TB

Dr. Hytham Nafady

PulmonaryTB

TB or not TB that is the question

Chest Doctor

Pathology of Primary T.B.

Pathology of post-primary T.B.

Radiological manifestations of TB

TB

Parenchymal TB

Mediastinal TB

Airway TB

Vascular TB

Pleural TB

Chest wall TB

Parenchymal TB

• TB pneumonia.

• Cavitary TB.

• Tuberculoma.

• Miliary TB.

Parenchymal TB

TB pneumonia

Cavitary TB

Tuberculoma

Miliary TB

1ry

Post-1ry

Post-1ry

1ry

Post-1ry

1ry

Post-1ry

Complications of parenchymal TB

Fibrosis Cavitation Endo-bronchial

spreadAspergilloma

Bronchogenic carcinoma

Tuberculoma Pathogenesis:• Localized parenchymal TB with alternating activation and

healing.• it may occur in the setting of 1ry and post-1ry TB.Location:Right upper lobe (but can occur in any other lobe).Radiological manifestations:• Rounded nodule with well defined margins.• 0.5 - 4cm in diameter• Usually single but may be multiple.• +/- calcification.• +/- cavitation.• +/- satellite nodules.

nodule

nodule

nodule

DD: Nodule

1. Tuberculoma2. Hamartoma3. Metastases4. Hydatid

Tuberculoma

TB pneumonia

1ry TB pneumonia Post-1ry TB pneumonia

Children Adult

Segmental or lobar consolidation.

Patchy & nodular opacities which may be bilateral

Involve any part of the lung. apico-posterior segment of UL.

Superior segment of LL.

Associated with lymphadenopathy.

Not associated with lymphadenopathy.

Healing is complete without any sequelae.

Healing by fibrosis.

Caviatation.

Or both.

1ry TB pneumonia with lympadenopathy

Miliary TBEtiology:• It results from hematogenous dissemination of

infection from pulmonary nidus.• It can be 1ry or post-1ry TB.Location:Randomly distributed with mild basilar predominance.Radiology:CXR: miliary shadows (nodules < 2mm). CT: sharply defined miliary shadows (nodules < 2mm).Association:TB chronic lesionsConsolidation, cavitation or calcified LN.

Millet seeds ( الدخن (بذور

The term miliary is derived from the radiographic picture of diffuse discrete nodular shadows about the size of millet seeds = 2mm.

Random distribution

Sarcoidosis

Thyroid metastases (snow storm)

Thyroid metastases (snow storm)

2ry hemosiderosis (MS)

Airway lesions of TB

• Endobronchial tuberculosis.

• Bronchiectasis.

• Broncho-stenosis.

• Broncholithiasis.

Endobronchial TBPathogenesis:• Cavitation & communication with bronchial treeLocation:• Lower dependent lung zones, distant from the

original cavity.Radiological manifestations:• X-ray: • Micro-nodules with lobar or segmental distribution.• CT: • Tree in bud opacities.Association:• Cavitation.

Tree in bud opacities

Bronchiectasis

• Irreversible dilatation of the cartilage containing airways.Pathogenesis:• Cicatricial bronchiectasis:Due to endobronchial TB & subsequent fibrosis.• Traction bronchiectasis:Due to pulmonary TB & subsequent fibrosis.Location:• Unilateral apical bronchiectasis is highly suspicious of TB.Radiological manifestations:• Dilated bronchi.• Bronchocele (dilated bronchi filled with mucus with branching

tubular opacities giving finger in glove appearance).

TB bronchiectasis

Broncho-stenosis

Pathogenesis::• Endobronchial TB.• Extrinsic pressure from enlarged peribronchial TB.Location:• Central air ways.CT:• Active stage:Irregular luminal narrowing with wall thickening,

enhancement & enlarged adjacent lymph nodes.• Fibrotic stage:Concentric narrowing, uniform thickening with involvement of

a long segment.

• Lymphadenopathy with partial obstruction of the left main bronchus resulting in obstructive emphysema of the left lung. Bronchoscopy and biopsy revealed T.B.

DD of broncho-stenosis

Endobronchial TB Bronchogenic carcinoma

Double obstructive lesions Low density mass at the obstructive site.

Multiple bronchial wall calcifications

Sever distortion of the bronchi

Broncholithiasis

• Presence of calcified or ossified material within the lumen of the tracheo-bronchial tree.

Pathogenesis:• Erosion of bronchial wall by calcified

peribronchial lymph node.CT:• Calcified lymph node with findings of

bronchial obstruction.

Vascular TB

• Hypertrophy of bronchial vessels.

• Rasmussen aneurysm.

Hypertrophy of bronchial arteries

Pathogenesis:• Due to vasculitis.

C.P:• Hemoptysis.

Location:• Peribronchial.

CT:• Peribronchial rounded & tubular densities similar to

enlarged lymph nodes.• It may protrude into the lumen of the ectatic bronchi.

Rasmussen aneurysm

Pathogenesis:• Vasculitis of a pulmonary artery within a

tuberculous cavity.Location:• Within a tuberculous cavity.CT:• Rounded enhancing lesions within a

tuberculous cavity.• It may cause life threatening hemoptysis.

Medically treated aneurysms

Rasmussen aneurysm Pulmonary pseudoaneurysm in Behcet syndrome

Anti-tuberculous therapy Corticosteroid therapy

Mediastinal TB

• TB Lymphadenopathy.

• TB pericarditis.

• Esophageal TB.

• Fibrosing mediastinitis.

TB lymphadenopathy• Is the hall mark of primary T.B.• Its incidence decreases with age.Pathogenesis:• Formation of tuberculous caseating granulomas in the lymph

nodes.Location:• Right paratracheal and hilar lymph nodes.CT:• Central low attenuation.• Peripheral rim enhancement.• Obliteration of the perinodal fat.• Usually nodal size doesn’t exceed 2 cm.Association:Parenchymal involvement.

TB Lymphadenopathy

Sequelae of TB lympadenopathy

Healing Complications

Fibrosis Calcification Compression of

adjacent bronchusExtranodal extension

DD of lymphadenopathy

• 1- Metastases

• 2- Lymphoma

• 3- other infections e.g. histoplasmosis & varicella.

• 4- Sarcoidosis

Esophageal TB

Pathogenesis:• Extension from adjacent lymph nodes.Location: • subcarinal region (due to anatomic proximity of

the esophagus to lymph nodes).Radiological manifestations:• Traction diverticula (triangular in shape).• Esophago-mediastinal or esophago-bronchial

fistula, manifested as (pneumomediastinum).• Esophagobronchopleural fistula:

Esophageal traction diverticulum

• Triangular or tent shaped.

• Wide neck.

• It empties when the esophagus is collapsed as it contains all layers.

• Calcified mediastinal LN adjacent to the diverticulum.

Esophageal diverticulum

Traction diverticulum Pulsion diverticulum

Esophago-mediasinal fistula

Esophago-broncho-pleural fistula

Pericardial tuberculosis

Pathogenesis:• Extension from adjacent lymph nodes due to close

anatomic proximity of the lymph nodes & posterior pericardial sac.

Location:Radiological manifestsions:• Pericardial effusion: • Constrictive pericarditis

– Pericardial thickening > 4 mm.– Pericardial calcification.

Association:• Lymphadenopathy.

Fibrosing mediastinitis• N.B: the most common cause of mediastinitis is

histoplasmosis.Pathogenesis:• TB lymphadenitis with reactive fibrous changes.Radiological manifestations:Plain x-ray:• Mediastinal widening or localized mass.CT:• Mediastinal or hilar mass with or without calcification.• Diffuse obliteration of mediastinal fat.• Tracheo-bronchial narrowing.• Vascular encasement.

Pleural manifestations of TB

• Pleural effusion.

• Chronic TB empyema.

• Fibrothorax.

• Broncho-pleural fistula.

• Pneumothorax.

• Malignancy associated with chronic empyema.

Pleural TB

TB empyema• Persistent purulent pleural fluid containing TB bacilli.Pathogenesis:• Rupture of subpleural cavity.• Hematogeneous dissemination.• Direct extension from infected lymph nodes.Location:• almost always unilateral.Radiological manifestations:• Plain x-ray:• CT:• L oculated fluid collection.• Pleural thickening.• Pleural calcification.• Extrapleural fat proliferation.• Milk of calcium with calcium / fluid level.• Pseudochylous effusion with fat / fluid level.• Associated pulmonary TB (subpleural cavitation)

TB empyema

Proliferation of extra-pleural fat

TB empyema with subpleural cavity

TB empyema with milk of calcium

Ca / fluid level

TB empyema with pseudochylus effusion

Fat / fluid level

DD of pleural calcification

• TB (usually unilateral).

• Old hemothorax (usually unilateral).

• Asbestosis (usually bilateral).

Pleural manifestations of TB

• Empyema necessitans.

• Pott’s disease of the dorsal verebrae.

• Sternum

• Rib.

• Sternoclavicular joint.

Chest wall TB

Empyema necessitans

Extra-pulmonary TB

Skeletal TB

• TB spondylitis.

• TB arthritis.

• TB osteomyelitis.

TB spondylitis TB arthritis TB osteomyelitis

50% of skeletal TB

34% of skeletal TB

16% of skeletal TB

Any age Middle age & elderly

Children < 5 y

(rare in adults)

Thoraco-lumbar region

Large weight bearing joints

Any bone can be affected.

Paradiscal type.

Central type.

Anterior type.

Appendicial type.

Mono-articular. Metaphyseal.

TB spondylitis TB arthritis TB osteomyelitis

Hematogeneous spread (Batson venous plexus).

Trans-cartilagenous spread into disc material.

Subligamentous spread (beneath anterior longitudinal ligament)

Hematogeneous spread

Transphyseal spread to the epiphysis (on the contrary to pyogenic osteomyelitis).

Tuberculousspondylitis

Pyogenicspondylitis

Early preservation of the disc space.

Early & sever narrowing of the disc space.

Absent reactive sclerosis Reactive sclerosis.

Marginal calcification of psoas abscess.

No calcification

Skip lesions No skip lesions

Tuberculous arthritis Pyogenic arthritis

Gradual narrowing of the joint space.

Early & sever narrowing of the joint space.

Peripheral bone erosions.

Central bone erosions.

Fibrous ankylosis Bony ankylosis.

Kissing sequestra

Phemister triad

• Periarticular osteopenia.

• Marginal bone erosions.

• Gradual narrowing of the joint space.

DD: Rheumatid arthritis.

(polyarticular).

Tuberculousosteomyelitis

Pyogenicosteomyelitis

Transphyseal spread. No transphyseal spread.

Little or no periosteal reaction. Periosteal reaction.

Little or no surrounding sclerosis Surrounding sclerosis.

Special forms of TB osteomyelitis

• TB dactylitis.

• Cystic TB.

TB dactylitisSpina ventosa

• Spina = sail.

• Ventosa = expanded with air

Ventosas

Cystic TB

TB spondylitis

1. Maginal Paradiscal (commonest).

2. Central.

3. Anterior (subperisteal).

4. Posterior (appendiceal).

Marginal (paradiscal) TB spondylitis

Plain x ray:

• Disc space narrowing:

• Due to involvement of the disc material.

MRI:

• Abnormal bone marrow signal along adjacent vertebral end plates.

• Disc space narrowing.

Anterior (subperiosteal) lesion

Plain x-ray:• Anterior scalloping (gouge effect):• Due to stripping of the periosteum and ALL

ischemia & pressure necrosis of the anterior vertebral body.

MRI:• Subligamentous abscess.• Preservation of the discs.• Abnormal signal involving multiple vertebral

segments.

Gouge

• Is a special type of chisel

Central lesion

• Centered on the vertebral body.• Disc is not involved.• Spread of infection through Baston’s venous

plexus.Plain x-ray:• Central rarefaction.• +/- Vertebral collapse (vertebra plana).MRI: • abnormal signal along the vertebral body with

preservation of the disc material.• DD with metastasis, lymphoma & eosinophilic

granuloma.

Posterior (appendicial) type

• Isolated infection of the pedicles, lamina, transverse processes & spinous process.

• Erosive lesions with paravertebral abscess.

Skip lesions

• Involvement of non contiguous vertebrae.

Paravertebral abscess

• Located at a some distance below the original lesion due to gravitation along the fascial planes.

• Calcifications are pathognomonic.

Angular kyphotic deformity gibbus deformity

CNS

TB meningitis:

• Leptomeningeal thickening & enhancement along the basal cisterns.

Parenchymal tuberculoma:

• Multiple ring enhancing lesions.

Gastrointestinal TB

• Most common location is ileocecal junction.

• Hypertrophy of ileocecal valve (Flischner sign).

• Cone shaped cecum (normally the cecum is purse shaped).

• Pulled up cecum (fibrosis).• DD: Crohn’s disease.

Ileocecal TB

• Pulled cecum.

• Narrowed terminal ileum

Ileocecal TB

Ileocecal TB

DD of Coned cecum• Crohn's - TI involved more than cecum

• TB - colon involvement greater than TI; usually have pulmonary TB; no reflux from cecum to TI

• Amebiasis - cecum involved in 90% of chronic amebiasis; TI normal; ileocecal valve fixed in open position

• UC - backwash ileitis occurs 10% of time through gaping ileocecal valve

• Actinomycosis - uncommon may simulate appendicitis, palpable abdominal masses and draining fistulas

• Typhlitis - necrotizing process of multifactorial origin involving predominantly the right colon; most common in children with leukemia; typically begins 1-2 weeks following chemotherapy- may also occur in adults with hematologic malignancy- there is bowel wall thickening, mucosal ulceration, intramural hemorrhage and necrosis

TB peritonitis

Pathology:

• Direct haematogenous spread,

• Rupture of a tuberculous intra-abdominal lymph node.

Types:

• Wet type (commonest).

• Dry type.

• Fibrotic type.

Wet TB peritonitis

• Exudative high attenuation ascites.

• May be free or loculated.

• Measurement of ascitic fluid adenosine deaminase level is diagnostic.

Dry type

• Matted small bowel loops.

Fibrotic type

• Omental & mesenteric caking

Scrofula = breeding sows

Cervical TB lymphadenopathyscrofula

US:• Nodal matting.• Surrounding soft tissue edema is less marked than

would be expected given the size of the collections.

Duplex:• Prominent hilar vascularity (on the contrary of

malignant LN which show prominent peripheral vascularity).

US guided FNAC:• Has 92% sensitivity & 97% specificity.

Genitourinary TB

Renal size

• Diffusely enlarged (T.B pyonephrosis from ureteric stricture).

• Focally enlarged with displacement of adjacent calyces (tuberculoma).

• Shrunken kidney small scarred non functioning kidney with dystrophic calcification (putty kidney).

• May be normal size.

Renal papillae

• Papillary irregularity (moth eaten calyces) earliest sign.

• Irregular papillary surface due erosions.

• Papillary necrosis (blunted dilated calyces).

• Parenchymal cavities communicating with collecting system.

Parenchymal calcifications

• Amorphous.• Punctate.• Confluent calcifications.• Cumulus cloud opacity:• Due to calcification in caseous material in

caverno-caseous type.• Complete cast of calcification (putty kidney)

end stage renal TB (autonephrectomized kidney).

Putty kidney

Collecting systemUneven caliectasis: unequal

dilatation of renal calyces due to varying degree of stenoses.

Hydrocalicosis:

• dilated calyx due to infundibular stenosis.

Phantom calyx:

• non opacified calyx due to infundibular stenosis.

Renal pelvis

• Reduced capacity.

• Sharp kinking (Kerr kink).

• Mural thickening.

Ureter• Spread:

• Direct spread from renal involvement:

• Early:

• Multiple filling defects (mucosal granulomas)

• Saw tooth ureter:

• Dilated ureter with irregular contour & mucosal ulcerations.

Late (fiborsis):

• Beaded ureter: alternating strictures & dilatations.

• Cork screw ureter: alternating strictures & dilatations with tortuousity.

• Pipe stem ureter: rigid, thick straight ureter.

Bladder

• Thickened contracted low capacity urinary bladder (thimble bladder).