DR WASEEM M.NIZAMANIMBBS,FCPS,EDIR (EUROPEAN BOARD)

CONSULTANT RADIOLOGISTZIAUDDIN UNIVERSITY HOSPITAL

KARACHI

Radiology in Pulmonary Tuberculosis

ROLES

FORINITIAL DIAGNOSISFOLLOW UPTREATMENT RESPONSECOMPLICATIONS SEQUELAE

RADIOLOGICAL MODALITIES

X-RAYSWELL KNOWNULTRASOUNDLIMITED ROLECT SCANWELL ESTABLISHED MAGNETIC RESONANCE IMAGING(MRI)LIMITED ROLE

INTERVENTIONAL RADIOLOGYLIMITED ROLENUCLEAR IMAGINGLIMITED ROLE Gallium-67 citrate, Indium-111–labeled white blood cell

scintigraphy, and fluorodeoxyglucose (FDG-PET)

EPIDEMIOLOGY

There has also been an increase in global prevalence, particularly in immuno-compromised patients, with a rate of increase of approximately 1.1% per year.

This increase has been seen not only in Africa and Asia, but also in Europe.

Early diagnosis promotes effective treatment and is, therefore, essential.

CATEGORIES

PRIMARY TUBERCULOSIS

POST PRIMARY TUBERCULOSIS

Primary Tuberculosis

Primary tuberculosis is seen in patients not previously exposed to M tuberculosis.

It is most common in infants and children and has the highest prevalence in children under 5 years of age.

Primary Tuberculosis

At radiology, primary tuberculosis manifests as four main entities:

1. Parenchymal disease, 2. Lymphadenopathy, 3. Miliary disease, and 4. Pleural effusion.

Parenchymal primary tuberculosisin an adult. Radiograph of the leftlung demonstrates extensive upper lobeand lingular consolidation.

Lymphadenopathy in a patient with primary tuberculosis. Chest radiograph shows a bulky left hilum and a right paratracheal mass,findings that are consistent with lymphadenopathy and are typical inpediatric patients.

A radiologic scar pers- ists that can calcify in

up to 15% of cases, an entity that is known as a Ghon focus.

Lymphadenopathy

Lymphadenopathy is seen in up to 96% of childrenand 43% of adults.

Lymphadenopathy is typically unilateral and right sided, involving the hilum and right paratracheal region

Lymphadenopathy

It can be the sole radiographic feature, afinding that is more common in infants

The combination of calcified hilarnodes and a Ghon focus is called a Ranke

complexand is suggestive of previous tuberculosis,

Miliary Disease

It is usually seen in the elderly, infants, and immunocompromised persons, manifesting within 6 months of initial exposure.

Chest radiography is usually normal atthe onset of symptoms

Miliary Disease

The classic radiographic findingsof evenly distributed diffuse small 2–3-mmnodules, with a slight lower lobe

predominance,are seen in 85% of cases.

Pleural Effusion

The effusion is often the sole manifestation of tuberculosis and usually manifests 3–7 months after initial exposure.

The effusion is usually unilateral, and complications

(eg, empyema formation, fistulization, bone erosion) are rare.

Post Primary TB

Postprimary tuberculosis is progressive, with cavitation as its hallmark,

1. Predilection for the upper lobes 2. The absence of lymphadenopathy 3. Cavitation.

ULTRASOUND

Ultrasonography is considered as gold standard for the diagnosis of pleural effusion

Blunting of CP angle is demonstrated on Xray after collection of 175 mls on PA and 75 mls on Lateral projection

On ultrasound 10 mls pleural effusion can be easily diagnosed

(US) often demonstrates a complex septated effusion in empyema and hemothorax

CT SCAN

CT is more sensitive than conventional radiography,

with nodules seen in a random distribution.

Any nodes greater than 2 cm in diameter generally

have a low-attenuation center secondary tonecrosis at CT and are highly suggestive of

activeDisease. CT is more sensitive than chest

radiography for assessing lymphadenopathy.

PATTERNS

Tuberculous empyema. Computed tomographic scan showing loculated pleural fluid and pleural thickening(arrow) in the right chest with associated right lower lobe atelectasis.

Some HRCT patterns.

(A) Large nodule; (B) Micronodule; (C) Tree-in-bud pattern; (D) Centrilobular nodule.

ATYPICAL PRESENTATIONS

CASE 1:

Diabetic tuberculous patient

LATERAL VIEW shows lesions and a cavity in the left lower lung field.

In this patient, the cavity is easily missed on PA VIEW and only observed over the lower vertebral shadows on the LATERAL view

In a number of published comparative studieschest X-ray images from DM patients have beendescribed as ‘atypical’, mainly because they frequently involve the lower lung fields, often with cavities.

**Atypical radiological images of pulmonary tuberculosis in 192 diabetic patients.2001

CASE 2Tuberculosis in 4-year-old girl. Patient presented with shortness of breath

and clinically suspected for foreign body in right bronchus.

Triangular opacity in right lower zone sillhouting right hemidiaphragm suggestive of right lower-lobe collapse.

shift of upper mediastinum to right.

CT scan showed right lower lobe collapse and mediastinal lymphadenopathy. Patient responds well with ATT

Case 3

Patient presented with atypical opacities on CXR.

No occupational historyNo exposure

CONFUSIONS?

WHICH ONE IS TUBERCULOSIS????