LUNG CANCER AND TUBERCULOSIS: A SERIAL CASES.

Armita Dewi*, Riswan Idris**, Muhammad Ilyas*,Irawaty Djaharuddin*, Nur Ahmad Tabri*

Department of Pulmonology and Respiratory Medicine*

Department of Internal Medicine**
Faculty of Medicine University of Hasanuddin
Dr. Wahidin Sudirohusodo Hospital, Makassar, Indonesia
ARMITA DEWI, armitadewi83@gmail.com,+6285262806434
ABSTRACT
Background
Tuberculosis and lung cancer co-incidence is challenging in diagnosis.
We report a serial cases of patient diagnosed with tuberculosis and non
small cell lung carcinoma. The awareness of pulmonary or extra
pulmonary tuberculosis in patient with lung cancer is important, because
tuberculosis is still a public health problem in developing country such as
Indonesia that causing high mortality and morbidity.

Case Presentation
Case A: Mrs. R, 47 years old, chief complain prolong cough. Referred
from regional hospital with right lung tumor. AFB sputum from broncho
alveolar lavage is scanty (5 AFB/100 high power field) and broncho
alveolar lavage cytology is squamous cell lung carcinoma.

Case B: Mr. Z, 47 years old, complain chest pain, cough, dysphonia, lost
of appetite and lost weight since 3 month before admission. AFB smear
scanty (3 AFB/100 high power field) and broncho alveolar lavage cytology
is non small cell carcinoma (squamous cell lung carcinoma).

Case C: Mr. T, 67 years old. He complain chest pain, cough, dyspnea,

fever and lost weight. AFB smear scanty (6 AFB/100 high power field) and
cytology from biopsy bronchus is non small cell carcinoma.

Case D: Mr. M, 75 years old, chief complain are shortness of breath. AFB
smear from pleural fluid aspiration is 1+ and pleural fluid cytology is non-
small cell carcinoma (adenocarcinoma).

Result
We reported three cases of non-small cell carcinoma with pulmonary
tuberculosis and one case with pleuritis tuberculosis. All patient treated
with anti-tuberculosis drug and chemotherapy.

Discussion
Lung cancer and tuberculosis can occur incidentally. There are similarities
in clinical symptoms so that can bias the diagnosis before cytology
examination.

Conclusion
Lung cancer can be found together with pulmonary tuberculosis and
extra pulmonary tuberculosis. Important to exanimated AFB smear from
broncho alveolar lavage and pleural fluid aspiration from patient with lung
cancer to identified existing of tuberculosis.

Keyword Lung cancer, tuberculosis

INTRODUCTION

Tuberculosis (TB) and lung cancer are common disease cause mortality
and morbidity, world wide TB is one of the top 10 causes of death and the
leading cause from a single infectious agent (above HIV/AIDS). Millions of
people continue to fall sick with TB each year. In 2017, TB caused an
estimated 1.3 million deaths (range, 1.2–1.4 million) among HIV-negative
people and there were an additional 300 000 deaths from TB (range, 266
000–335 000) among HIV-positive people.1

Globally, the best estimate is that 10.0 million people (range, 9.0–11.1
million) developed TB disease in 2017. There were cases in all countries
and age groups, but overall 90% were adults (aged ≥15 years), 9% were
people living with HIV (72% in Africa) and two thirds were in eight
countries: India (27%), China (9%), Indonesia (8%), the Philippines (6%),
Pakistan (5%), Nigeria (4%), Bangladesh (4%) and South Africa (3%).
These and 22 other countries in WHO’s list of 30 high TB burden
countries accounted for 87% of the world’s cases.4 Only 6% of global
cases were in the WHO European Region (3%) and WHO Region of the
Americas (3%).1

The relation between lung cancer and the subsequent development of

pulmonary TB has attracted attention for several decades. This is due to
the fact that both pulmonary TB and lung cancer are highly prevalent and
that have a major impact on public health.

CASE REPORT

Case A

Mrs. R, 47 years old, chief complain prolong a cough since 1 year ago.
Shortness of breath since 1 year ago. History of fever and night sweats
without activity. She was referred from a regional hospital with the right
lung tumor. There is no history of cigarettes smoking, no history of
tuberculosis before and contact with the contagious case of TB.

Physical examination found moderate illness, composmentis, and

malnutrition. Blood pressure is 120/80 mmHg, heart rate is 89
times/minute, respiratory rate is 20 times/minutes, the temperature is
37,2ºC. From the physical examination of thorax found symmetrically in
inspection, vocal fremitus is symmetrically in both hemithorax, percussion
is sonor and auscultation is bronchovesicular breath sound without ronchi
or wheezing.

In MSCT Scan thorax with contrast founded homogeny consolidation in

superior lobe of right hemithorax with atelectasis and right pleural
effusion. From bronchoscopy examination found chronic inflammation in
B6,B7,B8 in lower left lobe. AFB sputum from bronchoalveolar lavage is
scanty (5 AFB/100 field of view) and bronchoalveolar lavage cytology is
squamous cell carcinoma.

Figure.1 : MSCT Scan thorax with contras

Figure.2 : Bronchoscopy: chronic inflammation in B6,B7,B8 in lower left

lobe, Bronchoalveolar lavage cytology: group of round cell nucleus,atypic,
pleomorphic, eosinophilic (yellow arrow), suggesting a squamous cell
carcinoma.

From anamnesis, physical examination, radiologic imaging, diagnostic

modality procedures, cytology and AFB smear this case diagnosed as a
squamous cell carcinoma stage IVa PS 2 and bacteriological pulmonary
TB.

Case B

A 47-year-old Mr. Z, was admitted to the hospital with complaints of chest

pain experienced for 4 months, worsened in the past 1 week. Referred
chest pain and radiates to both arms. Hoarse voice since 3 months ago,
and increasingly disappeared. Shortness of breath exists, since 2 months
ago, triggered by activities. Cough since 3 months ago. History of a cough
accompanied by blood streak about <10 cc volume in 5 days ago.
Appetite decreases and weight loss around 12 kg in the last 3 months.
There was no history of TB before, no history of contact with contagious
case of TB, history of cigarette smoking for 28 years, 16 cigarettes per
day (Brinkman Index 448, Moderate Smoker)

Physical examination, moderate illness, malnutrition, composmentis,

blood pressure 130/80, pulse 92 times/minute, respiratory rate 20
times/minute temperature 36.7ºC. Chest examination, inspection obtained
asymmetrical movement, left hemithorax is left behind when static and
dynamic. Palpation there was no tenderness and vocal fremitus difficult to
assess, percussion deafness in the left hemithorax apex as high as the
ICS II to ICS III on auscultation examination decreased bronchovesicular
breath sounds in ICS II to ICS III left hemithorax.

The MSCT Scan thorax with contras, obtained the impression of the left
lung mass, bilateral pneumonia, atherosclerosis aorta. The results of
bronchoscopy procedure found infiltrative lesion in B 1+2 segment,
suggesting a malignancy and in the examination of AFB smear from
bronchial wash obtained scanty 3/100 field of view. Cytology result from
broncho alveolar lavage is non small cell lung carcinoma (squamous cell
lung carcinoma).

Figure. 3 : MSCT Scan thorax with contras

Figure.4 : Bronchoscopy: : infiltrative lesion in B 1+2 segment left lung

Figure.5: Cytology of bronchoalveolar lavage: round nucleolus cell,
eosinophilic, some cell are diffuse or in groups (yellow arrow), suggesting
non small cell lung carcinoma (squamous cell lung carcinoma).

Based on the anamnesis, physical examination, radiologic imaging and

laboratory finding and diagnostic procedures this case diagnosed as a
squamous cell lung carcinoma stage IIIA PS 2 and bacteriological
pulmonary TB.

Case C

Mr. T, age 67, entered the Wahidin Sudirohusodo hospital in emergency

department, with the chief complaint of chest pain. Left chest pain has
been experienced for the last 2 weeks continuously. He also complains of
cough since 3 months ago accompanied by white mucus, shortness of
breath worsened since 1 week ago, fever has been since last 2 week, a
decrease in appetite in the last 3 months, weight loss was in the last 5
months, no history of TB, smoking history since of 48 years ago, 16
cigarettes per day ((Brinkman Index 768, Heavy smoker)

General physical examination, moderate illness, malnutrition, compos

mentis. Blood Pressure 110/70 mmHg, Pulse 98 times / minute,
respiratory rate 20 times / minute, Temperature 38.1ºC. Pulmonary
physical examination, inspection is found asymmetrical chest shape, left
hemithorax left behind when static and dynamic. Vocal fremitus
decreases in left hemithorax as high as ICS IV to ICS VI. Hypersonor
percussion in left hemithorax as high as ICS IV to ICS VI. Auscultation,
bronchovesicular breath sounds and decrease in left hemithorax, no
ronchi or wheezing.
Chest X-rays expertise as suspected left pulmonary mass, dextra
bronchopneumonia, elongation, dilatation et atherosclerosis aortae.
MSCT scan with contrast showed the presence of left lung tumor
(T4N0M1), left emphysema pulmonalis, dextra bronchopneumonia and
left pleural effusion. Bronchoscopy procedures found infiltration mass in
1/3 distal of right main bronchus. Forcep biopsy examinations suggesting
non small cell lung carcinoma, AFB smear from broncho alveolar lavage
result is scanty ( 6 BTA / 100 field per view).

Picture.6 Chest X-ray and MSCT Scan with contrast

Figure.7: MSCT Scan thorax with contras and bronchoscopy

Figure.8: Histopathology from forcep biopsy: spindel cell with large
nucleus, morphic, hyperchromatic, and prominent nucleoli (white arrow),
suggesting non small cell lung carcinoma

Based on the anamnesis, physical examination, radiologic imaging and

laboratory finding and diagnostic procedures this case diagnosed as a
non-small cell lung carcinoma stage IV PS3, bacteriological pulmonary TB

Case D

Mr. M 76 years old complain cough since 2 month before admission and
shortness of breath worsen since 1 month before admission. Right chest
pain. No fever, but there is history of fever, lost appetite and night sweats.
History of frequent pleural punction in regional hospital, history of smoking
since 30 years ago, 12 cigarettes per day (Brinkman Index 360, Moderate
smoker ). No history contact with contangius TB case.

General physical examination found, moderate illness, malnutrition,

compos mentis. Blood Pressure is 100/60 mmHg, Pulse is 84 times /
minute, Breathing is 26 times / minute, Temperature is 36,7ºc. Pulmonary
physical examination, inspection is asymmetrical chest shape, right
hemithorax left behind when static and dynamic. Vocal fremitus
decreases in right hemithorax as high as ICS III to ICS VI. Dullness
percussion in right hemithorax as high as ICS III to ICS VI. Auscultation,
broncho vesicular breath sounds and decrease in right hemithorax.
Ronchi in right hemithorax and no wheezing

There is pleural effusion in Chest x-ray at 21 july 2018. MSCT Scan

thorax with contrast in 2 august 2018 expertise with right lung tumor,
irregular shape, hight resolution after contras (30-80 HU) in medius lobe
of right hemithorax. There is no enlargement of subcarina and
paratrachea lymph nodes, and also right pleural effusion.
Bronchoscopy procedures found infiltration lesion and intraluminal lesion
in upper lobe of right lung suggestive malignancy. But from broncho
alveolar lavage not found any malignancy in cytology and in AFB smear.
AFB smear from pleural fluid aspiration is 1+ and pleural fluid cytology is
non-small cell carcinoma (adenocarcinoma).

Figure.9: Chest X-ray

Figure.10: Bronchoscopy: infiltration lesion and intraluminal lesion in

upper lobe of right lung suggestive malignancy. Pleural fluid cytology: cell
atypic, pleomorphic and large nucleus, suggesting adenocarcinoma.

Based on the history, physical examination, radiologic imaging, diagnostic

procedures this case was diagnosed as adenocarcinoma stage IV PS 2
and extra pulmonary tuberculosis.

DISCUSSION

Lung cancer has been recognized as one of the greatest common

cancers, causing the annual mortality rate of about 1.2 million people in
the world. Lung cancer is the most prevalent cancer in men and the third
most common cancer among women (after breast and digestive
cancers).2

There is no difference in specific clinical symptoms between pulmonary

tuberculosis and lung cancer. In the late stage of lung cancer, clinical
symptoms of lung cancer are mimicking another lung disease such as
COPD, TB, and pneumonia.3 In this serial cases, patients complain of a
cough, chest pain, fever, night sweat, lost weight and appetite. These
symptoms are found in both pulmonary tuberculosis and lung cancer.

Varol et al in their study found, 8 (1.1%) male patients, lung cancer and
TB were found to coexist. Almost all of the patients were diagnosed at
Stage III (36.8%) or IV (44.7%).3 We found 3 cases co-existing TB and
lung cancer in male patients and diagnosed at stage III and IV.

Pathogenesis of coexisting TB and lung cancer remains unclear. Cicenas

et all in their study hypothesized that the tumor arose from a previous TB
lesion called scar cancer. TB may cause sustained inflammation leading
to fibrosis, scarring, and host-tissue damage. The fibrosis from the old TB
lesion may cause lymphostasis, enhancing carcinogen deposition in the
area.3,4 The association between TB and cancer can occur in several
ways describe in table.1

Table.1 Possible association between cancer and TB

 A chance co-incidence without any apparent relation

 Metastatic carcinoma developing in an old TB lesion
 Secondary infection of cancer with TB
 Chronic progressive tubercle in which a carcinoma develops
 Simultaneous development of both TB and cancer

Resource (5)

Generally, the incidence of lung cancer increases in elderly patients. This

is related to a decrease in immune function in the elderly causing
decrease in antigen-presenting cell function in presenting antigens,
increase in IL-6 levels, decrease in IL-2, decrease in effector T cells, Th2
polarization and increase in the number of Th cells without co-stimulation
by CD8 molecules. Immune system deficiencies also including the cellular
immune system, especially magrofag.3

Mycobacterium TB infected macrophages express high levels of inducible

nitric oxide synthase, resulting in the production of reactive nitrogen and
oxygen species (ROS) leading to DNA damage. Activation of transcription
factor, nuclear factor E2 related factor by oxidative stress, directly induced
squamous cell metaplasia.5
Pulmonary TB in immunocompetent individuals is a chronic infectious
process characterized by the formation of “granuloma”. In the natural
course of evolution of the granuloma, imbalance between tissue
damaging agents that can result in deoxyribonucleic acid (DNA) damage
and tissue repair mechanisms is thought to generate a microenvironment
that predisposes to malignant transformation.5,6,7

Varol et al also found squamous cell lung cancer was the predominant
histology (n=23, 60.7%).2 We found two cases with histology are
squamous cell lung carcinoma and the rest is undifferentiated type of non
small cell lung carcinoma and adenocarsinoma.

Clinical diagnosis of co-existing TB and cancer is often challenging. This

often causes a delay in diagnosis and treatment and is associated with
poor prognosis. The atypical course of TB, presence of pain, radiological
evidence of rib erosion and ipsylateral hilar lymphadenopathy casts doubt
on the possibility of coexistence of a malignancy.5

CONCLUSION

Lung cancer can be found together with pulmonary TB and extra

pulmonary TB especially in the high burden of TB country. In this four
cases, TB and lung cancer found in diagnostic procedure for lung cancer.
The co-existence of TB in the patient with lung cancer is challenging in
diagnosis because of similar clinical appearance. Important to examine
AFB smear from broncho alveolar lavage and pleural fluid aspiration from
the patient with lung cancer to identified existing of tuberculosis.
REFERENCES

1. World health organization. Global tuberculosis report 2018.

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SZ. Primary Lung Cancer Coexisting With Active Pulmonary
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Kanker Paru. In: Jusuf A,Editor. Jakarta.Penerbit Universitas
Indonesia.2017
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6. Russell DG. Who Puts The Tubercle In Tuberculosis?. National
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