Tuberculosis- Tuberculosis- what is essential what is essential

to know?to know?JK AmorosaJK Amorosa

23 m23 m LLL, L pl eff, LLL, L pl eff,

endobronchial endobronchial spreadspread

June October

23 m23 m

23 m23 m

TB - Endobronchial TB - Endobronchial spreadspread

Müller, N.L et al. Diseases of the Lung Radiologic and Pathologic Correlations 2003

granuloma

22 m fever22 m fever

RUL atelectasis, RUL atelectasis, endobronchial TB diff: endobronchial TB diff:

squamous cell casquamous cell ca

Airway TBAirway TB

Bronchial stenosis - lobar collapse or Bronchial stenosis - lobar collapse or hyperinflation, obstructive hyperinflation, obstructive pneumonia, mucoid impaction pneumonia, mucoid impaction

Long segment narrowing with Long segment narrowing with irregular wall thickening, luminal irregular wall thickening, luminal obstruction, and extrinsic obstruction, and extrinsic compression compression

Tree-in-bud opacities and traction Tree-in-bud opacities and traction bronchiectasis - upper lobes bronchiectasis - upper lobes

TB mediastinal TB mediastinal adenopathyadenopathy

19 f19 f

Young patient with fever Young patient with fever and chest painand chest pain

Harisinghani,MGRadiographics ’00

TB mediastinaladenopathy

51 yo immigrant with 51 yo immigrant with feverfever

TB mediastinal abscess

Intrathoracic- Intrathoracic- LymphadenopathyLymphadenopathy

96% of children and 43% of adults 96% of children and 43% of adults Unilateral and right sided, involving Unilateral and right sided, involving

the hilum and right paratracheal -the hilum and right paratracheal -bilateral in about one-third of casesbilateral in about one-third of cases

Low-attenuation center secondary to Low-attenuation center secondary to necrosis CT – active necrosis CT – active

Calcified hilar nodes and a Ghon Calcified hilar nodes and a Ghon focus (Ranke complex) - previous focus (Ranke complex) - previous tuberculosistuberculosis

12 yo with fever and cough

RUL cavity & RUL cavity & atelectasisatelectasis

RUL consolidation, minimal RUL consolidation, minimal atelectasis and R hilar atelectasis and R hilar

adenopathyadenopathy 29 f pregnant 29 f pregnant

fatiguefatigue

TB – lung parenchymaTB – lung parenchyma

Dense, homogeneous parenchymal Dense, homogeneous parenchymal consolidation in any lobe, consolidation in any lobe, predominance in the lower and predominance in the lower and middle lobes - especially in adults middle lobes - especially in adults

Looks like bacterial pneumonia Looks like bacterial pneumonia except for except for lymphadenopathylymphadenopathy and and the lack of response to conventional the lack of response to conventional antibiotics antibiotics

29 29 m m

Miliary patternMiliary pattern

32 m32 m

R hilar adenopathyR hilar adenopathy Miliary patternMiliary pattern Focal RUL Focal RUL

opacitiesopacities

Pattern? Pattern? Miliary

45 yo f asymptomatic SARCOIDOSISSARCOIDOSIS, , ddx:lymphomaddx:lymphoma

Calcified bilat nodules Calcified bilat nodules Ddx: chicken pox, histo, Ddx: chicken pox, histo,

TBTB

TB Lung parenchyma TB Lung parenchyma MiliaryMiliary

1% to 7% of patients 1% to 7% of patients elderly, infants, immunocompromised elderly, infants, immunocompromised manifestation within 6 months of initial exposure manifestation within 6 months of initial exposure Chest X-ray normal or hyperinflated Chest X-ray normal or hyperinflated evenly distributed diffuse small 2–3-mm nodules, evenly distributed diffuse small 2–3-mm nodules,

with a slight lower lobe predominance - 85% of with a slight lower lobe predominance - 85% of cases cases

CT is more sensitive than Chest X-ray CT is more sensitive than Chest X-ray The nodules usually resolve - 2–6 months with The nodules usually resolve - 2–6 months with

treatment, without scarring or calcification, treatment, without scarring or calcification, rare: coalescence c focal or diffuse consolidationrare: coalescence c focal or diffuse consolidation

37 yo m with 37 yo m with cough and chest cough and chest

painpain

Diff Dx: TB pleuritis, Malignancy Hemothorax Chylothorax

Intrathoracic - Intrathoracic - Pleural Pleural EffusionEffusion

one-fourth of patients with primary one-fourth of patients with primary tuberculosis tuberculosis

sole manifestation of tuberculosis, 3–7 sole manifestation of tuberculosis, 3–7 months after initial exposure months after initial exposure

very uncommon in infants very uncommon in infants UnilateralUnilateral empyema , fistulae, bone erosion rare empyema , fistulae, bone erosion rare Residual pleural thickening /calcification Residual pleural thickening /calcification Ultrasonography (US) often demonstrates Ultrasonography (US) often demonstrates

a complex septated effusiona complex septated effusion Sequalae: pleural thickening, calcification Sequalae: pleural thickening, calcification

(calcified fibrothorax(calcified fibrothorax

Tuberculoma RATuberculoma RA TB pericarditisTB pericarditis

Harisinghani

Cardiac TBCardiac TB

0.5% of cases of extrapulmonary 0.5% of cases of extrapulmonary tuberculosis tuberculosis

Pericardial Pericardial immunocompromised patients immunocompromised patients Myocardial involvement – rare, Myocardial involvement – rare,

asymptomatic asymptomatic Thickened, irregular pericardium with Thickened, irregular pericardium with

associated mediastinal associated mediastinal lymphadenopathylymphadenopathy

IVC distentionIVC distention

40 yo m with 40 yo m with coughcough RUL cavity; Ddx: TB, abscess, CA

55 f with fever, 55 f with fever, cough & wt losscough & wt loss

RUL cavity, atelectasis Ddx: TB, abscess, CA

66 m cough 66 m cough LUL cavity, Ddx: TB, abscess, CA

62 m c 62 m c coughcough

LUL cavities and bilateral endobronchial spreadDdx: TB, CA

69 m with 69 m with worsening worsening

COPDCOPD LUL cavitary lung opacity; TB Ddx:CA, abscess

Morbidly obese f in her 50’s with persistent post-op fever

R apical cavity, TB; Ddx: CA

Müller, N.L et al. Diseases of the Lung Radiologic and Pathologic Correlations 2003

Parenchymal Parenchymal manifestation-manifestation-cavitycavity

50% of patients 50% of patients thick, irregular walls, which become thick, irregular walls, which become

smooth and thin with successful smooth and thin with successful treatment treatment

multiple, occur within areas of multiple, occur within areas of consolidation Resolution : consolidation Resolution : emphysematous change or scarringemphysematous change or scarring

air-fluid levels: uncommonair-fluid levels: uncommon

Fibrosis, cavity and … Fibrosis, cavity and … fungus ballfungus ball

DX: SARCOIDOSIS STAGE IV

Single CavitySingle Cavity

TBTB HistoHisto CACA AbscessAbscess

69 yo pre-op

Calcified granulomatouscomplex

AsymptomaticAsymptomatic

Calcified granulomas

Pulmonary nodule, Pulmonary nodule, metabolically activemetabolically active dx: dx:

tuberculomatuberculoma

Harlsinghani

TB bronchiectasis c atelectasis RUL, LLL TB bronchiectasis c atelectasis RUL, LLL pneumoniapneumonia

TB bronchiectasis c TB bronchiectasis c atelectasisatelectasis

62 yo f chronic 62 yo f chronic coughcough

Total left lung atelectasis with bronchiectasis

TuberculosisTuberculosis Resurgence in nonendemic populations due Resurgence in nonendemic populations due

to 1.increased migration 2. HIV to 1.increased migration 2. HIV Respiratory, cardiac, CNS, musculoskeletal, Respiratory, cardiac, CNS, musculoskeletal,

GI, GU systems GI, GU systems History of infection or exposure to TB ca History of infection or exposure to TB ca

50% 50% Tuberculin skin test does not in exclude Tuberculin skin test does not in exclude

infection infection Mimics other diseases Mimics other diseases Biopsy or culture specimens are required to Biopsy or culture specimens are required to

make the definitive diagnosismake the definitive diagnosis

PulmonaryPulmonary TuberculosisTuberculosis

PrimaryPrimary Childhood and Childhood and

30% in adults 30% in adults because of lack of because of lack of unexposed adult unexposed adult populationspopulations

LymphadenopathyLymphadenopathy Mid and lower Mid and lower

lungslungs Self-limitingSelf-limiting

PostprimaryPostprimary Adults and adolescentsAdults and adolescents Reinfection Reinfection

with/reactivationwith/reactivation ProgressiveProgressive CavitationCavitation Upper>Lower lungsUpper>Lower lungs Hematogenous and Hematogenous and

endobronchial spreadendobronchial spread Airway and pleural invAirway and pleural inv Heals with fibrosis and Heals with fibrosis and

calcificationcalcification

LeungLeung

‘‘In 1993, the World Health In 1993, the World Health Organization declared TB to be a Organization declared TB to be a global emergency global emergency

At current control levels, it is At current control levels, it is estimated that between 1997 and estimated that between 1997 and 2020, nearly 1 2020, nearly 1 billionbillion people will people will become newly infected and 70 become newly infected and 70 million people will die from the million people will die from the disease “disease “

Increase, esp multidrug-Increase, esp multidrug-resistant (MDR) TBresistant (MDR) TB

AfricaAfrica Asia Asia EuropeEurope

TB in Immunocompromised TB in Immunocompromised patientspatients

Higher prevalenceHigher prevalence More MDR More MDR Higher prevalence of Higher prevalence of

extrapulmonary extrapulmonary Normal chest radiographic findingsNormal chest radiographic findings

TB Differential Dx “the TB Differential Dx “the mimicker”mimicker”

Primary:Primary: Focal opacity: pneumonia, histoFocal opacity: pneumonia, histo Adenopathy: lymphoma, sarcoid, histo, Adenopathy: lymphoma, sarcoid, histo,

metsmets Pleural eff: malignancy, hemothorax, histoPleural eff: malignancy, hemothorax, histo Reactivation:Reactivation: Cavity: lung ca, abscessCavity: lung ca, abscess Healed (fibrotic):Healed (fibrotic): radiation fibrosisradiation fibrosis

REFERENCESREFERENCES

Tuberculosis: A Radiologic ReviewTuberculosis: A Radiologic Review

Joshua BurrillJoshua Burrill,, Radiographics 2007; 27: 1255-73 Radiographics 2007; 27: 1255-73 Tuberculosis from Head to Toe1 (RSNA Link) Tuberculosis from Head to Toe1 (RSNA Link) Mukesh G. Harisinghani, MD , Theresa C. Mukesh G. Harisinghani, MD , Theresa C.

McLoud, MD, Jo-Anne O. Shepard, MD, Jane McLoud, MD, Jo-Anne O. Shepard, MD, Jane P. Ko, MD, ‘00P. Ko, MD, ‘00

Radiology.Radiology. 1999;210:307-322.) 1999;210:307-322.)State of the ArtState of the Art

Pulmonary Tuberculosis: The Essentials Ann Pulmonary Tuberculosis: The Essentials Ann N. Leung, MD1 N. Leung, MD1