PRESENTASI RADIOLOGI TUBERKULOSIS

Seorang wanita, Ny. W, Usia 59 tahun datang dengan keluhan batuk berdahak lebih dari 3 bulan. Berat badan pasien turun 7 kg dan demam beberapa kali. Pasien berobat ke Puskesmas tetapi batuk tidak berkurang. Pasien tidak patuh dalam mengahabiskan regime obat….

METODE Plain films:

Postero-anterior (PA),, lateral Antero-posterior (AP), supine, oblique Inspiratory-expiratory Lordotic, apical, penetrated Portable/mobile radiographs

Tomography CT scanning Radionuclide studies Needle biopsy Ultrasound Fluoroscopy Bronchography Pulmonary angiography Bronchial arteriography Magnetic Resonancy Imaging (MRI) Digital radiography Lymphangiography

Plain PA Chest Film Paling Sering Visualisasi yang jelas Foto baru vs Foto lama : Sangat penting

dalam menegakkan dx dan follow-up pasien

Foto plain penting sebelum melanjutkan ke pemeriksaan yang lebih kompleks

THE PLAIN FILM - PA view Positioning:

Patient faces the film chin up. The shoulders rotated forward Displace the scapulae.

Exposure: Full inspiration Optimal visualisation of the lung bases. Centring at T5.

Prevent obscuring the lung bases:The breasts should be compressed against the film.

THE PLAIN FILMThe PA view

Visualisasi jalan nafas, struktur vaskuler , area di belakang jantung termasuk spinal cord

Viewing the lateral filmBiasanya bahagian kiri di sebelah film.

karena

Lebih besar bahagian kiri yang terlindungi dari kanan pada PA view

tetapi

Jika ada lesi spesifik pada bahagian kanan, sebaiknya bahagian kanan yang diposisikan pada sebelah film

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Lung Unit

The approximate positions of the pulmonary segments as they can be seen on the PA and lateral radiographs

Paru Kanan Paru Kiri

TUBERKULOSIS

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ª TB CAUSED DEATH NO. 3 AFTER CARDIO VASCULAIR AND RESPIRATORY TRACT INFECTIONS (SKRT 1995)

ª TB ATTACK PRODUCTIVE AGE GROUP AND LOW IN COME SOCIETY(breadwinner)

ª DOTS IMPLEMENTATION HAS NOT BEEN CARRIED OUT BY ALL HEALTH SERVICES UNIT

ª POOR OF RECORDING AND REPORTING SYSTEM

Etiologi: Mycobacterium Tuberculosis

Other mycobacteria causing lung infection :

- M. avium Complex(MAC)

- M. kansasii

- M. bovis

- Transmission is by droplet inhalation

Predispose factor: - Contact

- Old age, Poor nutrition

- Alcoholism

- Diabetes

- Pregnancy

- Malignant disease

- Immunosuppression, especially HIV infection

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TB Disease(Active disease):

- Cough > 3 weeks - +/- blood in - Sputum- Decreased appetite- Weight loss- Weakness- Night sweats

Pathogenesis :

Inhalation of infected droplet

Alveoli, multiplication of M.tbc

Spread to regional lymph nodes

Acute inflamatory reaction: PMN and monocytes infiltration

Healing by resolution Chronic granuloma, consisting of multinucleated giant cells, epitheloid fibroblast, lymphocytes, monocytes

Development of peripheral fibrous tissue, Necrosis of central area

Spread of M.tbc through lymphatic Healing by fibrosis orchannel, blood stream, brochi, calcificationand gastrointestinal tract.

Infection in other organs system(extrapulmopnary tuberculosis)

TRANSMISSION and DISSIMINATION

A pulmonary or bronchial focus ulcerates into an airway,causing both an irritative cough and exessive secretotions laden with viable Mycobacterium tuberculosis. Acough,sneeze or even exhalation discharges droplet nuclei into the surrounding air.

TRANSMISSION and DISSIMINATION Once a focus of tuberculosis has

formed,the disease may be disseminated to other part of the body by the blood stream,by the lymphatic, by the gastrointestinal tract (occasionally from the intestine back to the blood via the thoracic duct).

TB diagnosis

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RADIOLOGY OF PULMONARY TB

CONSOLIDATION IN POST PRIMARY INFECTION

Nonspecific, affect small or an entire lobe

Tuberculoma A nodule or nodules Air bronchogram

Appears in the apex of an upper or lower lobe

Tuberculoma Patchy and nodular, maybe

bilateral.

•Healing : Often complete without any sequele

•Unilateral lymphadenophaty hilus and mediastinum

•Healing : Calcify, fibrotic contraction trachea pulled away, elevation hila & distortion lung parenchyma

•Lymphadenophaty is rare

CONSOLIDATION IN PRIMARY INFECTION

The role of X-ray in TB diagnosis

Diagnosis of TB by X-ray is unreliable, because : Other chest diseases can resemble TB on

an X-ray Pulmonary TB may show various types of

radiographic abnormalities Observer variations are greater with X-ray

Þ X-ray ALONE is unreliable for diagnosing and monitoring treatment of TB

Arrow points to cavity in

patient's right upper lobe

-- Typical finding in patient with TB

Tuberculous pneumonia. Air bronchograms are present in the left upper lobe consolidation. Less marked right upper lobe consolidation is also present

Tuberculosis. There is left hilar enlargement and perihilar consolidation.

TB PNEUMONIA HILAR ENLARGEMENT

TUBERCULOMA

Tuberculosis. Dense non-homogeneous opacities. Contracted right upper lobe.

Tuberculoma. A well-defined cavity is projected adjacent to the right hilum.

TB-CONTRACTED

Milliary tuberculosis. There are innumerabel well-defined nodules present

APICAL LESION MILIARY TUBERCULOSIS

Tuberculosis. Minimal right apical lesion

The cavity

Formation of the cavity is the pivotal event in the progression of pulmonary tuberculosis.

Mortality of cavitary pulmonary tuberculosis without treatment approaches 90%.

Pivote sngt pentinEvolution perkmbangang

Cavity

RO THORAX : PNEUMONIA BILATERAL TERUTAMA DEXTRA DENGAN SUSP ABSES PULMO

DEXTRA DD KAVITAS DAN SUSP.LIMFADENOPATI AXILA DEXTRA CURIGA MILIER TBCONFIGURASI COR DALAM BATAS NORMAL

Ny.WTY

30 tahun

1495654

(Ny. WTY) 30 thn B20 CD 4 = 1 TB Paru BTA (-) Keluhan :

demam, batuk tdk berdahak, diare, lemas, sariawan

Outcome : meninggal

Nn. DFS, 19 tahun, 01503807

Ro thorax :

Bronkhopneumonia dengan mixed miliary TB

(Ny. DFS)19 tahun

B20 CD4 = 1 TB milier BTA (-) Peritonitis TB Keluhan : sesak

nafas, batuk tidak berdahak, demam, sariawan, nyeri perut

Outcome = meninggal

Ny. SPH, 27 tahun, 01549285

Ro thorax : Gambaran miliar di kedua pulmo dominan di aspek caudal dd spesifik proses, besar cor normal

(Ny. SPH, 27 tahun

B20 CD4 = 17 TB Miliar BTA (-) Keluhan :

demam, batuk tidak berdahak, diare, sariawan, BB turun

Outcome : dalam terapi OAT , ARV tunda (2 minggu setelah OAT), Steroid

Ny. SN, 33 tahun

(Ny. SN) 33 tahun B20 dalam tex

ARV TB paru, BTA + CD = 6 Keluhan : Batuk

berdahak , tidak bercampur darah, demam ngelemeng, mual, muntah, keringat malam, BB turun

Outcome : ARV dilanjutkan, OAT katagori 1

TB peritonitis

TB spondylitis Tuberkuloma

POST PRIMARY PULMONARY TB

• Reactivation of primary infection or reinfection

• Sub apical upper lobes/ segment of the lower lobes

• Typically of the Cavity : A large cavity with several smaller satellite cavities, often bilateral

• Small cavities that heal Fibrotic• Large cavities Secondary infection or

Fungal colonisation

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Differential diagnosis of some common chest X-ray findings

Chest X-ray finding Differential diagnosis

Cavitation Some bacterial pneumonias Lung abcesses

Some fungal infection Non-infectious causes :

Bronchial carcinoma Occupational lung disease

Unilateral infiltrat Pneumonia Bronchogenic carcinoma

Bilateral infiltrat Pneumonia Connective tissue disease Occupational lung disease

Sarcoidosis

Mediastinal lymphadenopathy Lymphoma Bronchogenic carcinoma

Sarcoidosis

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Treating TB

Extrapulmonary TBLonger course (e.g. TB spine 12 months)Steroids, cotrimoxazole, vitamin B

Side effects of TB treatment Multi-Drug Resistant TB (“MDR TB”)

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Treating TB

Adherence to TB medication DOTS (Directly Observed Therapy Short

Course) “Treatment Supporter”

Adherence kesetiaan

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The success of the WHO case management intervention or “DOTS strategy” depends on the implementation of a policy package with 5 components :

Government commitment Case detection by microscopy Directly Observed Treatment, Short-course

chemotherapy Regular drug supply of all essential antituberculosis

drugs Establishment and maintenance of monitoring

mechanisms

Estab: esteblis

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Possible alternative treatment regimens for each treatment category (WHO guidelines)

TB Treatment Category

TB patients

Alternative TB Treatment Regimens

Initial phase (daily or 3 times/week)

Continuation phase

I

New smear-positive PTB;New smear-negative PTB with extensive parenchymal involvement;New cases of severe forms of extra-pulmonary TB

2 EHRZ (SHRZ)2 (EHRZ (SHRZ)

2 EHRZ (SHRZ)

6 HE4 HR

4 H3R3

II

Sputum smear-positive;Relaps;Treatment failure;Treatment after interruption.

2 SHRZE / 1 HRZE2 SHRZE / 1 HRZE

5 H3R3E3

5 HRE

III

New smear-negative PTB (other than in category I) new less severe forms of extrapulmonary TB

2 HRZ2 HRZ2 HRZ

6 HE4 HR

4 H3R3

IV

Chronic case (still sputum-positive after supervised retreatment)

Not application(Refer to WHO guidelines for use of second-line

drugs in specialized centres(,Interns-pulmonologist))

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Standardised Treatment Regimens by WHO

The essential anti-TB drugs

Essential Anti-TB Drug

(abbreviation)

Recommended dose (mg/kg)

Daily Intermittent

3 times/week 2 times/week

Isoniazid (H)Rifampicin ®(R)Pyrazinamide (Z)Streptomycin (S)Ethambutol (E)Thioacetazone (T)

5 (4-6)10 (8-12)

25 (20-30)15 (12-18)15 (15-20)

2.5

10 (8-12)10 (8-12)

35 (30-40)15 (12-18)30 (25-35)

15 (13-17)10 (8-12)

50 (40-60)15 (12-18)45 (40-50)

Not applicable

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Issues for advocacy

Improved application of DOTS Improved TB treatment completion rates Improved drugs! Availability and cost of drugs for MDR-

TB “DOTS does not work if not owned by

communities!”

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Thank you for your Attetion!

May Fortune be with You…