pulmonary tuberculosis is divided into primary and post - primary types according to pathogenic and radiological features . pleural involvement is generally seen in the form of a pleural effusion , which can be a component of both primary and post - primary tuberculosis . empyema , residual pleural thickening and calcification are other forms of pleural tuberculosis involvement and are generally seen in association with parenchymal disease . in approximately two - thirds of cases , there is no associated parenchymal lesion on the chest radiograph ; yet tubercle bacilli are frequently found in biopsy specimens of pleural tissue . we report an unusual form of pleural tuberculosis demonstrated by pleuroscopy and computed tomography ( ct ) presenting with multiple pleural nodules and masses with large hemorrhagic pleural effusion and without any evidence of either parenchymal or lymphatic disease . a 68-year - old male was admitted with complaints of gradually progressive exertional dyspnea and dry cough of three months duration . he had pleuritic chest pain , low grade fever and weight loss for one month . his routine hemogram , urine examination , renal and liver function tests and coagulation profile were normal except raised erythrocyte sedimentation rate . chest x - ray was suggestive of large right - sided pleural effusion . at thoracentesis , it was a lymphocytic exudate ( total protein  3.4 g / dl , sugar  76 mg / dl , cholesterol  67 mg / dl , lactate dehydrogenase  253 iu / l , adenosine deaminase  9 polymorphs : 5% , lymphocytes : 92% , cytology  negative for malignant cells , gram stain and afb smear  negative ) . post - aspiration chest x - ray showed multiple irregular pleural masses [ figure 1 ] . ct of the chest revealed multiple different size masses involving the parietal as well as visceral pleura [ figure 2 ] . post taping chest x - ray shows multiple irregular pleural masses computed tomography ( ct ) chest shows multiple different size masses on parietal pleura as well as on visceral pleura a medical pleuroscopy was performed using a flexible bronchoscope placed through the chest tube . multiple pleural - based ( parietal as well as visceral ) masses of varying sizes were observed . histopathological examination of the pleural biopsy from a parietal pleural mass revealed epitheloid cell granulomas indicative of tuberculosis [ figure 3 ] . the major differential diagnostic considerations in a patient with multiple pleural nodules and masses are malignant mesothelioma , pleural lymphoma , hematogenous pleural metastases , malignant thymoma and on rare occasion sarcoidosis.[38 ] although pleural tb infection is thought to result from the rupture of a subpleural caseous focus within the lung into the pleural space , it may occasionally be as a result of hematogenous dissemination or contamination from adjacent infected lymph nodes . pleural infection in tuberculosis is usually characterized by an effusion in early stages , or by diffuse pleural thickening and adhesions often with calcification in long standing cases . pleural thickening may also result from chronic inflammatory conditions , for example , hemothorax , empyema , tubercular effusion , or recurrent pneumothorax , often with calcification . in our case the provisional diagnosis was a pleural neoplasm ( primary or secondary ) based on clinical , radiological and pleuroscopic findings . to our knowledge , pleural tuberculosis presenting with multiple pleural nodules and masses without parenchymal involvement or lymphadenopathy have been reported rarely in the standard english medical literature,[1113 ] but pleural tuberculosis presenting as multiple pleural masses with large hemorrhagic pleural effusion has not been reported . it should be considered in the differential diagnosis of pleural masses without radiographically visible parenchymal lung disease even when there is large hemorrhagic effusion . confirmation of the diagnosis with sputum smears , culture , or histology is mandatory since treatment is highly successful .