An Unusual Presentation of Massive Intrathoracic Schwannoma with Concomittant Pleural Tuberculosis: About a Case and Review of the Literature

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Schwannomas are the most common neurogenic tumor of the thorax, and may involve any thoracic nerve The case of a 49-year old male patient with a massive intrathoracic schwannoma is reported. A thoracotomy resection of the tumor was performed. The presence of adhesions of the tumor to the chest wall pleura created a suspicion of malignancy. This article’s aim is to draw attention to this infrequent pathology with concomitant tuberculosis and to discuss different aspects regarding diagnosis and treatment of pleura schwannome.

A 49-year-old male with no significant clinical history, presented to the emergency department with a 1-month history of cough productive of white sputum, Haemoptysis, unexplained loss of weight and associated with progressive shortness of breath on exertion, which had persisted despite courses of co-amoxiclav. On examination, his vital parameters (temperature; oxygen saturation; blood pressure; respiratory rate; pulse rate) were all within the normal range for a man of his age. Physical examination revealed dull percussion note on right mid chest wall with diminished breath sound with occasional expiratory wheezing at the auscultation of the chest, and syndrome (facial swelling, neck distension). Lymph nodes examination is unremarkable and the rest of the examination was unrevealing. Standard chest X-ray showed a large, well-defined mass in the the right hemithorax, around 18cm in diameter, associated with displacement of the trachea to the opposite side. Initially, this was thought to be a bronchogenic cyst or un lymphoma process.

Computed Tomography (CT) scan of thorax demonstrated a large (20x15x13cm) well-circumscribed, heterogeneously enhancing rounded mass in the right hemithorax to whose density was mostly similar to fluid, associated with a solid component in the uppermost part. The mediastinal structures, particularly the trachea and right bronchus, were noted to be compressed and displaced to the left side by this lesion (Figure 2A,B). Examination of the sputum smear samples to identify AFB was positive. Fine needle aspiration was performed, but the specimen was insufficient for diagnosis. Results from percutanous biopsy confirmed a pleural schwannome and has eliminated a lymphoma process. Surgery was planned after ruling out an an intraspinal component of tumor. Complete excision of the well-encapsulated mass was achieved through the right posterolateral thoracotomy (Figure 3A). A 20cm tumor was found in the right chest cavity, adhering closely to the parietal pleura and superior vena cava, which was severely dilated. The mass was found to be benign schwannoma without malignant components and the anatomopathologic examination of pariétal pleura retained it to be tubercular (Figure 3B). The postoperative course of the patient was uneventful. The respiratory and vascular symptoms and facial edema resolved immediately after the surgery. The patient returned to her normal life and recovered gradually through regular chest physiotherapy. He has been followed-up for 1 year with no evidence of recurrence.