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Chest imaging of ntm pulmonary disease2


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Chest imaging of ntm pulmonary disease2

  1. 1. Chest Imaging of Non-tuberculous Mycobacteria (NTM) Pulmonary Disease 1 臨藥科技所 碩一 陳秋縈 指導老師 張慧真主任 Feb 20th, 2013
  2. 2. NTM pulmonary disease  The most common clinical manifestation of NTM disease  Incidence: 7.94 per 100,000  Most common pathogen in taiwan  M. avium complex (MAC), rapidly growing species (especially M. abscessus), M. kansasii  Susceptibility to NTM disease  Preexisting structural lung diseases − Prior pulmonary tuberculosis, cystic fibrosis, bronchiectasis, COPD, silicosis, pneumoconiosis  Conditions that might alter local or systemic host immune status − Alcoholism and smoking, esophageal reflux (especially with M. fortuitum /abscessus ), sinus disease, IFN-γ production or receptor abnormalities, HIV/AIDS, immune suppressing drugs and organ transplantation 2 Expert Rev Respir Med. 2012 Dec;6(6):597-612 Emerg Infect Dis. 2011 Mar;17(3):343-9.
  3. 3. Clinical  Pulmonary symptoms (Cough, fatigue, weight loss. Fever and hemoptysis are less common and suggest advance/extensive disease)  Exclusion of other disease (Such as TB, malignancy) Chest imaging  Radiograph: nodular or cavitary lesion on chest radiograph  HRCT: multifocal bronchiectasis with multiple small nodules Microbiologic  Positive cultures from two separate sputum specimens  Positive culture from >1 bronchial wash or BAL  Lung biopsy with histopathologic changes of granulomatous inflammation or AFB plus positive NTM culture 3 Am J Respir Crit Care Med. 2007;175:367–416. HRCT: high resolution computed tomography Diagnostic Criteria of NTM pulmonary disease Clinical, radiological, and microbiological all required and or or or
  4. 4. Image Findings of NTM Lung Disease  Usually nonspecific and variable, depending in part upon the species  Two common radiographic pattern  Cavitary tuberculosis-like  Nodular bronchiectasis 4 Clin Radiol. 2002 Aug;57(8):661-9. Expert Rev Respir Med. 2012 Dec;6(6):597-613. Comparison of radiographic features of NTM infection and TB
  5. 5.  Seen in approximately 90% of M. kansasii infection, and 50% of MAC infection  Often in the upper lobes  Tends to occur among male smokers with underlying COPD, prior TB  Characteristics compare with TB  Smaller, thinner walled cavities with less surrounding parenchymal opacity  More pleural involvement − Pleural thickening is common and probably more marked than in tuberculosis but pleural effusions are uncommon → insufficiently specific to exclude TB 5 Am J Respir Crit Care Med. 2007;175:367–416. Radiographic Findings of NTM Lung Disease Cavitary tuberculosis-like
  6. 6.  50% of MAC lung disease, also be seen with other NTM pathogens including M. abscessus, M. simiae, and M. kansasii  Right middle lobe and lingula are particularly affected  The nodules and bronchiectasis are usually present within the same lobe  Most prevalent in nonsmoking middle-aged or elderly women, no previous lung disease, tall and lean body habitus → “Lady Windemere’s Syndrome” 6 Clin Chest Med. 2002;23(3):603. Am J Respir Crit Care Med. 2007;175:367–416. Radiographic Findings of NTM Lung Disease Nodular bronchiectasis
  7. 7. High-resolution chest CT (HRCT) scan  Regardless of NTM species, the most common HRCT findings were  Small bilateral nodules  Branching centrilobular nodules, (ie, tree-in-bud pattern)  Bronchial wall thickening and cylindrical bronchiectasis 7 Radiology. 1995;194 (2): 413-7. Chest. 2004;126 (2): 566-81. Radiology 2004; 231, 880-886 22 y/old male, non-smoker, with cystic fibrosis and M. abscessus lung disease. Patient with diffuse nodular and reticulonodular densities including “tree- in-bud” appearance of densities in lung periphery. (順著支氣管散佈的病灶像是樹枝發芽一樣) 圓柱型支氣管擴張 樹芽狀散佈
  8. 8. 66 y/o man, smoker with MAC lung disease associated with large right upper lobe cavity and bilateral reticulonodular densities. 41 y/o female, smoker, with MAC lung disease associated with left apical confluent density with cavitation. (兩側網狀病灶) (左肺尖病灶匯集 density增加並有空洞之病灶形成)
  9. 9. 73 y/o non-smoking female with MAC lung disease demonstrating bilateral nodular densities and bronchiectasis. 9
  10. 10. 79 y/o non-smoking female with MAC lung disease CXR: primarily mid-lung nodular and reticulonodular densities and cavitation HRCT: nodules, bronchiectasis and cavitation 10
  11. 11. 42 y/o man, smoker, with M. kansasii disease associated with bilateral upper lobe reticulonodular densities 77 y/o man, smoker, with M. kansasii disease associated with bilateral mid and upper lung field reticulonodular densities with cavitation 11 (網狀病灶 左肺的比較淡)
  12. 12. 30 y/old male, non-smoker, with hypersensitivity-like lung disease following hot-tub exposure CXR: diffuse reticular densities HRCT: diffuse “ground glass” appearance of lung parenchyma 12 整個肺呈現”毛玻璃狀”的病灶(出現在肺組織 且瀰漫性分布的病灶) (兩邊肺看起來有網狀的結構病灶)
  13. 13. Thank you for your attention
  14. 14.  A much rarer pattern  Present with bilateral diffuse ground-glass infiltrates, nodules, reticulation, or mosaic attenuation consistent with patchy air trapping Radiographic Findings of NTM Lung Disease Hypersensitivity pneumonitis 14
  15. 15. 55 y/o non-smoking female with MAC lung disease CXR: cavitary right middle lobe (RML) density HRCT: destruction of the RML with bronchiectasis, and nodules in the lower lobes 15
  16. 16. 70 y/o female, non-smoker, with M. abscessus disease CXR: bilateral reticulonodular densities and cavitation HRCT: nodules and bronchiectasis in right middle lobe, lingula and lower lobes, and cavitation 16
  17. 17.  54-year-old man with mild emphysema, cough, and fever  MAC infection A. left upper lung shows well-circumscribed cavitary left upper lobe mass B, C. left upper lobe cavity and show adjacent cluster of small nodules 17
  18. 18. Chest CT scans  patient with MAC infection  Show nodules and multifocal bronchiectasis in the middle lobe and lingula 18
  19. 19. Chest CT scans  Patient with mycobacterium kansasii infection  Shows cavitation and fibrosis in the right upper lobe 19
  20. 20.  50 y/o male with COPD and a worsening cough, and a low-grade fever of 3 months' duration  Mycobacterium kansasii infection  show cavitating consolidation and volume loss, the primary pattern associated with nontuberculous mycobacterial infections. 20
  21. 21.  multidrug regimens to prevent the emergence of resistant strains 21
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  26. 26. TB  Micronodules and tree-in-bud appearance were the most common characteristic features of HRCT scans in patients with newly diagnosed pulmonary TB  These lesions are not seen on chest radiographs, HRCT may provide valuable information on the diagnosis of active TB 35
  27. 27. Distinguishing TB from NTM Disease Emerg Infect Dis. 2011 March; 17(3): 506–509. 36