THE INVISIBLE GIANT: A GIANT PLEURAL-BASED MASS LIKE CONSOLIDATION SUBTLE ON CHEST SCANOGRAM BUT REVEALED BY COMPUTED TOMOGRAPHY IN A PATIENT PRESENTING WITH LOWER RESPIRATORY TRACT INFECTION

Abstract

Pleural-based mass lesions are uncommon thoracic abnormalities that frequently pose a diagnostic challenge because of their nonspecific clinical presentation and variable radiological appearance. Patients often present with symptoms suggestive of lower respiratory tract infection (LRTI), resulting in delayed recognition of an underlying malignant process. Although chest radiography remains the initial imaging modality for evaluating respiratory complaints, its sensitivity is limited for detecting peripheral or pleural-based lesions located in anatomical blind spots. Computed tomography (CT) plays a pivotal role in identifying radiographically occult lesions and accurately defining their extent. We report the case of a 51-year-old woman who presented with fever and progressive shortness of breath of 15 days' duration. Based on the clinical presentation, she was initially diagnosed with suspected lower respiratory tract infection. A chest radiograph performed at presentation did not reveal any significant abnormality despite persistent respiratory symptoms. Owing to the continued clinical suspicion, a CT scan of the thorax was obtained, which demonstrated a large pleural-based mass-like consolidation measuring approximately 76 × 73 × 67 mm involving the anterior and lateral basal segments of the right lower lobe, associated with abrupt bronchial cut-off, multiple enlarged right hilar and mediastinal lymph nodes, and a 35 × 28 mm subcarinal nodal mass with internal calcifications. No pleural or pericardial effusion was identified. The radiological findings strongly suggested an underlying malignant etiology rather than an infective process. The patient was subsequently referred for histopathological evaluation to establish a definitive diagnosis. This case highlights the limitations of conventional chest radiography in detecting large pleural-based thoracic lesions and emphasizes the indispensable role of CT in patients with persistent respiratory symptoms despite a normal chest X ray. Early utilization of advanced cross-sectional imaging can facilitate prompt diagnosis, appropriate staging, and timely tissue sampling, thereby preventing delays in the management of potentially life-threatening thoracic malignancies. Clinicians should maintain a high index of suspicion when clinical findings and initial radiographic results are discordant, as reliance on chest radiography alone may overlook significant intrathoracic pathology.