Disseminated extrapulmonary tuberculosis with necrotic pleural involvement in a child

Abstract Extrapulmonary tuberculosis accounts for approximately 20–30% of pediatric tuberculosis cases, whereas necrotic pleural involvement is exceedingly uncommon, particularly in immunocompetent children. We report the case of a 4-year-old girl who presented with painless swelling of the left ankle. Initial ultrasound demonstrated an avascular heterogeneous soft-tissue lesion. Chest radiography subsequently revealed lobulated pleural thickening, prompting contrast-enhanced computed tomography (CT) of the chest and abdomen. CT demonstrated multiple subpleural nodular lesions characterized by central hypodensity and peripheral rim enhancement, associated with necrotic mediastinal and abdominal lymphadenopathies, some containing amorphous calcifications, as well as splenic and soft-tissue involvement. No pulmonary parenchymal abnormalities or pleural effusion were identified. Ultrasound-guided biopsy of the ankle lesion yielded caseous material, and polymerase chain reaction confirmed infection with Mycobacterium tuberculosis . Anti-tubercular therapy was initiated with rapid clinical improvement and subsequent radiological regression on follow-up magnetic resonance imaging (MRI). Necrotic pleural thickening with rim enhancement, even in the absence of pulmonary parenchymal involvement, may represent an atypical manifestation of extrapulmonary tuberculosis in children. Recognition of this imaging pattern is essential to guide diagnostic suspicion and prompt targeted image-guided biopsy.