Radiologic Deception: A Case Report of Tuberculosis with Nodular Onset and Cystic Conclusion

Cystic lung disease is a rare and underrecognized manifestation of pulmonary tuberculosis (TB), often masquerading as other diffuse cystic lung disorders and complicating timely diagnosis. We present the unusual case of a 25-year-old woman who developed progressive dyspnea and pleuritic chest pain shortly after initiating antituberculous therapy. Initial imaging revealed classical miliary nodules without cystic changes. However, within a month of treatment, follow-up high-resolution CT unveiled an unexpected transformation of numerous thin-walled cysts clustered in the upper lobes, accompanied by ground-glass opacities, septal thickening, and a tree-in-bud pattern suggestive of active endobronchial spread. This radiological evolution, occurring posttreatment initiation, points to a dynamic pathophysiological process likely involving immune-mediated airway obstruction, necrosis, and structural remodeling of the parenchyma. This case reveals a rare form of pulmonary TB that mimics other cystic lung diseases. In TB-endemic areas, early recognition of cystic transformation, especially with recurrent pneumothorax or atypical imaging, is vital. Though uncommon, it highlights TB's chameleon-like nature and the value of serial imaging in guiding timely, effective management. Radiologists and clinicians should remain vigilant for such rare yet reversible complications in TB-endemic settings.