Radiology versus reality: a case report of pulmonary tuberculoma following tuberculous pleurisy mimicking malignancy in an endemic country

Pulmonary tuberculosis and lung cancer are both highly prevalent in Indonesia, often leading to diagnostic dilemmas, as pulmonary tuberculosis can mimic malignant disease radiologically. We present a 39-year-old woman initially diagnosed with tuberculous pleurisy based on elevated adenosine deaminase levels and analysis of the pleural effusion. Despite anti-tuberculosis therapy, follow-up imaging revealed growing and suspicious lung nodules with irregular margins, strong enhancement on computed tomography (CT), and a high Fluorodeoxyglucose (FDG) uptake on positron emission tomography (PET)/CT, suggestive of malignancy. However, histopathological analysis demonstrated granulomatous inflammation consistent with pulmonary tuberculomas. She completed a nine-month anti-tuberculosis regimen with radiological resolution, leaving only fibrotic scarring. This case highlights the diagnostic challenge of distinguishing pulmonary tuberculomas and post-pleural tuberculosis sequelae from lung cancer in endemic regions. Retrospective review may clarify the diagnosis, but in clinical practice, physicians must rely on a multimodal approach. Clinical correlation remains essential, as radiology alone cannot stand as the final arbiter.