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TBC niños CT 1996


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TBC niños CT 1996

  1. 1. PulmonaryTuberculosis in Children: Evaluation with CT Woo Sun Kim1 OBJECTIVE. The purpose of our study was to describe the CT findings of pulmonary Woo Kyung Moon1 tuberculosis in children and to define indications for the use of CT. In-One Kim1 MATERIALS AND METHODS. CT findings in 41 consecutive children with con- Hoan Jong Lee2 firmed tuberculosis were retrospectively analyzed by two radiologists. Chest radiographs and medical records were also reviewed to determine whether additional information provided by Jung-Gi 1m1 CT scans had altered clinical management of the disease. Kyung Mo Yeon1 RESULTS. Mediastinal and hilar lymphadenopathy was seen in 34 patients (83%). In 29 Man Chung Han1 of these patients, enlarged nodes had low-attenuation centers and enhancing rims. In the five other patients, enlarged nodes had calcification. Segmental (n = 12) or loban (ii = 8) air space consolidation was seen in 20 patients (49%), nodules of bronchogenic spread were seen in 12 patients (29%), and miliary nodules were seen in seven patients (17%). Bronchial (ii = 15), pleural (n = 7), pericardiac (n = 1), or chest wall (n = I ) complications of tuberculosis were seen in 22 patients (54%). In eight (20%) of 41 patients, a diagnosis of tuberculosis was sug- gested only on CT scans, which revealed low-attenuation nodes with rim enhancement, calci- fications, and nodules of bronchogenic spread or miliary nodules. These findings were not seen on chest radiographs. In 15 patients (37%), CT scans provided information that altered clinical management. Also, two of these patients underwent surgery because of pleural and chest wall complications that were seen only on CT scans. CONCLUSION. Mediastinal or hilar lymphadenopathy revealed as low-attenuation nodes with rim enhancement or calcification was the most characteristic CT finding of pul- monary tuberculosis in children. CT can be useful when tuberculosis or its complications are suspected in children and the radiographic findings are normal on inconclusive. T ubenculosis cause of morbidity remains an and important mortality chymal graphic lesion finding being the most [4-7]. This common combination radio- is worldwide. Fueled by the worsen- helpful diagnostically when it occurs; how- ing HIV epidemic, homelessness, drug abuse, even, some children do not have these find- and immigration, the incidence of tuberculosis ings. Lymphadenopathy without pulmonary in Western countries has increased dnamati- infiltration can be seen in infants and children Received May 20, 1996; accepted after revision cally. Children represent one of the high-risk with AIDS. Chest CT findings and their role October 2, 1996. groups in the resurgence of this disease [ 1-3]. in managing patients with pulmonary tubencu- 1 Department of Radiology, Seoul National University Because bacteriologic confirmation is difficult losis have been described mainly in adults College of Medicine, 28 Yongon-Dong, Chongno-Gu, Seoul to obtain in children, a plain radiograph along with postprimary tuberculosis [8-1 1]. 110-744, Korea. Address correspondence to W. S. Kim. with contact screening and the tuberculin skin We retrospectively reviewed the chest CT 2Department of Pediatrics, Seoul National University test are integral ingredients in the early diagno- scans, chest radiographs, and medical records College of Medicine, Seoul 1 10-744, Korea. sis of tuberculosis in children. in a series of patients with primary tuberculosis AJR 1997;168:1005-1009 Most tuberculosis cases in children are to describe the CT findings of pulmonary 0361-803X/97/1 684-1005 related to primary infection and mediastinal or tuberculosis in children and to define the use of © American Roentgen Ray Society hilar lymphadenopathy, with a focal paren- CT in children with pulmonary tuberculosis. AJR:168, April 1997 1005
  2. 2. Kim etal. Materials and Methods ease causes were ruled out and the subsequent clini- paratracheal nodes were involved in 30 During a 6-year period (1989-1994). 41 consec- cal course was consistent with tuberculosis, or an patients, followed by the right hilar nodes in utive patients with bacteriologically or clinically adult with contagious disease caused by M. tuber- 29 patients. the left hilar nodes in 14 patients, confirmed tuberculosis were studied with CT scans cul#{252}sis as discovered. w and the subcarinal nodes in 13 patients. Multi- and chest radiographs. The study group included 29 CT scans were obtained with a CTTT-9800 scan- ple nodal involvement was seen in 32 boys and 12 girls who were 3 months to 14 years ner or a HiSpeed Advantage System (General Elec- patients; however, two patients had only a sin- old (mean age. 6 years old). Eight patients (20%) tric Medical Systems. Milwaukee. WI) at 1(X) mA. 120 kVp, and 1- to 2-sec scan time. In routine scan- gle nodal lesion. In three patients, lymphaden- were less than 2 years old. 13 patients (32%) were ning. contiguous 5- to 10-mm-thick sections after an opathy was seen without a concomitant between 2 and 5 years old, 13 (32%) patients were IV bolus injection of contrast media were taken from parenchymal lesion. On enhanced CT scans, between 5 and 10 years old. and seven (17%) patients were 10 and I 5 years between old. No the lung apex to the diaphragm. In 14 patients, a enlarged nodes with low-attenuation centers patients with AIDS were included in the study. high-resolution CT scan with 1 .5-mm-thick sections and peripheral enhancement were seen in 29 A CT scan was obtained 1-10 days (mean, 5 were obtained at 5- to 10-mm intervals. 280 mA, 120 of 34 patients (85%) (Fig. I ). In five patients, days) after chest radiography for one or more of the kVp. and I -sec scan time and processed with an calcification was seen within the enlarged following reasons: to find or to confirm lymphaden- edge-enhancing algorithm. In all patients, the poster- nodes. Three of them had taken antitubercu- opathy or a parenchymal lesion when radiographs oanterior and lateral chest radiographs were available bus therapy for 4-9 months. On chest radio- were inconclusive, to evaluate unusual presenta- and obtained at 55-77 kVp. High-kilovoltage filtered graphs, the enlarged lymph nodes were tions such as a masslike lesion or widespread dis- images were also available for 10 patients. CT scans and chest radiographs were analyzed difficult to identify in seven patients, and cal- ease, to detect or evaluate a complication such as separately by two independent radiologists with cification of the nodes was missed in three of bronchial or pleural tuberculosis. and to evaluate regard to lymphadenopathy and parenchymal. bron- five patients. the aggravation or incomplete resolution of the dis- ease despite antituherculous therapy. In I 3 patients chial, pleural. pericardiac, and chest wall lesions. Parenchymal lesions were seen in 31 (32%), a CT scan was obtained before the diagnosis When observers differed, they came to a mutual patients. and 20 patients (49%) had segmental of tuberculosis. In 1 8 patients (44%). a CT scan was agreement. The results of the CT scans and chest (ii = I 2) or lobar (ii = 8) air space consolida- obtained 1-54 weeks (mean. 3 weeks) after com- radiographs were then compared side by side and tion. Air space consolidation was most fre- mencement of antituberculous therapy. with the knowledge of the clinical diagnosis to see quently seen in the right lower lobes (ii 6) The diagnosis was established by positive cul- the additional diagnostic contributions of CT. Med- and in anterior segments of the right upper ture. staining of sputum. or gastric aspirates for ical records were also reviewed to see in how many lobes (ii = 6). The consolidation was well- acid-fast bacilli in 21 patients (51%) and by biopsy instances and in what circumstances the additional defined and homogeneous in I 4 patients; how- in I I patients (27%): surgical biopsy in six. pleural information provided by CT altered the clinical management of the disease. ever, in five patients with lobar consolidation, biopsy in three. and bronchoscopic biopsy in two. multifocal low-attenuation areas were seen Mvcobacteriuin tuberculosis was isolated in eight patients. In the remaining nine patients (22%), two within consolidation (Fig. I ). In six patients, Results calcifications were seen within consolidation. of three criteria were met: a tuberculin skin test with 5 TV of purified protein derivative resulted in an Mediastinal and hilar lymphadenopathy Two of the patients had a history of antituber- area of induration of 10 mm or greater, other dis- was seen in 34 patients (83%). The right culous therapy for 6 and I 2 months. Cavitation Fig. 1.-Pulmonary tuberculosis causing lymphadenopathy and lobar consolidation in 2-year-old boy. A, Plain radiograph shows bulging of upper mediastinum (arrow) and consolidation in right lower lobe of lung. B, CT scan obtained 3 days after A shows right paratracheal lymphadenopathy with central low attenuation and peripheral rim enhancement (arrowheads). C, CT scan obtained during same study as B shows dense air space consolidation of right lower lobe that contains spots of calcification and multifocal low-attenuation areas (arrows). 1006 AJR:168, April 1997
  3. 3. CT of Pulmonary Tuberculosis in Children of pneumonic consolidation was seen in three calcification of the parenchymal lesion was seven patients (17%), and in four of these infants, and in one of these patients, the necro- missed in four of six patients. patients, dense air space consolidation and sis progressed to extensive bilateral bullous Foci of nodular densities. from I mm to 2 atelectasis were combined. High-resolution CT lesions. Solitary masslike lesions were seen in cm, were seen in 12 patients (29%). On high- scans showed ponly or well-defined nodules three patients. The images of all three patients resolution CT scans, the foci were centrilobular of 1-2 mm widely disseminated throughout the were low in attenuation, and two of the three in location and appeared as nodules or branch- lungs (Fig. 3). On chest radiographs. areas of had peripheral rim enhancement. On chest ing linear structures, which suggested the bron- small nodules were missed in nine patients: radiographs. focal air space consolidations chogenic spread of tuberculosis (Fig. 2). nodules of bronchogenic spread in eight were difficult to identify in two patients, and Miliary on disseminated nodules were seen in patients and miliary nodules in one patient. Bronchial lesions were seen in I 5 patients (37%). On CT scans. involved bronchi were stenosed in seven patients and obstructed in four patients. Bronchial wall thickening was seen in nine patients. Endobronchial granu- loma was seen in three patients (Fig. 4): two lesions were calcified and one was of low attenuation. Peribnonchial lymphadenopathy was seen in 1 1 patients. Segmental (ii = ) or lobar (ii = 5) atelectasis was seen in 13 patients. Obstructive emphysema associated with hilar lymphadenopathy was seen in two patients: in one patient the right lower lobe was involved, and in the other patient the left lower lobe was involved. Cylindrical bron- chiectasis was seen in two patients and involved the left upper lobe and the left lower lobe in each patient. In the evaluation of bron- chial tuberculosis, chest radiographs. even with high-kilovoltage filtered techniques. failed to show a bronchial stenosis in three patients and failed to show an endobronchial granuloma in two other patients (Fig. 4). A B Pleural lesions were seen in seven patients Fig. 2.-Bronchogenic spread of tuberculosis in 8-year-old boy. (17%). The lesions were free effusion associ- A, Plain radiograph shows ill-defined dense opacity obscuring right cardiac border. ated with air space consolidation in two B, High-resolution CT scan obtained 2 days afterA shows atelectasis of right middle lobe (Ml, variably sized cen- trilobular nodules (arrowheads), and linear branching structures (arrows) in right lower lobe. Right hilar adenop- patients. loculated effusion in two. pleural athy (not shown) was also detected on CT scan. thickening with calcification in two, and a cal- A B Fig. 3.-Miliary tuberculosis in 13-year-old girl. A, Plain radiograph shows inconspicuous nodules in both lungs. B, High-resolution CT scan obtained 1 day afterA shows well-defined 1- to 2-mm nodules disseminated throughout lungs. AJR:168, April 1997 1007
  4. 4. Kim etal. Fig. 4.-Bronchial tuberculosis in 11-year-old girl. A, Plain radiograph shows ill-defined lesion (arrow) in left infrahilar area. B, CT scan obtained 1 day afterA shows round calcified lesion (arrows) in left main bronchus. Note collapse of superior lingular division of left upper lobe. ‘-.. . c... cal intervention was performed in two patients with pleural and chest wall tuberculosis. Discussion Lymphadenopathy with or without a con- comitant parenchymal abnormality is a radio- logic hallmark of primary tuberculoosis in childhood. Enlarged lymph nodes or parenchy- mal abnormality. although almost always present in pulmonary tuberculosis in children, may be difficult to identify even on high-qual- ity chest radiographs. A CT scan can be used to reveal on confirm the adenopathy or parenchy- mal lesions [12]. In our study. chest radio- graphs failed to reveal the adenopathy in 21% Fig. 5.-Pleural and pericardiac tuberculosis in 13-year-old girl. CT scan shows bilateral pleural effusion and of patients (seven of 34) and the parenchymal subpleural parenchymal lesions (arrow) in right middle lobe. Pericardium is irregularlythickened (arrowheads). abnormality in 35% of patients ( I I of 3 1 ). The lung lesions were often seen with a CT scan in areas of greatest ventilation: the middle lobe, cified mass with low-attenuation fluid in one. In eight of 41 patients, a diagnosis of tuber- the lower lobe, or the anterior segments of an CT scans showed parenchymal nodules on the culosis was suggested only after a CT scan upper lobe. This pattern differs from reactiva- same side as pleural lesions in all patients and revealed low-attenuation nodes with rim tion tuberculosis in adults, which is typically showed hilar or mediastinal adenopathy in enhancement. calcifications. and nodules of located in the apical or posterior segment of the three patients. In the evaluation of pleural bronchogenic spread or miliary nodules. These upper lobes [81. tuberculosis. chest radiographs failed to reveal findings were not seen on chest radiographs. In Characteristically. an enhanced CT scan pleural lesions in two patients and fluid in a nine (41 %) of 22 patients with complications shows enlarged nodes with low-attenuation calcified mass in one patient. oftubenculosis. a CT scan detected the compli- centers. which represent caseation necrosis and In one patient with bilateral pleural effusion. cations, which were missed on chest radio- peripheral rim enhancement representing pericardiac thickening was also found (Fig. 5). graphs. In 15 (37%) of 41 patients. a CT scan inflammatory hypervascularity in granuloma- In one patient with a lobar pneumonia and provided information that altered the clinical tous tissue [13]. These CT findings were seen in pleural effusion, an anterior chest wall abscess management of the disease. Antituberculous 85% of patients (29 of 34) with tuberculous and spinal tuberculosis were seen as a low- therapy was started before bacteriologic confin- lymphadenitis in this study and are not different attenuation soft-tissue mass with rim enhance- mation in eight patients with clinically sus- from those reported in adults [1 31. Calcification ment and bone destruction. Chest radiographs pected tuberculosis. steroid therapy was within the nodes was not commonly seen in our in these patients failed to detect the pericardiac combined with antituberculous therapy in five studies (five [ 15%] of 34 patients); however. if on chest wall involvement. patients with bronchial tuberculosis, and surgi- calcification was present. it could be a diagnos- 1008 AJR:168, April 1997
  5. 5. CT of Pulmonary Tuberculosis in Children tic clue for tuberculosis. We think that CT scans In the evaluation of children with known or 5. Leung AN. Muller NL. Pineda PR, FitzGerald JM. can be useful in differentiating tuberculosis from suspected pulmonary tuberculosis, CT scans Primary tuberculosis in childhoxl: radiographic manifestations. Rwlio!ogv 1992:182:87-91 other causes of lymphadenopathy in children cannot be routinely recommended because of 6. Laniont AC. Cremin BJ. Pelteret RM. Radiologi- because the CT findings are rarely seen in other the high costs. the need for sedation. and the cal pattems of pulmon-try tuberculosis in the diseases such as lymphoma, metastasis, sarcoi- risks involved in administering a contrast pediatric age group. Pediatr Radio! 1986:16:2-7 dosis, coccidioidomycosis, and histoplasmosis medium. However, in certain circumstances, 7. Agrons GA. Markowitz RI, Kramer 55. Primary I 13, 14]. In HIV-positive patients. findings of the additional information provided by CT can tuberculosis in children. Semi,z Roent,#{231}’enol 1993: low-attenuation nodes are considered sufficient suggest the diagnosis of tuberculosis. as 28:158-172 to warrant instituting empirical antitubenculous occurred in eight patients in our study. and can 8. Kuhlman JE. Deutsch JH, Fishman EK. Siegel- man 55. CT features of thoracic mycobacterial therapy [1 1]. alter the clinical management. as for I 5 patients dtsease. RadioGrapliie.s 1990: 10:4 I 3-43 1 Homogeneous. dense, and well-defined air in the study. We recommend CT when the 9. Lee KS, liii JG. CT in adults with tuberculosis of space consolidation is a typical CT appearance radiographic findings are normal or inconclu- the chest: characteristic findings and role in man- of primary tuberculosis [9]. However, low- sive and tuberculosis is suspected clinically; we agement. AiR 1995: 1 64: 136 1- I 367 attenuation areas representing caseation necrosis also recommend CT and when complications 10. Im JG. Itoh H, Shim YS, et al. Pulmonary tuber- or calcifications can be seen within consolida- of tuberculosis are suspected. culosis: CT findings-early active disease and tion (30% of the patients in our study). The In conclusion, the advantages and comple- sequential changes with antituberculous therapy. necrosis and liquefaction in areas of pneumonic mentary nature of CT in evaluating children Radiology 1993:186:653-660 I 1. Pastores SM, Naidich DP. Aranda CR McGuiness consolidation can progress to extensive lung with pulmonary tuberculosis are in the detec- G. Rom WN. Intrathoracic adenopathy associated damage [15, 16], as occurred in one infant in tion of disease in normal on equivocal chest with pulmonary tuberculosis in patients with this study. CT is particularly sensitive in identi- radiographs; in the characterization of lesions human immunodeficiency virus infection. C/zest fying the presence of endobronchial spread of by showing low-attenuation nodes with rim 1993:103:1433-1437 disease and nodular densities that vary in size enhancement, calcifications, and nodules of I 2. Delacourt C. Mani TM, Bonnerot V. et al. Computed and are seen in up to 95% ofpatients with newly bronchogenic spread or miliary nodules; and in tomography with nomml chest radiograph in tuber- diagnosed reactivation tuberculosis [10]. These defining the extent of disease and its complica- culous infection. Arch Dis Child 1993:69:430-432 findings were seen in 29% ( 12 of 41 ) of the tions with sectional imaging capability. 13. Im JG. Song KS. Kang HS, et al. Mediastinal tuberculous lymphadenitis: CT manifestations. patients in our study. Although a similar appear- Although chest radiography remains the fore- Radiolog 1987:164:115-119 ance can be seen in patients with atypical myco- most imaging technique in the evaluation of 14. McAdams HP, Rosado de Christenson ML, Lesar bacterial or bacterial bnonchopneumonia, we pulmonary tuberculosis in children, CT can be M, Templeton PA. Moran CA. Thoracic mycoses think that these CT findings, if present, can be useful in certain circumstances and can provide from endemic fungi: radiologic-pathologic corre- helpful in diagnosing tuberculosis in children. important information in the diagnosis and lation. RadioGraphic’s 1995:15:255-270 CT was also helpful in diagnosing miliaiy tuber- management of the disease. 15. Matsaniotis N, Kattamis C, Economou-Mavrou culosis in patients with normal or equivocal C. Kyriazakou M. Bullous emphysema in child- chest radiographic findings [17]. hood tuberculosis. J Pediatr 1967:71:703-707 The advantages of CT over chest radiographs 16. Hams VJ, Schauf V, Duda F, White H. Fatal References tuberculosis in young children. Pediatrics 1979: in defining the extent of tuberculous disease and 1 . Buckner CB, Leithiser RE, Walker CW. Allison 63:912-914 its complications (bronchial, pleural, pericardiac, Jw. The changing epidemiology of tuberculosis 17. McGuiness G. Naidich DP, Jagirdar J. Leitman B. and chest wall tuberculosis) have been well doc- McCauley DI. High resolution CT findings in mil- and other mycobacterial infections in the United umented in the literature [18-20] and were con- iary lung disease. J Comput Assist Tonogr 1992: States: implications for the radiologist. AiR 1991: fumed in our study. In nine patients, CT 156:255-264 16:384-390 revealed the complications of tuberculosis, 2. Amodio J, Abramson S. Berdon W. Primary pul- 18. Choe KO, Jeong HJ. Sohn HY. Tuberculous bron- missed on chest radiographs, and indicated the monary tuberculosis in infancy: a resurgent dis- chial stenosis: CT findings in 28 cases. AiR 1990; ease in the urban United States. Pediatr Radio! I55:971-976 need for two patients to undergo surgery. If pleu- 1986: 16: 185-189 19. Hulnick DH, Naidich DR McCauley Dl. Pleural ral thickening is shown on a plain radiograph, 3. Stark JR. Modem approach to the diagnosis and tuberculosis evaluated by computed tomography. CT is useful for determining whether the thick- treatment of tuberculosis in children. Pediatr C!in Radio!og 1983:149:759-765 ening represents pleural thickening or chronic North Am 1988:35:441-464 20. Adler BD. Padley SR Muller NL. Tuberculosis of loculated effusion, which usually needs decorti- 4. Stransherry SD. Tuberculosis in infants and chil- the chest wall: CT findings. J (‘oinputAssist Tonzogr cation [20], as in one patient in our study. dren. J Thorcic Imag 1990:5: 17-27 1993: 17:27 1-273 AJR:168, April 1997 1009