Radiology of Tuberculosis
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Radiology of Tuberculosis

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Collection of cases I saw during my residency.

Collection of cases I saw during my residency.

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Radiology of Tuberculosis Presentation Transcript

  • 1. 13th February, 2014 Radiology of Tuberculosis Mohit Goyal Under the guidance of: Sr. Prof. Dr. V.K. Goyal Department of Medicine, R.N.T. Medical College, Udaipur
  • 2. Radiology of Tuberculosis  Common Roentgenograms  Summary of Roentgenographic manifestations of TB  An extremely rare case  Some CT and MRI findings in TB
  • 3. Radiology of Tuberculosis XR01
  • 4. Presentation  This patient, a 32-year-old male presented with insidious onset, progressive, productive cough for 3 months; feverish feeling for a month and loosening of clothes over time.  Past history: No history of any other illnesses.  Over the counter medications taken on and off over the past month for cough and fever.  The patient had difficulty producing sputum for the examination. The sample mainly contained saliva and was found negative for AFB. The patient was referred to Dept. of TBCD. BAL sample was taken, subjected to microbiological examination and found positive for AFB. XR01
  • 5. Miliary shadows/mottling  Millet seed sized opacities ~ 2mm  Miliary densities are seen in: Miliary TB, Anthracosis, Sarcoidosis, Tropical eosinophilia, Fibrosing alveolitis, Allergic alveolitis, Histoplasmosis, Coccidioidomycosis, Blastomycosis, Cryptococcosis.  Pulmonary haemosiderosis and Silicosis are also seen as milliary mottling but the radiodensity is more than soft tissue.  Carcinomatosis, lymphoma and sarcoidosis have discrete but slightly larger shadows (> 2mm).  Some pneumonias, fat emboli and pulmonary oedema can present as shadows > 2mm that tend to coalesce.
  • 6. Metastasis from Papillary ca XR01 Miliary Tuberculosis
  • 7. Radiology of Tuberculosis XR02
  • 8. Presentation  This patient, a 23-year-old male presented with fever, productive cough and weight loss for one month.  Past history: No history of any other illnesses.  Over the counter medications taken over the past month for fever.  The patient’s sputum was sent for examination and found to be positive for acid fast bacilli. XR02
  • 9. Cavity  A gas containing space in the lungs surrounded by a wall whose thickness is >1mm.  In bullae, the wall thickness is <1mm.  Thin walled cavities may be seen in tuberculous cavity, infected bullae, staphylococcus, Klebsiella, post-traumatic cysts, Coccidioidomycosis, Mycobacterium kansasii infection, metastatic cavitating squamous cell ca of cervix.  Thick walled cavities may be seen in lung abscess, metastatic carcinoma, bronchogenic carcinoma, Wegener’s granulomatosis, fungal cavity, necrotising squamous cell carcinoma, Blastomycosis. XR02
  • 10. Cavity  The cavity wall is irregular or nodular in carcinoma, rugged or shaggy in acute lung abscess and smooth in other cavitating lesions.  Cavity with wall thickness <5mm is likely to be benign; 5-15mm may be benign or malignant and >15mm is likely to be malignant.  Lung abscess - superior segment of the lower lobe and axillary sub segments of anterior and posterior segment of the upper lobe.  Tubercular – superior segments of upper and lower lobes.  Klebsiella, SCC – upper lobes.  Cystic bronchiectasis, hydatid cyst – lower lobes Note: when a cavity in the anterior segment is encountered, strong suspicion for lung cancer should be raised.
  • 11. Radiology of Tuberculosis XR03
  • 12. Presentation  This patient, a 70-year-old male presented with insidious onset, progressive shortness of breath. No history of cough, expectoration.  Past history: Taken ATT 10 years back for pulmonary TB.  The patient’s sputum was sent for examination and was found to be negative for acid fast bacilli. CT imaging of thorax was planned but the patient refused. XR03
  • 13. Radiology of Tuberculosis XR04
  • 14. Presentation  This patient, a 60-year-old male presented with difficulty breathing, pain on the right side of chest and dry cough on and off.  Past history: Taken ATT 8 years back for pulmonary TB with possibly pleural effusion. Documents not available but the patient describes both parenchymal disease as well as pleural effusion.  The patient’s sputum was sent for examination and was found to be negative for acid fast bacilli. CT imaging of thorax revealed pleural thickening and calcification. There was not evidence of activity. XR04
  • 15. Radiology of Tuberculosis XR05
  • 16. Radiology of Tuberculosis XR05
  • 17. Presentation  This patient, a 20-year-old male presented with insidious onset, progressive shortness of breath for 2 months.  Past history: No history of any chronic illnesses.  Pleural fluid was sent for analysis. It was found to have 800 cells, with 90% lymphocytes. Proteins were 6 g% and the fluid was positive for ADA. Patient’s ESR was 63.  The patient’s sputum was sent for examination and was found to be negative for acid fast bacilli. XR05
  • 18. Radiology of Tuberculosis XR06
  • 19. Presentation  This patient, a 57-year-old male presented with acute onset shortness of breath.  Past history: Two years back he took ATT for 6 months.  Emergency management was done. The patient’s sputum was sent for examination and was found to be negative for acid fast bacilli. XR06
  • 20. Radiology of Tuberculosis XR07
  • 21. Presentation  This patient, a 40-year-old male presented with insidious onset, progressive edema and shortness of breath.  Past history: He was diagnosed to have pericardial effusion an year back, which was found to be tubercular, and he was given ATT for it.  The patient’s sputum was sent for examination and was found to be negative for acid fast bacilli.  ECHO revealed pericardial calcification, constrictive pericarditis. The patient was taken over by the Dept. of Cardio-Thoracic-Vascular surgery for further management. XR07
  • 22. Radiology of Tuberculosis XR08
  • 23. Radiology of Tuberculosis  Common Roentgenograms  Summary of Roentgenographic manifestations of TB  An extremely rare case  Some CT and MRI findings in TB
  • 24. Consolidation in primary infection  This may involve any part of the lung, and the appearance is nonspecific unless there is coincidental lymphadenopathy.  The area involved may be small or affect an entire lobe, and an air bronchogram may be visible. Occasionally consolidation appears as a well-defined nodule or nodules.  Healing is often complete without any sequelae on the chest radiograph although fibrosis and calcification may occur.  Tuberculous bronchopneumonia may occur in both primary and post-primary infection, causing patchy, often nodular, areas of consolidation.
  • 25. Consolidation in post-primary infection  This usually appears in the apex of an upper or lower lobe, and almost never in the anterior segments of the upper lobes.  The consolidation is often patchy and nodular and may be bilateral.  A minimal apical lesion can easily be overlooked because of overlapping shadows of ribs and clavicle. Comparison with the opposite side is then helpful, looking for asymmetries of density. The apical projection was designed to overcome this difficulty, but is rarely useful.  Progressive infection is indicated by extension and coalescence of the areas of consolidation, and the development of cavities.
  • 26. Consolidation in post-primary infection  Simultaneously there may be fibrosis and volume loss indicating healing.  Cavities may be single or multiple, large or small and thin or thick walled. Fluid levels are sometimes visible within cavities.  With fibrosis there is often obliteration of cavities; however, larger cavities may persist and areas of bronchiectasis and emphysema may develop. Healed lesions often calcify.  Because the upper lobes are predominantly involved, the effects of fibrotic contraction are seen as the trachea being pulled away from the midline, elevation of the hila and distortion of the lung parenchyma.
  • 27. Radiology of Tuberculosis XR02
  • 28. Miliary tuberculosis  This is due to haematogenous spread of infection and may be seen in both primary and post-primary disease. In the former the patient is often a child, and in the latter case the patients are often elderly, debilitated or immunocompromised.  At first the chest radiograph may be normal, but then small, discrete nodules, 1-2 mm in diameter, become apparent, evenly distributed throughout both lungs.  These may enlarge and coalesce, but with adequate treatment they slowly resolve. Occasionally, some may calcify.
  • 29. Radiology of Tuberculosis XR01
  • 30. Tuberculoma  This is a localized granuloma due to either primary or post-primary infection. It usually presents as a solitary well-defined nodule, up to 5 cm in diameter. Calcification is common but cavitation is unusual. Lymphadenopathy  Hilar and mediastinal lymphadenopathy is a common feature of primary infection and may be seen in the presence or absence of peripheral consolidation. Following healing, involved nodes may calcify. Lymphadenopathy is usually unilateral but may be bilateral where the differential diagnoses of lymphoma and sarcoidosis come in. It is often more pronounced in children.
  • 31. Pleural changes  Pleural effusion complicating primary infection is usually unilateral and due to subpleural infection. Pulmonary consolidation and/or lymphadenopathy may or may not be apparent.  At presentation the effusion may be large and relatively asymptomatic. These effusions usually resolve without complication.  Pleural effusion in post-primary infection, however, often progresses to empyema. Healing is then complicated by pleural thickening and often calcification. Uncommon complications of tuberculous empyema are bronchopleural fistula , osteitis of a rib, pleurocutaneous fistula and secondary infection. Previous thoracoplasty may also complicate the appearances.
  • 32. Radiology of Tuberculosis XR05
  • 33. Pleural changes  Pleural thickening over the apex of the lung often accompanies the fibrosis of healing apical tuberculosis. Pneumothorax may complicate subpleural cavitatory disease. Airway Involvement  This may be secondary to lymphadenopathy or endobronchial infection and may therefore complicate both primary and postprimary disease. Compression of central airways by enlarged nodes may cause pulmonary collapse or air trapping. Healing of endobronchial infection with fibrosis may result in bronchostenosis. The lung distal to bronchial narrowing may develop bronchiectasis.
  • 34. Radiology of Tuberculosis XR04
  • 35. Radiology of Tuberculosis  Common Roentgenograms  Summary of Roentgenographic manifestations of TB  An extremely rare case  Some CT and MRI findings in TB
  • 36. Radiology of Tuberculosis Rare Case
  • 37. Presentation  This patient, a 48-year-old male presented with insidious onset, progressive dysphagia for 5 months.  Past history: ATT taken 1 year back for pulmonary TB.  Endoscopic biopsy and CT thorax and abdomen were planned.  Biopsy examination revealed casseating epitheloid granuloma and positive acid fast staining.  The oesophagus was dilated and the patient has been put on ATT. Rare Case
  • 38. Radiology of Tuberculosis Rare Case
  • 39. Radiology of Tuberculosis  Common Roentgenograms  Summary of Roentgenographic manifestations of TB  An extremely rare case  Some CT and MRI findings in TB
  • 40. Radiology of Tuberculosis XR08
  • 41. CT08
  • 42. CT08
  • 43. CT08
  • 44. CT09
  • 45. Presentation  This patient presented with fever for one month, altered behavior for 3 days and loss of consciousness for 6 hours.  Past history: No history of any chronic illnesses.  CSF examination revealed 100 cells, mainly lymphocytes. Proteins were 6.4 g% and the fluid was positive for Adenosine deaminase. CT09
  • 46. CT09
  • 47. Neuroimaging findings in TB  Hydrocephalus – seen in 50-80% cases  Enhancement of basal meninges – 60%  Cerebral infarctions – 28%  Tuberculomas – 10%  Mass effects due to tuberculomas and abscess  Vasculitis  Thrombosis
  • 48. MR10
  • 49. MR10
  • 50. MR10
  • 51. MR10
  • 52. THANK YOU for the patience Acknowledgements:  Dept. of Radiodiagnosis, R.N.T. Medical College  Dr. Rambir Singh, MRI Centre, M.B. Govt. Hospital  Dr. Vinita Goyal, M.D. Radiodiagnosis Sources:  Harrison’s Principles of Internal Medicine  Textbook of Radiology and Imaging, David Sutton  Tuberculosis, Surendra K. Sharma Department of Medicine, R.N.T. Medical College, Udaipur