Diagnostic and therapeutic strategies for solitary pulmonary nodules mimicking malignancy: Insights from two cases of pulmonary tuberculosis

Pulmonary nodules present a diagnostic dilemma, particularly in differentiating tuberculous nodules from malignant lesions. Misdiagnosis may lead to unnecessary surgery or delayed treatment. We report two cases where solitary pulmonary nodules were initially suspected as malignancies but were ultimately diagnosed as pulmonary tuberculosis. In Case #1, a diabetic patient with a left lower lobe nodule underwent resection, and postoperative pathology and molecular tests confirmed tuberculosis. In Case #2, a patient with prior pulmonary surgery developed a new right upper lobe nodule. Despite malignant imaging features, CT-guided biopsy and GeneXpert plus nanopore sequencing confirmed Mycobacterium tuberculosis, and anti-tuberculosis therapy led to lesion absorption without repeat surgery. CT imaging alone is insufficient to distinguish tuberculosis from malignancy. Integrating percutaneous biopsy with molecular diagnostics is essential for accurate diagnosis. In high-risk patients, postoperative anti-tuberculosis treatment should be considered. An individualized, multidisciplinary approach is critical to avoid overtreatment and improve outcomes.