Nodular reverse halo sign in a hemodialysis patient with polycystic kidney disease and pulmonary tuberculosis

A 56-year-old man with polycystic kidney disease (PKD) and end-stage renal disease (ESRD) on long-term hemodialysis presented with decreased appetite, malaise, cough and fever. Chest CT revealed a nodular reverse halo sign (NRHS), a rare but relatively specific feature associated with pulmonary tuberculosis (TB). Although conventional sputum smears were negative for acid-fast bacilli, Mycobacterium tuberculosis was identified in bronchoalveolar lavage fluid through Xpert MTB/RIF testing and targeted next-generation sequencing. This case highlights: (1) NRHS as a significant radiologic indicator of TB, even in immunocompromised patients; (2) the need for advanced diagnostic tools when conventional tests are inconclusive; and (3) the impact of economic barriers in resource-limited settings, which can delay treatment and contribute to poor outcomes. Timely TB screening and accessible treatment are essential for high-risk populations, particularly those undergoing hemodialysis.