pulmonary tuberculosis is divided into primary and post - primary types according to pathogenic and radiological features .
pleural involvement is generally seen in the form of a pleural effusion , which can be a component of both primary and post - primary tuberculosis .
empyema , residual pleural thickening and calcification are other forms of pleural tuberculosis involvement and are generally seen in association with parenchymal disease . in approximately two - thirds of cases
, there is no associated parenchymal lesion on the chest radiograph ; yet tubercle bacilli are frequently found in biopsy specimens of pleural tissue .
we report an unusual form of pleural tuberculosis demonstrated by pleuroscopy and computed tomography ( ct ) presenting with multiple pleural nodules and masses with large hemorrhagic pleural effusion and without any evidence of either parenchymal or lymphatic disease .
a 68-year - old male was admitted with complaints of gradually progressive exertional dyspnea and dry cough of three months duration .
he had pleuritic chest pain , low grade fever and weight loss for one month .
his routine hemogram , urine examination , renal and liver function tests and coagulation profile were normal except raised erythrocyte sedimentation rate .
chest x - ray was suggestive of large right - sided pleural effusion . at thoracentesis ,
it was a lymphocytic exudate ( total protein  3.4 g / dl , sugar  76 mg / dl , cholesterol  67 mg / dl , lactate dehydrogenase  253 iu / l , adenosine deaminase  9
polymorphs : 5% , lymphocytes : 92% , cytology  negative for malignant cells , gram stain and afb smear  negative ) .
post - aspiration chest x - ray showed multiple irregular pleural masses [ figure 1 ] .
ct of the chest revealed multiple different size masses involving the parietal as well as visceral pleura [ figure 2 ] .
post taping chest x - ray shows multiple irregular pleural masses computed tomography ( ct ) chest shows multiple different size masses on parietal pleura as well as on visceral pleura a medical pleuroscopy was performed using a flexible bronchoscope placed through the chest tube .
multiple pleural - based ( parietal as well as visceral ) masses of varying sizes were observed .
histopathological examination of the pleural biopsy from a parietal pleural mass revealed epitheloid cell granulomas indicative of tuberculosis [ figure 3 ] .
the major differential diagnostic considerations in a patient with multiple pleural nodules and masses are malignant mesothelioma , pleural lymphoma , hematogenous pleural metastases , malignant thymoma and on rare occasion sarcoidosis.[38 ] although pleural tb infection is thought to result from the rupture of a subpleural caseous focus within the lung into the pleural space , it may occasionally be as a result of hematogenous dissemination or contamination from adjacent infected lymph nodes .
pleural infection in tuberculosis is usually characterized by an effusion in early stages , or by diffuse pleural thickening and adhesions often with calcification in long standing cases .
pleural thickening may also result from chronic inflammatory conditions , for example , hemothorax , empyema , tubercular effusion , or recurrent pneumothorax , often with calcification . in our case
the provisional diagnosis was a pleural neoplasm ( primary or secondary ) based on clinical , radiological and pleuroscopic findings .
to our knowledge , pleural tuberculosis presenting with multiple pleural nodules and masses without parenchymal involvement or lymphadenopathy have been reported rarely in the standard english medical literature,[1113 ] but pleural tuberculosis presenting as multiple pleural masses with large hemorrhagic pleural effusion has not been reported .
it should be considered in the differential diagnosis of pleural masses without radiographically visible parenchymal lung disease even when there is large hemorrhagic effusion .
confirmation of the diagnosis with sputum smears , culture , or histology is mandatory since treatment is highly successful .
 tuberculous involvement of the pleura usually presents as pleural effusion , empyema or pleural thickening . 
 pleural tuberculosis presenting with multiple masses without parenchymal involvement or lymphadenopathy has been reported rarely in the english literature . 
 we report a case of a 68-year - old male with unilateral pleural tuberculosis presenting as multiple different sized nodular masses evident on computed tomography ( ct ) of the chest with a large hemorrhagic pleural effusion , which initially raised a possibility of mesothelioma . 
 pleuroscopy also revealed multiple pleural masses . 
 pathological examination of the biopsy specimen showed multiple epitheloid cell granulomas confirming the diagnosis . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION