A 52-year-old man presented with dyspnea, fatigue, weight loss, diarrhea and a swollen right testis. Imaging showed hilar lymphadenopathy, a miliary pattern, mediastinal and hilar lymphadenopathy, pericardial effusion, splenomegaly with hypodense lesions, and micronodules in the lungs. A biopsy of the right testis revealed necrosis and acid-fast bacteria, leading to a diagnosis of disseminated tuberculosis. Tuberculosis commonly involves the abdomen and can affect lymph nodes, the peritoneum, gastrointestinal tract, liver, spleen, kidneys and genitals. Imaging plays a key role in the diagnosis and management of abdominal tuberculosis.

1. A 52-year old man with
dyspnea, fatigue and
loss of weight
M. TORFS
B. CORTHOUTS
B. OP DE BEECK
STAFF MEETING RADIOLOGY, 09-12-2014

2. Case presentation
 Medical history:
- HIV (stopped treatment 3 years before, lost to
follow-up by the ITM)
- Depression
 Current medical problems:
- Dyspnoea
- Extreme fatigue
- Weight loss (15 kgs in 3-4 months)
- Diarrhea
- Right testis ‘problem’ (R/ ciprofloxacin)

3. Case presentation
 Clinical examination:
- Cachexia
- Tachycardia
- Bilateral crepitations on auscultation
- Red, swollen right testis

4. Chest radiograph

5. Chest radiograph: imaging
findings
Hilar lymphadenopathy

6. Chest radiograph: imaging
findings
Miliary pattern

7. CT thorax

8. CT thorax

9. CT thorax

10. CT thorax

11. CT thorax

12. CT thorax

13. CT thorax

14. CT thorax

15. CT thorax

16. CT thorax

17. CT thorax

18. CT thorax

19. CT thorax

20. CT thorax

21. CT thorax

22. CT thorax

23. CT thorax

24. CT thorax

25. CT thorax

26. CT thorax

27. CT thorax

28. CT thorax

29. CT thorax

30. CT thorax: imaging findings
Hypodense mediastinal
lymphadenopathy with rim
enhancement
Hypodense right hilar
lymphadenopathy

31. CT thorax: imaging findings
Pericardial effusion
Splenomegaly with numerous
hypodense splenic lesions
(miliary pattern)

32. CT thorax: imaging findings
Small right adrenal
calcifications

33. CT thorax: imaging findings
Micronodules, tree-in-bud
pattern

34. CT abdomen

35. CT abdomen

36. CT abdomen

37. CT abdomen

38. CT abdomen

39. CT abdomen

40. CT abdomen

41. CT abdomen

42. CT abdomen

43. CT abdomen

44. CT abdomen

45. CT abdomen

46. CT abdomen

47. CT abdomen

48. CT abdomen

49. CT abdomen

50. CT abdomen

51. CT abdomen

52. CT abdomen

53. CT abdomen

54. CT abdomen

55. CT abdomen

56. CT abdomen

57. CT abdomen

58. CT abdomen

59. CT abdomen

60. CT abdomen

61. CT abdomen

62. CT abdomen

63. CT abdomen: imaging findings
Splenomegaly with numerous
hypodense splenic lesions
(miliary pattern)
Inflammation of the right seminal
vesicles

64. CT abdomen
Hyperenhancement of the right
spermatic cord
Intussusception

65. Diagnosis?
 R/ Right orchidectomy
 Pathology:
- Abcedation and necrosis
- Presence of numerous acid fast bacteria
 Diagnosis: Disseminated tuberculosis

66. Tuberculosis: epidemiology
 Leading cause of death from infection worldwide
 1/3 of world population infected
 2010: 8.8 million incident cases worldwide, 1.4 million deaths
 1.2 million cases among HIV-infected persons
 Largest number of incident cases: India, China, South Africa,
Indonesia, Pakistan
 Highest prevalence rates (> 300 cases/100,000 population) in African
region
 Increased susceptibility in patients with impaired cellular
immunity
 HIV infection, elderly, prisoners, congregate settings,
indigent/homeless

67. Tuberculosis: pathology
 M. tuberculosis: Aerobic, nonmotile
bacillus
 Stains red with Ziehl-Neelsen stain
 Acid-fast: Resists discoloration with acid alcohol
 Granulomatous infection/inflammation
 Macrophage aggregates transform into
epithelioid cells, epithelioid cells fuse to form
multinucleated Langhans giant cells
 Central necrosis, satellite granulomas
 May heal as fibrous scar or calcified lesion

68. ABDOMINAL
MANIFESTATIONS IN
TUBERCULOSIS

69. Abdominal manifestations
in tuberculosis
 Abdomen is the most common site of extrapulmonary TB (can be
involved without lung disease)
 Abdominal lymphadenopathy is most common manifestation of
abdominal TB
 Any abdominal or pelvic organ or structure may be involved
 Tuberculosis peritonitis
 Gastrointestinal tuberculosis
 Hepatosplenic tuberculosis
 Renal tuberculosis

70. Abdominal
lymphadenopathy
 Enlarged nodes with hypoattenuating centers and
hyperattenuating enhancing rims on CT (40-60%)
 With healing, nodes calcify
 Enteric TB probably most common cause of mesenteric
nodal calcification
26-year old patient with
disseminated TB

71. Tuberculous peritonitis
 Wet type: Large amount of free or
loculated ascites (higher than water
density due to protein and cellular
content)
 Dry type: Mesenteric and omental
thickening, fibrous adhesions, and
caseous nodules
 Difficult to distinguish from peritoneal
carcinomatosis

72. Gastrointestinal
tuberculosis
 Ileocecal region most commonly affected
 Cecum & terminal ileum are usually contracted with
wall thickening; ileocecal valve is "gaping"
 Regional lymphadenopathy with central caseation
 Colon tuberculosis less common
24-year old patient with
intestinal TB and
enterocutaneous fistula

73. Gastrointestinal tuberculosis
42-year old patient with
TB colitis

74. Hepatosplenic tuberculosis
• Micronodular, miliary
• Macronodular
 CT
 Acute lesions are hypoattenuating nodules with ill-defined,
enhancing margins
 Chronic: Hepatic and splenic tuberculomas tend to calcify as they
heal
 MR
 T1WI: Hypotense, minimally enhancing, honeycomb lesions
 T2WI: Hyperintense with less intense rim relative to surrounding liver

75. Renal tuberculosis
• 75% unilateral
• Most common CT finding is renal
calcification (50%)
• IVP: "Moth-eaten" calix due to erosions
and progression to papillary necrosis
• Caliectasis & hydronephrosis with irregular
margins and filling defects due to caseous
debris
• Irregular pools of contrast due to renal
parenchymal cavitation
• Strictures of renal pelvis and infundibula
www.statdx.com

76. Ureteric and bladder
tuberculosis
• Ureteric tuberculosis:
- Thickened ureteric wall with
strictures
- Most common in distal 1/3 of
ureter
- Hydronephrosis & hydroureter
can occur upstream
• Bladder tuberculosis:
- Decreased bladder volume
with wall thickening,
ulceration, and filling defects
http://www.isradiology.org/tr
opical_deseases/tmcr/chapt
er5/lymphadenopathy2.htm

77. Genital tuberculosis
 Male genital tuberculosis
- Affects seminal vesicles or prostate
gland, rarely testes
- Occasional calcification
 Female genital tuberculosis
- Involves fallopian tubes in 94% of cases
- Bilateral salpingitis with strictures ±
occlusion

78. Differential diagnosis
• Abdominal lymphadenopathy:
- Metastases or lymphoma
- Whipple disease
- MAI infection
• Tuberculosis peritonitis:
- Nontuberculous peritonitis
- Peritoneal metastases and
lymphoma
- Mesothelioma
• Ileocecal lesions:
- Amebiasis
- Crohn disease
- Primary cecal malignancy
• Miliary hepatic lesions:
- Hepatic metastases and
lymphoma
- Hepatic opportunistic infection
- Sarcoidosis
• Renal Lesions:
- Renal papillary necrosis
- Renal transitional cell
carcinoma
- Other infections

79. DD: abdominal
lymphadenopathy
41-year old man with Hodgkin lymphoma

80. DD: abdominal
lymphadenopathy
68-year old man with Whipple disease
Courtesy of Dr. Tom Seerden (Amphia Ziekenhuis Breda) and Dr. Bart Op De Beeck

81. DD: ileocecal lesions
55-year old female with M. Crohn

82. Take home messages
 Tuberculosis is leading cause of death from
infection worldwide
 TB lymphadenitis is characterised by enlarged
nodes with hypoattenuating centers and
hyperattenuating enhancing rims on CT (tend to
calcify with healing)
 Disseminated TB: look at the whole picture!

83. Remember this patient?

84. References
 Statdx.com
 Radiopaedia.org
 http://www.isradiology.org/tropical_deseases/tm
cr/chapter5/lymphadenopathy2.htm