Abstract: Pulmonary tuberculosis is rarely characterized by symmetrical bilateral diffuse ground-glass opacities on chest imaging, which can lead to diagnostic confusion. We report a case of a 52-year-old male who initially presented with bilateral pulmonary diffuse ground-glass opacity as the primary manifestation on chest CT, initially diagnosed as pneumocystis carinii pneumonia. purified protein derivative test and tuberculosis interferon gamma release assay were both negative. Sputum smears, mycobacterial cultures, and GeneXpert MTB/RIF were also negative. However, targeted second-generation sequencing of the bronchoalveolar lavage fluid detected specific sequences of the Mycobacterium tuberculosis complex, leading to the final diagnosis of pulmonary tuberculosis. After receiving regular anti-TB treatment, the patient exhibited improvements in clinical symptoms and resolution of lung lesions. This case suggests that pulmonary tuberculosis can manifest as bilateral, diffuse ground-glass opacities. When traditional detection methods do not suggest pulmonary tuberculosis, it should not be entirely ruled out, and consideration may be given to performing targeted next-generation sequencing of pulmonary lavage fluid to assist in differential diagnosis.

Key words: Diffuse ground-glass opacities, Pneumocystis carinii pneumonia, Pulmonary tuberculosis, Targeted next-generation sequencing