The chest CT of my patient with “B” symptoms shows hilar mass and mediastinal lymphadenopathy, highly suspicious for lymphoma or malignancy per radiology report. Should I still consider tuberculosis (TB) as a possibility?

Absolutely! TB often mimics malignancy, particularly lymphoma, both clinically and radiographically, even when sophisticated imaging techniques are used.1  

There are ample reports of TB being confused with mediastinal lymphoma, 1-6 with several reports also stressing abdominal TB mimicking malignancy. 7-10 As early as  1949, a  NEJM autopsy study emphasized “the difficulty in differentiating primary progressive TB and some types of lymphoma” and metastatic neoplasms, clinically and radiographically.  Over half-century later, despite major advancement in imaging techniques, TB is often confused for lymphoma or malignancy.

One reason for confusing TB with lymphoma is that primary TB can involve any pulmonary lobe or segment and is often associated with hilar and mediastinal adenopathy. 1 TB may also be overlooked in the differential diagnosis of mediastinal mass that often highlights neoplasms such as lymphoma, thymoma and germ cell tumors. 3 Lack of concurrent pulmonary infiltrates in the presence of mediastinal adenopathy may also veer clinicians away from TB diagnosis. 2,3,6 Unfortunately, even more sophisticated PET/CT scans may not be able to differentiate TB from lymphoma.5,6,9

Besides chest and abdomen, TB can also mimic malignancy in cervical nodes, bones (particularly the spine), bowels, and brain.1,2,6,8,9  To make matters worse, splenomegaly 2,10 and elevated LDH 3 may also be seen with TB and TB may coexist with lymphoma and other malignancies. 7,9,11

One of the best advices I ever received from a radiologist was “Think of TB anytime you think of lymphoma.”

Bonus Pearl: Did you know that TB lymphadenitis is the most common form of extrapulmonary TB with the majority involving the mediastinum? 4

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  1. Tan CH, Kontoyiannis DP, Viswanathan C, et al. Tuberculosis: A benign impostor. AJR 2010;194:555-61.
  2. Smith DT. Progressive primary tuberculosis in the adult and its differentiation from lymphomas and mycotic infections. N Engl J Med 1949;241:198-202.
  3. Maguire S, Chotirmall SH, Parihar V, et al. Isolated anterior mediastinal tuberculosis in an immunocompetent patient. BMC Pulm Med 2016;16:24.
  4. Tang SS, Yang ZG, Deng W, et al. Differentiation between tuberculosis and lymphoma in mediastinal lymph nodes: evaluation with contrast-enhanced MDCT. Clin Radiol 2012;67:877-83.
  5. Hou S, Shen J, Tan J. Case report: Multiple systemic disseminated tuberculosis mimicking lymphoma on 18F-FDG PET/CT. Medicine 2017;96:29(e7248).
  6. Tian G, Xiao Y, Chen B, et al. Multi-site abdominal tuberculosis mimics malignancy on 18F-FDG PET/CT: Report of three cases. World J Gastroenterol 2010;16:4237-4242.
  7. Dres M, Demoule A, Schmidt M, et al. Tuberculosis hiding a non-Hodgkin lymphoma “there may be more to this than meets the eye”. Resp Med Case Rep 2012;7:15-16.
  8. Banerjee Ak, Coltart DJ. Abdominal tuberculosis mimicking lymphoma in a patient with sickle cell anemia. Br J Clin Pract 1990;44:660-61.
  9. Gong Y, Li S, Rong R, et al. Isolated gastric varices secondary to abdominal tuberculosis mimicking lymphoma: a case report. Gastroenterology 109;19:78.
  10. Uy AB, Garcia Am Manguba A, et al. Tuberculosis: the great lymphoma pretender. Int J Cancer Res Mol Mech 2016; 2(1):doi
  11. Nayanagari K, Rani R, Bakka S, et al. Pulmonary tuberculosis with mediastinal lymphadenopathy and superior veno caval obstruction, mimicking lung malignancy: a case report. Int J Sci Study 2015;2:211-14.
The chest CT of my patient with “B” symptoms shows hilar mass and mediastinal lymphadenopathy, highly suspicious for lymphoma or malignancy per radiology report. Should I still consider tuberculosis (TB) as a possibility?

Can native valve infective endocarditis be associated with hemolytic anemia?

Yes, but it’s rare!  Hemolytic anemia (HA) in the setting of infective endocarditis (IE) has only been described in a few case reports (1-3).  Although diseased valves may cause shearing stress that fragments RBCs, similar to that associated with mechanical heart valves, an autoimmune hemolytic process has also been implicated. 

A 2018 case report describes a patient with hypertrophic obstructive cardiomyopathy (HOCM) with left ventricular outflow tract (LVOT) obstruction who had HA secondary to subacute IE due to Actinomyces israelii (1).   The anemia completely resolved after treating the IE (1). The cause was most likely mechanical shearing (schistocytes or fragmented RBCs present on peripheral smear) by the diseased valves; autoimmune hemolysis was considered unlikely in this case due to consistently negative Coombs tests and failure to respond to corticosteroids (1). 

An autoimmune mechanism was invoked by a 1999 report reviewing 6 cases of HA associated with IE (3).  All patients had fragmented erythrocytes, but several also demonstrated an immune-mediated mechanism for their HA, supported by the presence of spherocytes, splenomegaly, and + Coombs test (2,3).  The production of anti-erythrocyte antibodies, modification of antigenicity of erythrocyte antigens, or unmasking of antigens in IE may play a role (1,3). Additional evidence in support of an immune-mediated mechanism of HA in IE has been provided by an experimental study demonstrating significantly shorter RBC half-life in rabbits with intact spleen compared to that of splenectomized animals (4).



1. Toom S, Xu Y. Hemolytic anemia due to native valve subacute endocarditis with Actinomyces israellii infection. Clin Case Rep 2018;6: 376-79. 

2. Hsu CM, Lee PI, Chen JM, et al. Fatal Fusarium endocarditis complicated by hemolytic anemia and thrombocytopenia in an infant. Pediatr Infect Dis 1994;13:1146-48. 

3. Huang HL, Lin FC, Hung KC, et al. Hemolytic anemia in native valve infective endocarditis. Jpn Circ J 1999;63:400-403. 

4. Joyce RA, Sand MA. Mechanism of anaemia in experimental bacterial endocarditis. Scand J Haematol 1975;15:306-11. 


Contributed by Scott Goodwin, Medical Student, Harvard Medical School, Boston, MA. 


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Can native valve infective endocarditis be associated with hemolytic anemia?