Radiology of pulmonary tuberculosis

1. Dr Hasna E
JR 3 Pulmonary medicine

2. Dr. B. Vidyasagar , Professor & Head of Department
Dr. Rajesh B.P. , Associate Professor
Dr. Akshay M.Hiremath , Associate Professor
Dr. Arjun H. , Associate Professor
Dr. Santhosh V.G. , Associate Professor
Dr. Nandish C. , Associate Professor
Dr. Adheep B.Amberker , Assistant Professor

3. Disease caused by M TB
in person with no
previous exposure

4. • CHEST XRAY
• ULTRASOUND
• CT SCAN
• MRI
• NUCLEAR IMAGING

5. MODALITY ADVANTAGES DISADVANTAGES
Radiography Inexpensive, easily
available
Radiation exposure
Low sensitivity and specificity
Ultrasonography Radiation
free,portable,guide pleural
sampling
Limited field of view
Computed
tomography
Excellent resolution, high
sensitivity, guide sampling
Radiation,iodinated,relatively
expensive
Magnetic resonance
imaging
Radiation free,Accurate for
lymphadenitis and
associated spinal disease
Expensive,CI,less accurate for
parenchymal lesions
PET CT/PET High sensitivity Low specificity,radiation
exposure

6.  TYPICAL RADIOLOGRAPHIC PATTERN OF PRIMARY TUBERCULOSIS
 POST PRIMARY TUBERCULOSIS
 COMPLICATION OR SEQUEALE OF TB
 ATYPICAL PATTERNS

7. Radiological Features of primary TB
 Lymphadenopathy
 Parenchymal consolidation
 Tuberculoma
 Miliary Tb
 Pleural Effusion
 Airway involvement
Commonly in children
Structure involved –Lymphnode ,Pulmonary parenchyma ,pleura,
Tracheobronchial tree

8. 83-96% pediatric cases.
10-43% adults.
m/c site Right paratracheal and Hilar region.
WHY RIGHT SIDED?
In a study -Subcarinal>hilar>anterior mediatinum>
precarinal>Right paratracheal.
B/L lymphadenopathy 31%cases
CT higher sensitivity >CXR
Lymphnode >1cm in SAD considered enlarged.
LYMPHADENOPATHY

9. Stage Of Lymphoid
Hyperplasia
Homogeneous Enhancement
Stage Of Caseous Necrosis Heterogeneous Enhancement With Small Necrotic Area In Early
stage
Peripheral Thin Rim Enhancement With No Central
Enhancement
Stage Of Periadenitis Peripheral Irregular Enhancement With Central Non
Enhancement with clear surrounding fat plane
Stage Of Liquefaction Peripheral Rim Enhancement With Central Enhancement and
obliterated surrounding fat plane
pretracheal Hilar and subcarinal

10. 1 Homogeneous Enhancement
2 Inhomogeneous with strong peripheral enhancement
3 No contrast enhancement
Mediastinal and hilar lympahdenopathy
Hilar and subcarinal

11. • Lymphnode +Draining lymphatics
called Primary complex.
• Subpleural lesion-middle portion
of lung
• Upper region of lower lobe,
lower portion of middle
lobe(Right side)
PARENCHYMAL LESION

12. GHONS focus +enlarged or calcified lymphnode.

13. • Small round/oval opacity in primary and postprimary tb
• Seen in 7-9% patients
• 0.5 to 4cm diametre
• seen commonly -Upperlobe right side
• Satellite lesion in 80 %cases

14. • Primarily seen in primary tb,although may be seen in post primary
• Innumerable 2mm or less non calcified nodules scatttered throughout lung
• Mild basilar preponderance.
• Coalesce -Snowstorm apparence(3-5mm)
• HRCT more sensitive .

15. PLEURAL INVOLVEMENT IN TB
PLEURAL EFFUSION
• Uncommon in primary TB
• Develops same side of initial TB
• Bilateral effusion 12% cases
• USG
Pleural effusion can be quantified,evaluation of septations,sampling
10 ml

16. Unilateral >90% cases
Smallto moderate in size
10% case Large effusion
CT more sensitive
Pleural based nodules identified-Pseudotumour

17. Enhancement of thickened inner
visceral and outer parietal pleura
with separation by pleural fluid
SPLIT PLEURA SIGN
TB EFFUSION fail to resolve
Chronic suppurative form
Fibrous scar tissue

18. Occur in chronic cases
Usually occur as result of fibrin deposition causing thickening ,adhesion and
calcification.

19. • Can be extrinsic due to compression by enlarged lymphnode
• Lymphnode compression leads to atlectasis or hyperinflation.
• Occurs –level of lobar bronchus or bronchus intermedius
• Anterior segment of UPPER LOBE OR MEDIAL SEGMENT OF MIDDLE LOBE
Intrinsic by endobronchial spread

20. FEATURES OF ACTIVE TB ON CT
Centrilobular nodules
Lobular consolidations
Cavitations
Bronchial wall thickening
Necrotic mediastinal and hilar lympahdenopathy
Pleural Effusion

21. • Predilection of apical and posterior segment of upper lobe
superior segment of lower lobes
• Rarity of lymphadenopathy.
• Propensivity for calcification.

22. Cavitation
Local exudative lesion
Local fibroproductive lesion
Tuberculoma
Bronchogenic spread
Miliary tb
Bronchostenosis
Pleural disease

23. m/c lesion focal or patchy heterogenous consolidation involving apical or posterior
segment of UL or superior segment of LL
• Poorly defined Nodules
• Cavitation 45% cases
• Lobar or total lung consolidation.

24. Healing –replacement of TB granulation tissue by fibrous tissue
Fluffy opacity
well defined reticular and nodular opacity

25. Occurs when area of caseation necrosis liquefies.
Cavity in 40-45 % patients.
Wall of cavity ----thin and smooth
----Nodular
Air fluid level are uncommon in TB
MYCETOMA –intracavitary fungal ball

26. occurs in 95% cases
due to communication to tb cavity or
intrabronchial rupture.
• TREE IN BUD appearance
• Acinar nodule-5mm

27. • Direct extension from adjacent parenchyma.
• Occurs due to cavitation,lymphnode erosion,hematogenous spread, extension
due to the peribronchialregion.
Sub mucosal site of
infection
Ulcerations
Heals by fibrosis
with circumferential
stenosis

28. Parenchymal Complication
Airway Complication
Pleural Complications
Vascular Complications
Mediastinal Complications
Chest Wall Complications

29. Can occur
• consequence of cicatrization of
Previous active tb cavity after therapy
• sequeale of ARDS

30. Ectatic bronchus or residual tb cavity colonised by
Aspergillus species.
CT-Mobile intracavitary nodule or mass surrounded
By air

31. Characterised by artitectural distortion,calcification
Retraction of adjacent parenchyma

32. Occur in severe TB
MILIARY TB OR TB BRONCHOPNEUMONIA
Predisposing factors-Malnutrition,Alcoholism,diabetes mellitus,Immunosuppressive
therapy,HIV infection, Pregnancy

33. BRONCHIECTASIS
Due to destruction and fibrosis of lung
parenchyma result in retraction and
irreversible bronchial dilatation

34. BRONCHOLITH BRONCHOSTENOSIS
Endogenous Calcified material Chronic narrowing of bronchus

36. Empyema communicate with bronchial tree by bpf and shows air fluid level

38. Pseudoaneurysm
Weakening of pulmonary artery wall by adjacent Cavitary TB
AIR CRESCENT on cxr
CTPA confirm diagnosis

39. Soft tissue encasing major vessels and airway

40. Pleural collection track exteriorly through chest wall

41. Atypical findings
Early stage-Typical post primary TB with upper lobe infiltrates
Late stage-Noncavitatory,lower lobs infiltrates,Hilar adenopathy,pleural effusion

42. Coexist with extensive pulmonary parenchymal or intrathoracic lymphnode infection.
10-20% have Normal Chest Xray

43. Refers to imaginary horizontal line traced across hilum includes parahilar region.
Includes middle lobe and lingula with lower lobes.
Large cavities 3-4 cm.
 Pt receiving corticosteroids
 Hepatic /Renal disease
 DM
 Pregnancy
 HIV

44. Silicosis-Pneumoconiosis caused by inhalation of silica
Coexistance of TB AND SILICOSIS called silicotuberculosis
3-7% increased incidence of TB in person with silicosis.

45. FIBROTIC MASS

46. Primary TB –M/C form in children
Lymphadenopathy –mayb only feature in primary TB
Cavity less common in children

48. Newer imaging modality
Quantifiable-Amount of radiation depends on rate of metabolic activity
Non invasive
Appear as focal increase in FDG uptake
Can detect early response of treatment by quantitative reduction in FDG
uptake.