An Atlas of Imaging Findings in Pulmonary and Gastrointestinal Tuberculosis Stanley Kim University of Maryland School of Medicine, MS-IV Gillian Lieberman, MD

Stanley Kim, MS-IV Gillian Lieberman, MD

September 2015

Agenda • Patient Presentation • Overview of Tuberculosis

• Epidemiology • Evaluation of Pulmonary and Gastrointestinal TB

• Radiographic Appearance • Pulmonary TB

• Primary • Post-Primary • Miliary

• Gastrointestinal TB • Management • Patient Clinical Course • Summary

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Stanley Kim, MS-IV Gillian Lieberman, MD

HPI: • 56 year old male presenting with two months of loss of

appetite and weight loss and approximately three weeks of nausea, vomiting, and abdominal pain

• Found to have positive QuantiFERON-TB Gold and caseating granulomas on colonoscopy at an outside hospital

• Visiting from South America Social: • Former healthcare worker

Our Patient: History

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Stanley Kim, MS-IV Gillian Lieberman, MD

Our Patient: Chest X-ray

AP portable chest x-ray: Distended loops of bowel.

PACS, UMMC

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*

Stanley Kim, MS-IV Gillian Lieberman, MD

AP portable chest x-ray: Opacity in left lung near lingula. Bilateral pleural effusions.

Our Patient: Chest X-ray

PACS, UMMC

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Stanley Kim, MS-IV Gillian Lieberman, MD

C- coronal chest CT: Multiple nodules in right upper lobe.

Our Patient: Chest CT

PACS, UMMC

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Stanley Kim, MS-IV Gillian Lieberman, MD

C- axial chest CT: Tree-in-bud pattern in right upper lobe.

Our Patient: Chest CT

PACS, UMMC

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Stanley Kim, MS-IV Gillian Lieberman, MD

C- axial chest CT: Patchy consolidation in lingula. Bilateral opacities in posterior lungs indicating atelectasis, abutting pleural effusions.

Our Patient: Chest CT

PACS, UMMC

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Stanley Kim, MS-IV Gillian Lieberman, MD

C+ axial abdomen/pelvis CT: Bowel wall thickening in hepatic flexure of colon, consistent with colitis.

Our Patient: Abdomen CT

PACS, UMMC

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Stanley Kim, MS-IV Gillian Lieberman, MD

C+ axial abdomen/pelvis CT: Inflammation in terminal ileum and cecum.

Our Patient: Abdomen CT

PACS, UMMC

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Stanley Kim, MS-IV Gillian Lieberman, MD

Differential Diagnosis Tuberculosis Crohn’s disease Sarcoidosis Lymphoma

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Stanley Kim, MS-IV Gillian Lieberman, MD

Differential Diagnosis

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Tuberculosis Crohn’s disease Chest radiograph Positive chest film

(50%) Negative chest film

Barium Fleischner sign Cobblestone mucosa

CT No creeping fat Creeping fat Omental and peritoneal thickening

Normal omentum and peritoneum

Enlarged low density nodes

Enlarged soft tissue density nodes

Distinguishing Tuberculosis from Crohn’s on Imaging:

Source: http://www.isradiology.org/goed_tb_project/im-library/ECR2010_C-1658.pdf

Stanley Kim, MS-IV Gillian Lieberman, MD

Differential Diagnosis Tuberculosis, with both pulmonary and GI involvement • Positive QuantiFERON-TB Gold • Caseating granulomas on colonoscopy • Imaging consistent with infectious process • Inhabitance in endemic region Crohn’s disease • Rarely affects lungs • Tree-in-bud pattern more consistent with infectious than

inflammatory process • Presents with non-caseating, rather than caseating granulomas Sarcoidosis • Not consistent with +QuantiFERON-TB Gold or caseating

granulomas Lymphoma • Tree-in-bud pattern and bowel wall thickening less consistent with

lymphoma • Not consistent with +QuantiFERON-TB Gold 13

Stanley Kim, MS-IV Gillian Lieberman, MD

Differential Diagnosis Tuberculosis, with both pulmonary and GI involvement • Positive QuantiFERON-TB Gold • Caseating granulomas on colonoscopy • Imaging consistent with infectious process • Inhabitance in endemic region Crohn’s disease • Rarely affects lungs • Tree-in-bud pattern more consistent with infectious than

inflammatory process • Presents with non-caseating, rather than caseating granulomas Sarcoidosis • Not consistent with +QuantiFERON-TB Gold or caseating

granulomas Lymphoma • Tree-in-bud pattern and bowel wall thickening less consistent with

lymphoma • Not consistent with +QuantiFERON-TB Gold 14

Stanley Kim, MS-IV Gillian Lieberman, MD

Agenda • Patient Presentation • Overview of Tuberculosis

• Epidemiology • Evaluation of Pulmonary and Gastrointestinal TB

• Radiographic Appearance • Pulmonary TB

• Primary • Post-Primary • Miliary

• Gastrointestinal TB • Management • Patient Clinical Course • Summary

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Stanley Kim, MS-IV Gillian Lieberman, MD

Epidemiology • Annually:

• 9 million new cases • 1.5 million deaths • 9,500 cases reported in

U.S. • Caused by M. tuberculosis • Transmitted through

respiratory fluids • Classic symptoms

• Fever • Night sweats • Cough • Weight loss

• Can impact nearly every organ system

Source: www.natureworldnews.com

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Stanley Kim, MS-IV Gillian Lieberman, MD

Evaluation • Pulmonary:

• Acid-fast bacilli smear, sputum culture, CXR • PPD, IGRA (eg, QuantiFERON Gold, T-SPOT) • Chest CT is more sensitive than chest x-ray for

diagnosis, due to its ability to identify smaller nodules and abnormalities

• Gastrointestinal: • Biopsy

• Caseating granulomas • Imaging

• Non-specific findings • CT is the imaging modality of choice

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Stanley Kim, MS-IV Gillian Lieberman, MD

Evaluation

Proposed algorithm for diagnosis of abdominal TB Source: Sood et al., 2007.

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Stanley Kim, MS-IV Gillian Lieberman, MD

Agenda • Patient Presentation • Overview of Tuberculosis

• Epidemiology • Evaluation of Pulmonary and Gastrointestinal TB

• Radiographic Appearance • Pulmonary TB

• Primary • Post-Primary • Miliary

• Gastrointestinal TB • Management • Patient Clinical Course • Summary

19

Stanley Kim, MS-IV Gillian Lieberman, MD

Pulmonary TB • Primary vs. post-primary TB are often difficult to

distinguish with imaging due to overlapping characteristics

• Features seen in primary vs. post-primary TB: • Primary TB

• Often normal imaging • Hilar and/or mediastinal lymphadenopathy • Pleural effusions • Focal consolidation, affecting any lobe

• Post-primary TB • Usually abnormal imaging • Consolidation, nodular opacities in

apical/posterior segments of upper lobes, superior segment of lower lobes

• Cavitary lesions 20

Stanley Kim, MS-IV Gillian Lieberman, MD

Let’s view three companion patients with findings indicative of primary tuberculosis.

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Stanley Kim, MS-IV Gillian Lieberman, MD

Companion Patient #1: Primary TB

Often non-specific findings, like patchy opacities

Source: Frank Gaillard, MD. Radiopaedia.

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Stanley Kim, MS-IV Gillian Lieberman, MD

Companion Patient #2: Primary TB

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Consolidation may mimic bacterial pneumonia

Source: Tara Catanzano, MD. Medscape.

Stanley Kim, MS-IV Gillian Lieberman, MD

Companion Patient #3: Primary TB

May observe Ghon lesion (calcified granuloma), or Ranke complex (Ghon lesion with calcified hilar node)

Source: William Herring, MD. Learning Radiology.

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Stanley Kim, MS-IV Gillian Lieberman, MD

Let’s view three companion patients with findings suggestive of post-primary tuberculosis.

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Stanley Kim, MS-IV Gillian Lieberman, MD

Companion Patient #4: Post-Primary TB

Cavitary lesions may occur (chest x-ray)

Source: Hani Al Salam, MD. Radiopaedia.

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Stanley Kim, MS-IV Gillian Lieberman, MD

Companion Patient #5: Post-Primary TB

Cavitary lesions may occur (chest CT)

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Source: Natalie Yang, MD. Radiopaedia.

Stanley Kim, MS-IV Gillian Lieberman, MD

Companion Patient #6: Chest X-ray • 70 year old male presenting

with weight loss and 2.5 wks of productive cough

• History of treated TB • Chest X-ray:

• Cavitary left apical lung mass

• Differential diagnosis • Post-primary TB • Mycetoma • Neoplasm

PACS, BIDMC

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Stanley Kim, MS-IV Gillian Lieberman, MD

Companion Patient #6: Chest CT • CT advised for further

evaluation • Sputum and

bronchoscopy: • Negative for TB • Positive for aspergillus

Demonstrates importance of both clinical and radiologic information in diagnosis

PACS, BIDMC

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Stanley Kim, MS-IV Gillian Lieberman, MD

Let’s view two companion patients with findings of miliary tuberculosis.

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Stanley Kim, MS-IV Gillian Lieberman, MD

Companion Patient #7: Miliary TB

• Can occur with either primary or post-primary TB, although more common with primary

• Randomly distributed nodules

Source: Mark Holland, MD. Radiopaedia.

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Stanley Kim, MS-IV Gillian Lieberman, MD

Companion Patient #8: Chest X-ray • 31 year old male

presenting with fever, mild dyspnea, 3-4 weeks of non-productive cough

• Chest X-ray: • Superior mediastinal

mass • CT revealed bilateral

lymphadenopathy and tree-in-bud opacities

• Mediastinoscopy, lymph node biopsy, bronchoscopy: AFB+

• Started RIPE treatment 32

PACS, BIDMC

Stanley Kim, MS-IV Gillian Lieberman, MD

Companion Patient #8: Chest CT

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• Patient found to have isoniazid resistance • Follow-up CT: new, diffuse random small nodules

consistent with hematogenous spread (miliary TB)

PACS, BIDMC

Stanley Kim, MS-IV Gillian Lieberman, MD

Agenda • Patient Presentation • Overview of Tuberculosis

• Epidemiology • Evaluation of Pulmonary and Gastrointestinal TB

• Radiographic Appearance • Pulmonary TB

• Primary • Post-Primary • Miliary

• Gastrointestinal TB • Management • Patient Clinical Course • Summary

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Stanley Kim, MS-IV Gillian Lieberman, MD

Gastrointestinal TB • Abdominal involvement may occur through:

• Ingestion • Hematogenous spread • Lymphatics • Nearby infected foci

• Gastrointestinal TB is rare • Increased frequency in high-risk individuals (eg,

immunosuppressed) • May impact any area of the GI tract

• Especially: • Ileocecal valve • Terminal ileum • Cecum

• Ileocecal area is involved in nearly 80-90% of cases 35

Stanley Kim, MS-IV Gillian Lieberman, MD

Gastrointestinal TB • Plain radiograph

• Dilated bowel loops caused by obstruction • Signs of perforation

• CT • Bowel wall thickening • Lymphadenopathy • Low attenuated areas suggesting caseous necrosis • Strictures

• Barium studies • Mucosal involvement (eg, ulcers) • Fleischner sign – thickening or widening of the

ileocecal valve with narrowed terminal ileum • Stierlin sign – narrowing of terminal ileum with rapid

emptying into a diminished cecum 36

Stanley Kim, MS-IV Gillian Lieberman, MD

Let’s view five companion patients with findings of gastrointestinal tuberculosis on different modalities.

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Stanley Kim, MS-IV Gillian Lieberman, MD

Companion Patient #9: Abdomen X-ray • Plain radiograph

• Dilated bowel loops caused by obstruction

• Signs of perforation

Source: Jeremy Jones, MD. Radiopaedia.

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Stanley Kim, MS-IV Gillian Lieberman, MD

Companion Patient #10: Abdomen CT

• CT • Bowel wall thickening, lymphadenopathy • Low attenuated areas suggesting caseous necrosis • Strictures

Source: Park MJ, et al., 2013.

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Stanley Kim, MS-IV Gillian Lieberman, MD

Companion Patient #11: Barium Study

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Source: Eisenberg, 1990.

• Barium studies • Stierlin sign

• Narrowing of terminal ileum with rapid emptying into a diminished cecum

Stanley Kim, MS-IV Gillian Lieberman, MD

Companion Patient #12: Barium Study

Thickened, incompetent ileocecal valve 41

Source: Burrill J, et al., 2007.

Stanley Kim, MS-IV Gillian Lieberman, MD

Companion Patient #13: Barium Study

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Source: Aditya Shetty, MD. Radiopaedia.

1

2

3

Small cecum (1), narrowed terminal ileum (2), and dilated proximal ileum (3)

Stanley Kim, MS-IV Gillian Lieberman, MD

Agenda • Patient Presentation • Overview of Tuberculosis

• Epidemiology • Evaluation of Pulmonary and Gastrointestinal TB

• Radiographic Appearance • Pulmonary TB

• Primary • Post-Primary • Miliary

• Gastrointestinal TB • Management • Patient Clinical Course • Summary

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Stanley Kim, MS-IV Gillian Lieberman, MD

Management • Most patients: 6 month empiric treatment

• 2 months – Rifampin, Isoniazid, Pyrazinamide, Ethambutol (RIPE)

• 4 months – Rifampin, Isoniazid • Latent TB:

• Isoniazid daily for 9 months • Multi-drug resistant tuberculosis:

• Combination therapy • Surgical resection, if poor prognosis

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Stanley Kim, MS-IV Gillian Lieberman, MD

Agenda • Patient Presentation • Overview of Tuberculosis

• Epidemiology • Evaluation of Pulmonary and Gastrointestinal TB

• Radiographic Appearance • Pulmonary TB

• Primary • Post-Primary • Miliary

• Gastrointestinal TB • Management • Patient Clinical Course • Summary

45

Stanley Kim, MS-IV Gillian Lieberman, MD

Our Patient: Clinical Course • After being diagnosed with gastrointestinal tuberculosis,

our patient was treated with rifampin, isoniazid, pyrazinamide, and ethambutol

• Although several AFB smears returned negative, the decision to forgo bronchoscopy was made because RIPE therapy had already been initiated and bronchoscopy findings would not change management

• Our patient was discharged from the hospital with follow-up arranged in his home country

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Stanley Kim, MS-IV Gillian Lieberman, MD

Agenda • Patient Presentation • Overview of Tuberculosis

• Epidemiology • Evaluation of Pulmonary and Gastrointestinal TB

• Radiographic Appearance • Pulmonary TB

• Primary • Post-Primary • Miliary

• Gastrointestinal TB • Management • Patient Clinical Course • Summary

47

Stanley Kim, MS-IV Gillian Lieberman, MD

Summary • You learned how to distinguish tuberculosis from

Crohn’s disease on imaging • You learned about the most appropriate imaging

modalities for pulmonary and gastrointestinal TB • You were shown images demonstrating findings of

primary, post-primary, and miliary tuberculosis and learned distinguishing features of each

• You learned about gastrointestinal TB and its predilection for the ileocecal area

• You were shown findings of gastrointestinal TB on different imaging modalities and learned about its characteristic features

• You briefly learned about the management of tuberculosis

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Stanley Kim, MS-IV Gillian Lieberman, MD

• Al Salam H. Pulmonary Tuberculosis. Radiopaedia website. http://radiopaedia.org/cases/pulmonary-tuberculosis-2. Accessed 9/10/15.

• Burrill J, Williams CJ, Bain G, et al. Tuberculosis: a radiologic review. Radiographics. 2007; 27(5):1255-73.

• Catanzano TM. Primary Tuberculosis Imaging. Medscape website. http://emedicine.medscape.com/article/358610-overview#a2. July 30, 2013. Accessed 9/9/15.

• da Rocha EL, Pedrassa BC, Bormann RL, et al. Abdominal tuberculosis: a radiological review with emphasis on computed tomography and magnetic resonance imaging findings. Radiol Bras. 2015; 48(3):181-91.

• Debi U, Ravisankar V, Prasad KK, et al. Abdominal tuberculosis of the gastrointestinal tract: revisited. World J Gastroenterol. 2014; 20(40):14831-40.

• Eisenberg RL. Gastrointestinal Radiology: A Pattern Approach. 2nd ed. Philadelphia, PA: J.B. Lippincott Company; 1990.

• Engin G, Acunaş B, Acunaş G, et al. Imaging of extrapulmonary tuberculosis. Radiographics. 2000; 20(2):471-88.

• Gaillard F. Pulmonary tuberculosis – on chest radiograph. Radiopaedia website. http://radiopaedia.org/cases/pulmonary-tuberculosis-on-chest-radiograph. Accessed 9/9/15.

• Herring W. Pulmonary Tuberculosis. Learning Radiology website. http://learningradiology.com/lectures/chestlectures/Pulmonary%20Tuberculosis-2012/Pulmonary%20Tuberculosis-2012.html. Accessed 9/11/15.

• Holland M. Miliary Tuberculosis. Radiopaedia website. http://radiopaedia.org/cases/miliary-tuberculosis-5. Accessed 9/10/15.

• Jones J. Tuberculosis with small bowel obstruction. Radiopaedia website. http://radiopaedia.org/cases/tuberculosis-with-small-bowel-obstruction. Accessed 9/7/15.

References

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Stanley Kim, MS-IV Gillian Lieberman, MD

• Leder RA, Low VH. Tuberculosis of the abdomen. Radiol Clin North Am. 1995; 33(4):691-705. • Leung AN. Pulmonary tuberculosis: the essentials. Radiology. 1999; 210(2):307-22. • McAdams HP, Erasmus J, Winter JA. Radiologic manifestations of pulmonary tuberculosis. Radiol

Clin North Am. 1995; 33(4):655-78. • Park MJ, Lim JS. Computed tomography enterography for evaluation of inflammatory bowel

disease. Clin Endosc. 2013; 46(4):327-66. • Shetty A. Ileocaecal tuberculosis. Radiopaedia website.

http://radiopaedia.org/cases/ileocaecal-tuberculosis-1. Accessed 9/7/15. • Sood R, Sethu Madhavan M. Diagnostic approach to abdominal tuberculosis. In: Agarwal AK,

Jain DG, editors. Clinical Medicine: A Practical manual for students and practitioners. India: Jaypee Brothers Medical Publishers Ltd, 2007: 249.

• Stallard B. Researchers Barcode Tuberculosis. Nature World News website. http://www.natureworldnews.com/articles/8903/20140905/researchers-barcode-tuberculosis.htm. September 2014. Accessed 9/9/15.

• Vanhoenacker FM, De Backer AI, Op de BB, et al. Imaging of gastrointestinal and abdominal tuberculosis. Eur Radiol 2004; 14 Suppl 3: E103-E115.

• WHO. Global Tuberculosis Report 2014. World Health Organization, Geneva; 2014. http://apps.who.int/iris/bitstream/10665/137094/1/9789241564809_eng.pdf. Accessed 9/9/15.

• Williams AL, Stockley H, Filobbos R, et al. A pictorial review of the imaging findings in abdominal tuberculosis. The International Society of Radiology website: http://www.isradiology.org/goed_tb_project/im-library/ECR2010_C-1658.pdf. March 2010. Accessed 9/9/15.

• Yang N. Pulmonary Tuberculosis. Radiopaedia website. http://radiopaedia.org/cases/pulmonary-tuberculosis-6. Accessed 9/10/15.

References

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Stanley Kim, MS-IV Gillian Lieberman, MD

Thank you to all the BIDMC faculty, residents, and staff who made this a wonderful rotation! A special thank you to: • Gillian Lieberman, MD and Katie Armstrong • Ronald Eisenberg, MD • Matt Miller, MD • Robert Pugatch, MD

Acknowledgements

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Stanley Kim, MS-IV Gillian Lieberman, MD