Imaging: Endobronchial TB

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  • Figure 1. Photograph of a twig obtained from a budding tree in spring.
  • Figure 1.  High-resolution CT scan (far left) and drawings of the lung (middle left), a budding tree (middle right), and tree buds (far right) show the tree-in-bud pattern. Note the similarity of the obstructed bronchioles to the objects used in the game of jacks.
  • Figure 2.  Postprimary active tuberculosis in a 66-year-old woman with a chronic cough. High-resolution CT scans of the right lung show peripheral, poorly defined, small (2–4-mm-diameter) centrilobular nodules and branching linear opacities of similar caliber originating from a single stalk (the tree-in-bud pattern) in the lower lobe (arrow). These findings represent endobronchial spread of tuberculosis.
  • Imaging: Endobronchial TB

    1. 1. PROF.DR.G.SUNDARAMURTHY’S UNIT M7 DR.BHARGAVI.K
    2. 2. HISTORY IN BRIEF  48 yr old male was admitted  With c/o hemoptysis for 1 day-10 episodes  c/o giddiness  k/c/o HT on Rx  not a k/c/o PT  On examination:Gen exmn- was normal  Cvs-NAD  Rs-fine crepts + right interscapular and subscapular areas.
    3. 3.  INVESTIGATIONS  Rbs,Rft- within normal limits  Hb-9.2 gms, complete profile- normal  Sputum AFB- negative  Further imaging ensued…….
    4. 4.  Lung parenchyma shows TREE IN BUD OPACITY S/O ENDOBRONCHIAL SPREAD OF INFECTION, noted in R UPPER LOBE INVOLVING AZYGOUS LOBE ,LIMITED BY AZYGOUS fissure, apical anterior segment.  Tiny nodular opacities noted in throughout lung tissues on both sides.  ?TB etiology.
    5. 5. .
    6. 6. Figure 1. High-resolution CT scan (far left) and drawings of the lung (middle left), a budding tree (middle right), and tree buds (far right) show the tree-in-bud pattern.
    7. 7. Rossi S E et al. Radiographics 2005;25:789-801 ©2005 by Radiological Society of North America
    8. 8.  THE TERMINAL TUFTS -inflammation with caseous material in the respiratory bronchioles and alveolar ducts  STALKS -caseous material within the terminal bronchiole
    9. 9. Secondary PULMONARY lobule is supplied by a lobular bronchiole and a lobular artery that are located in the center of the lobule.
    10. 10.  Under normal circumstances, the intralobular bronchiole is less than 1 mm in diameter and is not normally visible on CT scans  However, diseased bronchioles with mucous plugging with pus,fluid, wall thickening, or dilatation and peribronchiolar inflammation can be visualized on thin- section CT scans, often displaying the tree- in-bud phenomenon
    11. 11. Abnormal – tree in bud Normal ct section
    12. 12. TREE IN BUD PATTERN  Infection  Bacterial  Tuberculosis(72%)  Non-tuberculosis-MAC,staph aureus,H.influenzae.  Fungal  Aspergillus  Viral  Cytomegalovirus  Respiratory syncytial virus  Idiopathic disorders  Obliterative bronchiolitis  Diffuse panbronchiolitis
    13. 13. CONGENITAL DISORDERS Cystic fibrosis Kartagener’s syndrome IMMUNOLOGICAL DISORDERS  Allergic bronchopulmonary aspergillosis CONNECTIVE TISSUE DISORDER  Rheumatoid arthritis Sjogren’s syndrome MISCELLANEOUS  Aspiration Inhalation of toxic fumes of gases Langerhans cell histocytosis Sarcoidosis TUMOURS PERIPHERAL PULMONARY VASCULAR DISEASE Thrombotic micro-angiography
    14. 14. ENDOBRONCHIAL TB -TUBERCULOUS INFECTION OF THE TRACHEOBRONCHIAL TREE WITH MICROBIAL AND HISTOPATHOLOGICAL EVIDENCE -10-40% OF PATIENTS WITH ACTIVE PULMONARY TUBERCULOSIS.
    15. 15. ENDOBRONCHIAL TB PATHOGENESIS direct implantation of tubercle bacilli into the bronchus from an adjacent pulmonary parenchymal lesion direct airway infiltration from an adjacent tuberculous mediastinal lymph node Erosion and protrusion of an intrathoracic tuberculous lymphnode into the bronchus hematogenous spread extension to the peribronchial region by lymphatic drainage.
    16. 16. CLASSIFICATION OF ENDOBRONCHIAL TB (chung n lee)  ACTIVELY CASEATING(43%)  EDEMATOUS-HYPEREMIC,  FIBROSTENOTIC  TUMOROUS  GRANULAR  ULCERATIVE  NONSPECIFIC
    17. 17. CLINICAL SYMPTOMS  COUGH  DYSPNEA  LOCAL WHEEZE  HEMOPTYSIS  HOARSENESS  ANOREXIA
    18. 18. SEQUELAE….  BRONCHOSTENOSIS  BRONCHOSTRICTURES  bronchiolitis obliterans  bronchocentric granulomatosis  BRONCHIECTASIS
    19. 19. DIAGNOSIS SPUTUM EXAMINATION is the essential and first step . C X-RAY: NORMAL IN 10-20% BRONCHOSCOPY(BRONCHIAL BIOPSY/BRUSHING/ WASHINGS) AND CT are the methods of choice for accurate diagnosis of Bronchial involvement . Typical bronchoscopic finding is the presence of white gelatinous granulation tissue. The mucosa is nodular, red, vascular and some times ulcerated. It may simulate a bronchogenic Carcinoma Nucleic acid amplification tests, such as PCR and other methods for amplifying DNA
    20. 20. TREATMENT  ATT-conventional chemotherapy containing INH, rifampicin, pyrazinamide and ethambutol.  CORTICOSTERIODS  balloon dilatation, self expanding metallic stent(FOR BRONCHIAL STENOSIS)  laser, curettage, resection and anastomosis

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