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Extraordinary Patterns of Tuberculosis

E. KadakovskaInfectology Center of Latvia, Clinic of Tuberculosis and Lung Diseases, Diagnostics and Radiology Department

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Target

Importance of recognizing of tuberculosis (TB)Identify the clinical and radiological findings in lung:

common, uncommon,

Identify TB of extrapulmonary sites.

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Tuberculosis (TB)

airborne, contagious disease with chronic coursethe most common cause of infectious disease – related mortality worldwide. definitive diagnosis of TB can only be made by culturing M. Tuberculosis or histology.

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Epidemiology2 billion people, 1/3 of the world’s population, are infected with TB bacillisomeone in the world is newly infected every second 3 million people worldwide die each year there were ~ 9.4 million new TB cases in 2008, ~ 8.000 lethal cases every day, ~ 2 – 3 million deaths per year

UNAIDS, WHO. AIDS Epidemic Update, December 2009WHO. Global Tuberculosis Control, A short update to the 2009 report

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Epidemiology

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“HOT SPOTS” of TB

95 % of new TB cases

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Case notification of TB in Latvia

36.640.3

53.5

47.2

68.374

68.459

50.444.1

33.328.7

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70.5

72.965.4

63.359

49.7

01020304050607080

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

years

/ 100

.000

Infectology centre of Latvia, 2010

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Data collected from TB control programmes and estimates generated by WHO, 2010

Prevalence of TB in Baltic States

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Data collected from TB control programmes and estimates generated by WHO, 2010

TB treatment success rate in Baltic States

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Clinical manifestations

variable and depend on a number of factors. before global epidemic of HIV,

~ 85% - limited to the lungs, ~ 15% nonpulmonary or both pulmonary and nonpulmonary sites

Farer, L. S., L. M. Lowell, and M. P. Meador. 1979. Extrapulmonary tuberculosis in the United States. Am. J. Epidemiol. 109: 205-217

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Pulmonary tuberculosis

classically divided:primarypostprimary (reactivation) tuberculosis.

MaherD, Raviglione M. Global epidemiology of tuberculosis. Clin Chest Med 2005;26(2):167–182.McAdamsHP, Erasmus J, Winter JA. Radiological manifestations of pulmonary tuberculosis. Radiol Clin North Am 1995;33(4):655–678.

Primary TB –lymphadenopathy and parenchymal disease

Postprimary TB – parenchymal disease

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Primary tuberculosis

parenchymal disease lymphadenopathy pleural effusion miliary disease atelectasis (compression of airways)

Woodring JH, Vandiviere HM, Fried AM, Dillon ML, Williams TD, Melvin IG. Update: the radiographic features of pulmonary tuberculosis. AJR Am J Roentgenol 1986;146(3):497–506

Lymphadenopathy and parenchymal disease

Lymphadenopathy and parenchymal disease

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Postprimary tuberculosis

parenchymal disease with cavitation:

S1/2,S6,patchy, poorly defined consolidation,

airway involvement, pleural extension other complications

Parenchymal disease with cavitation

Parenchymal disease with airway involvement

Andreu J, Cáceres J, Pallisa E, Martinez-Rodriguez M. Radiological manifestations of pulmonary tuberculosis.

Eur J Radiol 2004;51(2):139–149.

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Postprimary tuberculosis

Most challenging issue -differentiate

severe postTb changes, new onset Tb.

TB, parenchymal disease with cavitation

TB, parenchymal disease & HIV

TB scars, bronchopneumonia

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Typical CT finding“tree – in bud”:

5 – 10 mm centrilobular nodulesbranching linear structures

lobular consolidationcavitationbronchial wall thickening

TB, “”tree – in – bud”

TB, parenchymal disease with cavitation COPD, bronchiectasis,

bronchopneumonia

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MDR TB – ordinary or extraordinary?

The imaging patterns of MDR (multidrug – resistant) Tb are similar to those of non-MDR Tb.

TB, parenchymal disease with cavitation

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Causes of a missed diagnosis

failure to recognize hilar and mediastinal lymphadenopathy as a manifestation of primary or postprimary disease in adults,

TB with predominantly l/n + airways involvement

TB with predominantly l/n + airways involvement

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Causes of a missed diagnosis

overlooking of mild parenchymal abnormalities in patients with reactivation disease,

Chest plain film, without pathology

Miliary pattern of TB

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Causes of a missed diagnosis

failure to recognize that an upper lobe nodule or mass surrounded by small nodular opacities or scarring may represent Tb. TB, parenchymal disease

TB, parenchymal disease

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Causes of a missed diagnosis

any image of lung pathology can mimic an image of Tb and vice versa, clinical examination and etiology are of paramount importance.

TB, parenchymal disease – right lobeSquamous cell carcinoma – left lobe

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Causes of a missed diagnosis

One of the biggest challenges in differential diagnosis of chest imaging remains single pulmonary nodule (SPN).

TB, parenchymal disease – both lungs, squamous cell carcinoma – left lobe

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Causes of a missed diagnosisCT has had a major influence on the evaluation of SPNs and/or Tb

with regard to defining morphological features, detecting calcification, planning and performing diagnostic FNA or biopsy,evaluation of chest pathology at all.

TB, parenchymal disease like SPN

Multiple mieloma, same patient

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Extraordinary patterns

Recently we face a new complexity as presentations of Tb become change constantly. TB, with “galaxy” sign – like sarcoidosis

TB, with ground – glass opacity

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Extraordinary patterns

single or multiple nodules or masses,basilar infiltrates,miliary TB with diffuse bilateral areas of ground – glass opacityreversible multiple cysts.

TB, parenchymal disease – described as reversible multiple cysts

Lee JY, Lee KS, Jung KJ, Han J, Kwon OJ, Kim J, Kim TS.J Pulmonary tuberculosis: CT and pathologic correlation. Comput Assist Tomogr. 2000 Sep-Oct;24(5):691-8.

TB, miliary pattern with diffuse bilateral areas of GGO

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“weakest links”

HIV infection immunosuppressant therapy:

steroid therapy,chemotherapy,

diabetics,elderly people,alcohol abuse,malnutrition,children without vaccination.

Lymphadenopathy and severe parenchymal disease, 9 month

Mild parenchymal disease

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Immunocompromised patients

higher prevalence of multiple cavities in a tuberculous lesionwith nonsegmental distribution compared to patients without underlying disease.

TB, parenchymal disease with cavitation

TB, sever parenchymal disease with cavitation

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Immunocompromised patients

the incidence of Tb in patients with idiopathic pulmonary fibrosis (IPF) is 4x higher. atypical manifestations

subpleural nodules lobar or segmental airspace consolidation

may mimic lung cancer or bacterial pneumonia.

IPF + TB, subpleural nodules & airspace consolidation

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Epidemiology – HIV/TB

29Small and Fujiwara, N Eng J Med 343:189, 2001

The annual risk of TB in HIV infected

approximates the lifetime risk of HIV uninfected

HIV/TB: Profound Effect on Individuals

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HIV is fueling the TB epidemics,the presence of other infections,

including TB, may allow HIV to multiply more quicklyresult in more rapid progression of HIV disease

HAART may result in paradoxical worsening or TB manifestations,may become typical as immune system repairs.

HIV/TB: extraordinary patterns of TB

TB, parenchymal disease and miliary pattern, ground glass opacity

Paradoxical worsening of TB lymphadenitis

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Clinical presentation and CD4

Mild immunosuppression (CD4 > 500) are more likely to present with signs and symptoms of pulmonaryTB.

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Clinical presentation and CD4

Advanced stages of HIV (CD4 < 500):pulmonary cavities absent infiltrates in middle and lower lobesnodular infiltrateseffusions can be pleural and pericardial mediastinal lymphadenopathy with no pulmonary infiltrates normal CXR 10 %

TB, lymphadenopathy with no parenchymal changes

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Immunocompromised patientspattern of disease is different, have a higher prevalence of extrapulmonary involvement.

38% of immunocompromised patients with Tb had pulmonary involvement only, 30% had extrapulmonary involvement only, 32% had both pulmonary and extrapulmonary involvement

Small PM, Schecter GF, Goodman PC, Sande MA, Chaisson RE, Hopewell PC. Treatment of tuberculosis in patients with advanced human immunodeficiency virus infection. ;(5):–294

TB, parenchymal disease –described as lymphoproliferative type

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Extrapulmonary involvement

diagnosis of TB some times becomes a dilemma delay in diagnosis and immunocompromised patients increase number of cases of extra-pulmonary tuberculosis. negative smear for AFB, a lack of granuloma on histopathology, and negative culture do not exclude the diagnosis of tuberculosis.

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Diagnosis of TB some times becomes a dilemma

Plain film due to painMR – ankylosis due to postTB

changes

Chest CT – without changesBone destructions and abscesses

Chest CT – miliary TB

Miliary TB

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Miliary TB

widespread hematogenousmay be the only pulmonary abnormality

1- to 3-mm diameter nodules randomly distributed throughout both lungs thickening of interlobular septa and fine intralobular networks localized ground-glass opacity

Chest CT – miliary TB

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Complications and Sequelae of Tuberculosis

airways, vessels, mediastinum, pleura, or chest wall

Chest CT – pleural and chest wall TB

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Airway Tuberculosis

the most common cause of inflammatory stricture –bronchial stenosiscircumferential wall thickening and luminal narrowing, with involvement of a long segment of the bronchiairways are irregularly narrowed in their lumina and have thick walls

Chest CT – bronchial deformity

Chest CT – TB bronchiolithiasis

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Lymphadenopathy and extrapulmonary involvement

enlarged necrotic lymph nodes,central areas of low attenuation and peripheral enhancement

Chest CT – intea & rxtrathoracic l/n & abscess

US – supraclavicular, axillar l/n

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TB of larynx, throatresult of direct extension from tuberculous lymph nodes, endobronchial spread of infection, lymphatic dissemination,patients: 20 – 40 y., elderly.

Chest CT – larynx TB

Chest CT – throat TB

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Skeletal TB

pulmonary involvement < 50 %spine is the most frequent site,the most frequent - vL1, 1< vertebra is typically affected, vertebral body is more commonly involved than the posterior elements paravertebral abscesses

MR – spinal TB

CT – spinal TB

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TB of mammary glands

infrequent occurrencetypes:

nodular – mimics carcinoma,diffusesclerosing.

spread:direct,lymphatic,haematogenous.

Mammography –spiculated mass

Ultrasound – untypical cystic mass

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Diagnosis of TB some times becomes a dilemma

biopsy or culture specimens are required to make the definitive diagnosis, radiologists and clinicians have to understand

distribution, patterns, imaging manifestations.

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TB cannot be confidently diagnosed on the basis of chest radiographic or CT findings alone technical parameters are important.

Diagnosis of TB some times becomes a dilemma

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Tuberculosis (TB) WHO future plans

WHO is working to dramatically reduce the burden of TB, halve TB deaths and prevalence by 2015, through its Stop TB Strategy and supporting the Global Plan to Stop TB.

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WHO: The Global Plan to Stop TB 2006-2015

access to quality (individual) TB diagnosis and treatment for all TB/HIV, MR TBEU:

↓ morbidity of TB (65/100.000→42/100.000 2015.)↓ mortality of TB (8/100.000 → 4/100.000 2015.)TM+ (46% → 70% 2015.)to cure 85% of TB patients (in Latvia 75% 2009.)

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1. Tb exists.2. Tb has lots of faces.3. Diagnosis of Tb is teamwork.4. Technical parameters of exams

are very important.

take home message

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Conclusion I

1. TB is the most common cause of infectious disease – related mortality worldwide

2. It can sometimes be difficult to differentiate between primary and postprimary TB both clinically and radiologically, since their features can overlap.

3. There are not actually just TB specific clinical or radiological signs.

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Conclusion II

4. Tuberculosis may simulate many other diseases.

5. Tuberculosis can affect virtually any organ system in the body

6. Diagnostic of tuberculosis is complex action and result of team - work.

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Features, Pathology, HRCT, Springer, 20075. W. Richard Webb et al., High-Resolution CT of the Lung,

Second Edition, Lippincott – Raven,6. S. Raoof, A. Amchentsev et al, Multinodular Disease: A HRCT

Scan Diagnostic Algorithm, Chest 2006, 129, 805-8157. E.Eisenhuber, The Tree in Bud Sign, Radiology 2002, 222, 771-

7728. Jud W. Gurney et al., Diagnostic Imaging: Chest, 2006,

Amirsys, V1/30-339. O.N. Hatipoglu, E Osama et al, High resolution computed

tomographic findings in pulmonary tuberculosis, Thorax 1996, 51, 397-402.

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10. Jung-Gi Im, Harumi Itoh et al, Pulmonary Tuberculosis: CT Findings – Early Active Disease and Sequential Change with Antituberculous Therapy, Radiology 1993, 186, 653-660.

11. Fumito Okada, Yumiko Ando, Clinical/Pathologic Correlations in 533 Patients With Primary Centrilobular Findings on High-Resolution CT

12. K.S.Ko et al, Reverible Cystic Disease Associated with Pulmonary Tuberculosis, Radiology, 1997, 204, 165-169

13. M.I. Najjar et al, Case of Miliary Tuberculosis With Cystic CT Scan Changes, Chest, 2003.

References

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