic lung cancers, especially adenocarcinoma. Early
diagnosis and proper treatment are the key point in patients' survival.

\textbf{Declaration}

We have no conflict of interest to declare.

\textbf{References}

1. Hutchinson BD, Shroff GS, Truong MT, Ko JP. Spectrum of Lung
Adenocarcinoma. Semin Ultrasound CT MR. 2019;40(3):255-64.

2. Succony L, Rassl DM, Barker AP, McCaughan FM, Rintoul RC.
Adenocarcinoma spectrum lesions of the lung: Detection, pathology and
treatment strategies. Cancer Treat Rev. 2021;99:102237.

3. Myers DJ, Wallen JM. Lung Adenocarcinoma. StatPearls. Treasure Island
(FL): StatPearls Publishing

Copyright \selectlanguage{ngerman}© 2022, StatPearls Publishing LLC.; 2022.

4. Sharma SK, Mohan A. Miliary Tuberculosis. Microbiol Spectr.
2017;5(2).

5. Kim JH, Langston AA, Gallis HA. Miliary tuberculosis: epidemiology,
clinical manifestations, diagnosis, and outcome. Rev Infect Dis.
1990;12(4):583-90.

6. Pillai S, Khan A, Khan S. Adenocarcinoma of the Lung Presenting with
Intrapulmonary Miliary Metastasis. Cureus. 2019;11(8):e5430.

7. Zia Z, Iqbal QZ, Narula N, Sattar SBA, Rafay Khan Niazi M. Miliary
Tuberculosis in a Young Patient? Let's Not Forget the Lung
Adenocarcinoma! Cureus. 2020;12(8):e10058.

8. Sun GZ, Zhao TW. Lung adenocarcinoma pathology stages related gene
identification. Math Biosci Eng. 2019;17(1):737-46.

9. Sharma SK, Mohan A, Sharma A. Challenges in the diagnosis \&
treatment of miliary tuberculosis. Indian J Med Res. 2012;135(5):703-30.

10. Pascoe HM, Knipe HC, Pascoe D, Heinze SB. The many faces of lung
adenocarcinoma: A pictorial essay. J Med Imaging Radiat Oncol.
2018;62(5):654-61.

11. Khan D, Danjuma M, Saddique MU, Murshed KAH, Yassin MA.
Adenocarcinoma of the Lung Mimicking Miliary Tuberculosis. Case Reports
in Oncology. 2020;13(1):139-44.

12. Mermi, t Ç, li, ngi, r B, Sunnetcioglu A, et al. A Case of Lung
Adenocarcinoma Presenting as Miliary Appearance. Eastern Journal Of
Medicine. 2020;25(2):315-7.

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