[A case of multiple and metachronous pleural tuberculomas during the course of anti-tuberculous chemotherapy and follow-up of a caseous pneumonia].

A 21-year-old woman was admitted to our hospital because of high fever, a productive cough and general fatigue. Her chest radiography scan revealed dense consolidation with air-bronchograms in the left lower lobe. Bacterial pneumonia was diagnosed and she was treated with antibiotics, although the specific cause could not be identified. After one month, a bronchoscopy was performed due to lack of improvement of consolidation in chest radiography. A smear examination of the bronchial washing specimen was positive for acid-fast bacilli (AFB) and Mycobacterium tuberculosis (MTB) was confirmed by PCR. After anti-tuberculous drugs (INH, RFP, EB, and PZA) were prescribed for 6 months, chest X-ray findings improved markedly. Two pleural tuberculomas were found in the left upper and lower lung fields 3 months after beginning therapy, and a new pleural tuberculoma appeared in the left upper lung fields 6 months after finishing therapy. Histopathological findings (HE stain) of a CT-guided needle lung biopsy showed epithelioid cell granulomas without caseous necrosis with multinuclear giant cells which were negative for acid-fast bacterium. All of the pleural tuberculomas improved without any additional therapy 18 months after finishing therapy. It was thought that such cases of multiple and metachronous pleural tuberculomas during the course of anti-tuberculous chemotherapy and follow-up of caseous pneumonia are rare. We suggest the possibility that the pleural tuberculomas were due to a paradoxical or hypersensitive reaction to the anti-tuberculous chemotherapy in this case.