Pulmonary TB
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Transcript of Pulmonary TB
بسم الله الرحمن الرحيم
Introduction
Up until the mid 1980s, there was a steady decline in the prevalence of T.B.Since then, there has been a resurgence of T.B. due to AIDS epidemics
Increasing no. of resistant strains of mycobacterium T.B.
Groups of increased risk e.g. poor, alcoholics, homeless
Why is T.B. still considered a major issue?
T.B remains the major cause of death from a single infectious agent among adults in developing nations.
In 1993, the WHO declared T.B to be a global emergency.
It is estimated that between 1997-2020, nearly 1 billion people will become newly infected and 70 x 106
will die from the disease (WHO, 1998)
Primary Post primary (reactivation
)There is considerable overlap in radiologic manifestations of these 2 entities.Results of radiography may be normal in 15% of cases
Primary T.B.
Lymphadenopathy
Radiology of Primary T.B.
Parenchymal disease
Pleural effusion
Miliary T.B
Is the radiological hallmark of the disease
Radiology of Primary T.B.1) Lymphadenopathy:
83-96% of pediatric cases
Is the radiological hallmark of the disease
Radiology of Primary T.B.1) Lymphadenopathy:
hilar lymphadenopathy
Is the radiological hallmark of the disease
Radiology of Primary T.B.1) Lymphadenopathy:
83-96% of pediatric cases
Prevalence with age
Rt. paratracheal + hilar stations are most common sites
Is the radiological hallmark of the disease
Radiology of Primary T.B.1) Lymphadenopathy:
hilar lymphadenopathy
Is the radiological hallmark of the disease
Radiology of Primary T.B.1) Lymphadenopathy:
83-96% of pediatric cases
Prevalence with age
Rt. paratracheal + hilar stations are most common sitesCT has a characteristic appearance
Is the radiological hallmark of the disease
Radiology of Primary T.B.1) Lymphadenopathy:
PrecontrastPostcontrast
Is the radiological hallmark of the disease
Radiology of Primary T.B.1) Lymphadenopathy:
83-96% of pediatric cases
Prevalence with age
Rt. paratracheal + hilar stations are most common sitesCT has a characteristic appearance
D.D.: 1- Metastases2- Lymphoma3- other infections e.g. 4- Sarcoidosis
- Varicella pneumonia
- histopalmsmosis
Radiology of Primary T.B.2) Parenchymal disease:
Affects areas of greatest ventilation upper lobe
38-81% of adult cases
Rt. Sided predominance
Homogenous consolidation in segmental or lobar pattern
Radiology of Primary T.B.2) Parenchymal disease:
Para.T LN
Displaced OF
consolidation
hilar LN
consolidation
Radiology of Primary T.B.2) Parenchymal disease:
Affects areas of greatest ventilation, middle & lower lobes & anterior segment of upper lobe
38-81% of adult cases
Rt. Sided predominance
Homogenous consolidation in segmental or lobar patternTuberculoma
- Round or oval sharply marginated- 0.5- 4 cm- + calcifications- Surrounding satellites
Radiology of Primary T.B.2) Parenchymal disease:
nodule
nodule
nodule
DD: Nodule
1. Tuberculoma2. Hamartoma3. Metastases4. Hydatid
Radiology of Primary T.B.2) Parenchymal disease:
Affects areas of greatest ventilation, middle & lower lobes & anterior segment of upper lobe
38-81% of adult cases
Rt. Sided predominance
Homogenous consolidation in segmental or lobar patternTuberculomaObstructive atelectasis 2ry compression of adjacent enlarged LN
Radiology of Primary T.B.2) Parenchymal disease:
cavityLNs
collapse
Displaced OF LNs
collapse
Radiology of Primary T.B.3) Pleural effusion:
Unilateral
hilar LNs
pleural effusion
pleural effusion
Enhancing parietal pleura
Radiology of Primary T.B.4) Miliary T.B.:
Innumerable 1-3 mm, non-calcified nodules scattered through both lung fields with basal predominance
High resolution CT.
Exclusively a disease of adolescens + adults
Post Primary T.B.
Results from
Radiological features:
10%
Reactivation of a previously dormant 1ry infection
Continuation of 1ry disease
90%
1- Parenchymal disease with cavitation2- Air way involvement3- Pleural extension 4- Complications Endo bronchial spread
Aspergilosis
Radiology of Post Primary T.B.1) Parenchymal disease :
Predilection
Consolidation: Patchy, ill-defined, segmental
* to upper lobes
a- O2 tensionb- Impaired lymphatic drainage
* Apical segment of lower lobe
Tw0 or more segments are involved in most of casesBilateral upper lobe disease may be present
Cavitations: • Multiple with thick irregular walls• May show air fluid level
Radiology of Post Primary T.B.1) Parenchymal disease with cavitations:
Cavitary postprimary TB
thick-walled cavity
Radiology of Post Primary T.B.1) Parenchymal disease with cavitation:
cavitynodule
cavity
air-fluid level
Radiology of Post Primary T.B.1) Parenchymal disease with cavitations:
Predilection
Consolidation: Patchy, ill-defined, segmental
* to upper lobes
a- O2 tensionb- Impaired lymphatic drainage
* Apical segment of lower lobe
Tw0 or more segments are involved in most of casesBilateral upper lobe disease may be present
Cavitations:•Multiple with thick irregular walls•May show air fluid level
Radiology of Post Primary T.B.1) Parenchymal disease with cavitation:
air-fluid level
Thick walled cavity
Radiology of Post Primary T.B.2) Air way involvement:
Bronchial stenosis
CollapseConsolidation
Hyperinflation
due to 1- direct extension from TB LN2- Endobronchial spread of infection3- lymphatic dissemination to the airway
Radiology of Post Primary T.B.2) Air way involvement:
Tuberculous bronchostenosis.
narrowing
Radiology of Post Primary T.B.2) Air way involvement:
Tuberculous broncholithiasis
partial atelectasis
calcified LN
calcified LN
Eroding into bronchuscalcified LN
calcified LN
Radiology of Post Primary T.B.2) Air way involvement:
D.D.
1- Longer segment of involvement2- Circumferential luminal narrowing3- No intraluminal mass
Carcinoma
} TB
Radiology of Post Primary T.B.3) Pleural extension: Pleural effusion
Small associated with parenchymal disease
Empyema loculated
Subpleural cavitation
Air fluid level in pleura = bronchopleural fistula
Radiology of Post Primary T.B.3) Pleural extension: Pleural effusion
TB empyema with bronchopleural fistula
Subpleural cavitating nodule
bronchusair
Enhancing pleura
Radiology of Post Primary T.B.4) Complications:If left untreated disease progress to
Lobar or complete lung opacification + destruction
Lung destruction in postprimary TB
bronchiectatic changes
bronchiectatic changes
Radiology of Post Primary T.B.4) Complications:If left untreated disease progress to
Lobar or complete lung opacification + destruction
Coarse reticular + nodular opacified areas fibroproliferative dse
Radiology of Post Primary T.B.4) Complications:
Fibroproliferative disease.
Cavitating nodule
volume loss + apical pleural
thickening
reticulonodular infiltrates
Radiology of Post Primary T.B.4) Complications:If left untreated disease progress to
Lobar or complete lung opacification + destruction
Coarse reticular + nodular opacified areas fibroproliferative dseHealing of lesions traction bronchiactasis
Radiology of Post Primary T.B.4) Complications:
fungal ball
Complications of childhood TB
bronchiectasis
Bronchiectasis in postprimary TB.
bronchiectasis
Radiology of Post Primary T.B.4) Complications:If left untreated disease progress to
Lobar or complete lung opacification + destruction
Coarse reticular + nodular opacified areas fibroproliferative dseHealing of lesions traction bronchiactasis
Endobronchial spread commonest complication of T.B cavitation
Radiology of Post Primary T.B.4) Complications:
Cavitary postprimary tuberculosis
LN
endobronchial spread
cavity
cavities
tree-in-bud”
Radiology of Post Primary T.B.4) Complications:If left untreated disease progress to
Lobar or complete lung opacification + destruction
Coarse reticular + nodular opacified areas fibroproliferative dseHealing of lesions traction bronchiactasis
Endobronchial spread commonest complication of T.B cavitationSmall, poorly defined centrilobular nodules +
branching centrilobular areas of increased opacity “tree-in-bud” appearance
Radiology of Post Primary T.B.4) Complications:
Endobronchial spread of tuberculosis
bronchiolar wall thickening
tree-in-bud
Radiology of Post Primary T.B.4) Complications:If left untreated disease progress to
Lobar or complete lung opacification + destruction
Coarse reticular + nodular opacified areas fibroproliferative dseHealing of lesions traction bronchiactasis
Endobronchial spread commonest complication of T.B cavitationMycetomaAspergillus superimposed infection
Radiology of Post Primary T.B.4) Complications:
Complications of childhood TB
nodule in the cavity
Radiology of Post Primary T.B.4) Complications: Cavitary TB associated with aspergilloma
Post primary TB
air crescent sign
aspergilloma
aspergilloma
air crescent sign
Radiology of Post Primary T.B.4) Complications:If left untreated disease progress to
Lobar or complete lung opacification + destruction
Coarse reticular + nodular opacified areas fibroproliferative dseHealing of lesions traction bronchiactasis
Endobronchial spread commonest complication of T.B cavitationMycetomaBroncholithiasisCalcified T.B LN in the mediastinum may occasionally erode into adjacent airway.
Radiology of Post Primary T.B.4) Complications:
calcified LN
calcified LN
Eroding into a bronchus
Tuberculous broncholithiasis
Can X-ray D.D. active / inactive T.B?
1-D.D can be reliably made on basis of temporal evolution i.e. lack of radiographic change over 4-6 months.Thus radiology can say that the dse. is stable rather than inactive .
2-Fibrosis +calcification are found in both healed + active disease
Can X-ray D.D. active + inactive T.B? Sputum culture–positive TB
Close-up radiographic view CT scan with 1-mm collimation
retroclavicular calcifications
calcified nodules
Fibrosis +calcification are found in both healed + active dse
Fibrosis
Fibrosis
Can X-ray play role in assessing treatment response?
Postprimary TB Pre-Treatment 3 months Post- treatment
confluent consolidation
nodules
Regression of radiographic abnormalities in pulmonary TB is a slow process
Can X-ray play role in assessing treatment response?
1st 3 months of treatmentWorsening of X-Ray findings : - Progress of parenchymal involvement-development or enlargement of LN
cause
Unknown , may be due to: development of hypersensitivity reaction 2-10 weeks after initial infection
Can X-ray play role in assessing treatment response?
1st 3 months of treatmentworsening of the radiographic findings i.e. extension of parenchymal involvement +development or enlargement of LN
6m-2 years of treatmentresolution of parenchymal abnormalities on X-ray this is seen earlier on CT (15 months)
Failure of improvement of radiographic findings after 3 months of treatmentdrug resistant
organismsuperimposed infection
2ry to
Characterized by
1.Pleural disease +empyema2.Haematogenous spread of
disease
1.Destruction of bone or costal cartilage2.Soft tissue masses may show
calcifications + rim enhancement3.Fistulation
TB of the sternoclavicular J
Clavical with irregular margin
soft-tissue mass
Rarely involves the heartTuberculoma of the Rt atrium in a patient with miliary T.B.
mass
pleural effusion
MRI-Axial T2WI
Rarely involves the heart
Pericardial involvement may be seen with mediastinal + pulmonary TB
Tuberculous pericarditis in a patient with pleuropulmonary T.B.
pericardial thickening
tuberculomapleural effusion
Axial CT scan
Spine is the comment site of osseous involvement in T.B
T.B. spondylitis (Pott’s disease):
Upper lumbar + lower dorsal are most frequently involvedVertebral body is more commonly affected than post. elementsDisease process begins in ant. part of the vertebral bodyinfection spread to disc space by
extension beneath the ant./
post. L. L.
or
penetration of subchondral bone
plateCollapse of
disc
Spine is the comment site of osseous involvement in T.B
T.B. spondylitis (Pott’s disease):
Upper lumbar + lower dorsal are most frequently involvedVertebral body is more commonly affected than post. elementsDisease process begins in ant. part of the vertebral bodyDisease progression vertebral collapse
T.B. spondylitis (Pott’s disease):
Tuberculous spondylitis. Lateral radiograph
Obl
itera
ted
disk
spa
ce
Destructed end plates
Spine is the comment site of osseous involvement in T.B
T.B. spondylitis (Pott’s disease):
Upper lumbar + lower dorsal are most frequently involvedVertebral body is more commonly affected than post. elementsDisease process begins in ant. part of the vertebral bodyDisease progression vertebral collapse
with ant. wedging gibbus deformity Extension may be subligamentous to distant vertebra
T.B. spondylitis (Pott’s disease):
Subligamentous spread of spinal T.B. Lateral radiograph
erosion
Spine is the comment site of osseous involvement in T.B
T.B. spondylitis (Pott’s disease):
Upper lumbar + lower dorsal are most frequently involvedVertebral body is more commonly affected than post. elementsDisease process begins in ant. part of the vertebral bodyDisease progression vertebral collapse
Paravertebral abscess In the thoracic region =Post.mediastinal mass
T.B. spondylitis (Pott’s disease):
Tuberculous spondylitis. Axial CT scan
lytic destruction
soft-t
issue absc
ess
Spine is the comment site of osseous involvement in T.B
T.B. spondylitis (Pott’s disease):
Upper lumbar + lower dorsal are most frequently involvedVertebral body is more commonly affected than post. elementsDisease process begins in ant. part of the vertebral bodyDisease progression vertebral collapse
Paravertebral abscess In the thoracic region =Post.mediastinal muscles
In the lumbar region =Psoas abscess
T.B. spondylitis (Pott’s disease):
Iliopsoas abscess. Axial CT scan
absc
esse
sabscesses
presacral abscess
erosion
Spine is the comment site of osseous involvement in T.B
T.B. spondylitis (Pott’s disease):
Upper lumbar + lower dorsal are most frequently involvedVertebral body is more commonly affected than post. elementsDisease process begins in ant. part of the vertebral bodyDisease progression vertebral collapse
Paravertebral abscess In the thoracic region =Post.mediastinal muscles
In the lumbar region =Psoas abscess
may calcify when healed
T.B. spondylitis (Pott’s disease):
Calcified psoas abscess. Axial CT scan
abscesses +
calcificationabscesses +
calcification
Spine is the comment site of osseous involvement in T.B
T.B. spondylitis (Pott’s disease):
Upper lumbar + lower dorsal are most frequently involvedVertebral body is more commonly affected than post. elementsDisease process begins in ant. part of the vertebral bodyDisease progression vertebral collapse
Paravertebral abscess
MR helps in diagnosis =focal area of low T1 + high T2 SI with increased SI of
disc
T.B. spondylitis (Pott’s disease):
Tuberculous spondylitis. Sagittal T2WI
disk
nar
row
ing intraspinal
extension
D.D.
1- Pyogenic vertebral osteomyelitis2- Metastases3- Sarcoid4- Tumor = lymphoma, multiple myeloma, chordoma5- Other infections = brucellosis, fungus, hydatid