Pulmonary TB

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Pulmonary TB

  1. 1. ‫بسم ا الرحمن‬ ‫الرحيم‬
  2. 2. Introduction Up until the mid 1980s, there was a steady decline in the prevalence of T.B. Since then, there has been a resurgence of T.B. due to AIDS epidemics Increasing no. of resistant strains of mycobacterium T.B. Groups of increased risk e.g. poor, alcoholics, homeless
  3. 3. Why is T.B. still considered a major issue? T.B remains the major cause of death from a single infectious agent among adults in developing nations. In 1993, the WHO declared T.B to be a global emergency. It is estimated that between 1997-2020, nearly 1 billion people will become newly infected and 70 x 106 will die from the disease (WHO, 1998)
  4. 4. Primary Post primary (reactivation) There is considerable overlap in radiologic manifestations of these 2 entities. Results of radiography may be normal in 15% of cases
  5. 5. Primary T.B.
  6. 6. Radiology of Primary T.B. Lymphadenopathy Parenchymal disease Pleural effusion Miliary T.B
  7. 7. Radiology of Primary T.B. 1) Lymphadenopathy: Is the radiological hallmark of the disease 83-96% of pediatric cases
  8. 8. Radiology of Primary T.B. 1) Lymphadenopathy: Is the radiological hallmark of the disease hilar lymphadenopathy
  9. 9. Radiology of Primary T.B. 1) Lymphadenopathy: Is the radiological hallmark of the disease 83-96% of pediatric cases Prevalence with age Rt. paratracheal + hilar stations are most common sites
  10. 10. Radiology of Primary T.B. 1) Lymphadenopathy: Is the radiological hallmark of the disease hilar lymphadenopathy
  11. 11. Radiology of Primary T.B. 1) Lymphadenopathy: Is the radiological hallmark of the disease 83-96% of pediatric cases Prevalence with age Rt. paratracheal + hilar stations are most common sites CT has a characteristic appearance
  12. 12. Radiology of Primary T.B. 1) Lymphadenopathy: Is the radiological hallmark of the disease Precontrast Postcontrast
  13. 13. Radiology of Primary T.B. 1) Lymphadenopathy: Is the radiological hallmark of the disease 83-96% of pediatric cases Prevalence with age Rt. paratracheal + hilar stations are most common sites CT has a characteristic appearance D.D.: 1- Metastases 2- Lymphoma 3- other infections e.g. 4- Sarcoidosis - Varicella pneumonia - histopalmsmosis
  14. 14. Radiology of Primary T.B. 2) Parenchymal disease: Affects areas of greatest ventilation upper lobe 38-81% of adult cases Rt. Sided predominance Homogenous consolidation in segmental or lobar pattern
  15. 15. Radiology of Primary T.B. 2) Parenchymal disease: consolidation Para.T LN hilar LN consolidation Displaced OF
  16. 16. Radiology of Primary T.B. 2) Parenchymal disease: Affects areas of greatest ventilation, middle & lower lobes & anterior segment of upper lobe 38-81% of adult cases Rt. Sided predominance Homogenous consolidation in segmental or lobar pattern Tuberculo ma - Round or oval sharply marginated - 0.5- 4 cm - + calcifications - Surrounding satellites
  17. 17. Radiology of Primary T.B. 2) Parenchymal disease: nodule DD: Nodule nodule nodule 1. 2. 3. 4. Tuberculoma Hamartoma Metastases Hydatid
  18. 18. Radiology of Primary T.B. 2) Parenchymal disease: Affects areas of greatest ventilation, middle & lower lobes & anterior segment of upper lobe 38-81% of adult cases Rt. Sided predominance Homogenous consolidation in segmental or lobar pattern Tuberculo ma Obstructive atelectasis 2ry compression of adjacent enlarged LN
  19. 19. Radiology of Primary T.B. 2) Parenchymal disease: cavity LNs Displaced OF LNs collapse collapse
  20. 20. Radiology of Primary T.B. 3) Pleural effusion: Unilateral pleural effusion hilar LNs Enhancing parietal pleura pleural effusion
  21. 21. Radiology of Primary T.B. 4) Miliary T.B.: Innumerable 1-3 mm, non-calcified nodules scattered through both lung fields with basal predominance High resolution CT.
  22. 22. Post Primary T.B. Exclusively a disease of adolescens + adults Results from 90% % 10 Reactivation of a previously dormant 1ry infection Continuation of 1ry disease Radiological features: 1- Parenchymal disease with cavitation 2- Air way involvement 3- Pleural extension Endo bronchial spread 4- Complications Aspergilosis
  23. 23. Radiology of Post Primary T.B. 1) Parenchymal disease : Consolidation: Patchy, ill-defined, segmental Predilection * to upper lobes * Apical segment of lower lobe a- O2 tension b- Impaired lymphatic drainage Tw0 or more segments are involved in most of cases Bilateral upper lobe disease may be present Cavitations: • Multiple with thick irregular walls • May show air fluid level
  24. 24. Radiology of Post Primary T.B. 1) Parenchymal disease with cavitations: thick-walled cavity Cavitary postprimary TB
  25. 25. Radiology of Post Primary T.B. 1) Parenchymal disease with cavitation: nodule cavity cavity air-fluid level
  26. 26. Radiology of Post Primary T.B. 1) Parenchymal disease with cavitations: Consolidation: Patchy, ill-defined, segmental Predilection * to upper lobes * Apical segment of lower lobe a- O2 tension b- Impaired lymphatic drainage Tw0 or more segments are involved in most of cases Bilateral upper lobe disease may be present Cavitations: •Multiple with thick irregular walls •May show air fluid level
  27. 27. Radiology of Post Primary T.B. 1) Parenchymal disease with cavitation: Thick walled cavity air-fluid level
  28. 28. Radiology of Post Primary T.B. 2) Air way involvement: Bronchial stenosis Collapse Consolidation due to Hyperinflation 1- direct extension from TB LN 2- Endobronchial spread of infection 3- lymphatic dissemination to the airway
  29. 29. Radiology of Post Primary T.B. 2) Air way involvement: narrowing Tuberculous bronchostenosis.
  30. 30. Radiology of Post Primary T.B. 2) Air way involvement: partial atelectasis calcified LN calcified LN calcified LN Eroding into bronchus calcified LN Tuberculous broncholithiasis
  31. 31. Radiology of Post Primary T.B. 2) Air way involvement: D.D. Carcinoma 1- Longer segment of involvement 2- Circumferential luminal narrowing 3- No intraluminal mass } TB
  32. 32. Radiology of Post Primary T.B. 3) Pleural extension: Pleural effusion Small associated with parenchymal disease Empyema  loculated Subpleural cavitation Air fluid level in pleura = bronchopleural fistula
  33. 33. Radiology of Post Primary T.B. 3) Pleural extension: Pleural effusion air Subpleural cavitating nodule bronchus Enhancing pleura TB empyema with bronchopleural fistula
  34. 34. Radiology of Post Primary T.B. 4) Complications: If left untreated disease progress to Lobar or complete lung opacification + destruction bronchiectatic changes bronchiectatic changes Lung destruction in postprimary TB
  35. 35. Radiology of Post Primary T.B. 4) Complications: If left untreated disease progress to Lobar or complete lung opacification + destruction Coarse reticular + nodular opacified areas fibroproliferative dse
  36. 36. Radiology of Post Primary T.B. 4) Complications: volume loss + apical pleural thickening reticulonodular infiltrates Cavitating nodule Fibroproliferative disease.
  37. 37. Radiology of Post Primary T.B. 4) Complications: If left untreated disease progress to Lobar or complete lung opacification + destruction Coarse reticular + nodular opacified areas fibroproliferative dse Healing of lesions  traction bronchiactasis
  38. 38. Radiology of Post Primary T.B. 4) Complications: bronchiectasis bronchiectasis fungal ball Complications of childhood TB Bronchiectasis in postprimary TB.
  39. 39. Radiology of Post Primary T.B. 4) Complications: If left untreated disease progress to Lobar or complete lung opacification + destruction Coarse reticular + nodular opacified areas fibroproliferative dse Healing of lesions  traction bronchiactasis Endobronchial spread commonest complication of T.B cavitation
  40. 40. Radiology of Post Primary T.B. 4) Complications: tree-in-bud” LN endobronchial spread cavities cavity Cavitary postprimary tuberculosis
  41. 41. Radiology of Post Primary T.B. 4) Complications: If left untreated disease progress to Lobar or complete lung opacification + destruction Coarse reticular + nodular opacified areas fibroproliferative dse Healing of lesions  traction bronchiactasis Endobronchial spread commonest complication of T.B cavitation Small, poorly defined centrilobular nodules + branching centrilobular areas of increased opacity “tree-in-bud” appearance
  42. 42. Radiology of Post Primary T.B. 4) Complications: tree-in-bud Endobronchial spread of tuberculosis bronchiolar wall thickening
  43. 43. Radiology of Post Primary T.B. 4) Complications: If left untreated disease progress to Lobar or complete lung opacification + destruction Coarse reticular + nodular opacified areas fibroproliferative dse Healing of lesions  traction bronchiactasis Endobronchial spread commonest complication of T.B cavitation Mycetoma Aspergillus superimposed infection
  44. 44. Radiology of Post Primary T.B. 4) Complications: nodule in the cavity Complications of childhood TB
  45. 45. Radiology of Post Primary T.B. 4) Complications: Cavitary TB associated with aspergilloma Post primary TB air crescent sign air crescent sign aspergilloma aspergilloma
  46. 46. Radiology of Post Primary T.B. 4) Complications: If left untreated disease progress to Lobar or complete lung opacification + destruction Coarse reticular + nodular opacified areas fibroproliferative dse Healing of lesions  traction bronchiactasis Endobronchial spread commonest complication of T.B cavitation Mycetoma Broncholithiasi s alcified T.B LN in the mediastinum may occasionally erode C into adjacent airway.
  47. 47. Radiology of Post Primary T.B. 4) Complications: Tuberculous broncholithiasis calcified LN calcified LN Eroding into a bronchus
  48. 48. Can X-ray D.D. active / inactive T.B? 1-D.D can be reliably made on basis of temporal evolution i.e. lack of radiographic change over 4-6 months. Thus radiology can say that the dse. is stable rather than inactive . 2-Fibrosis +calcification are found in both healed + active disease
  49. 49. Can X-ray D.D. active + inactive T.B? Sputum culture–positive TB Fibrosis +calcification are found in both healed + active dse Fibrosis retroclavicular calcifications calcified nodules Fibrosis Close-up radiographic view CT scan with 1-mm collimation
  50. 50. Can X-ray play role in assessing treatment response? nodules Pre-Treatment confluent consolidation Postprimary TB 3 months Post- treatment Regression of radiographic abnormalities in pulmonary TB is a slow process
  51. 51. Can X-ray play role in assessing treatment response? Worsening of X-Ray findings : 1st 3 months of treatment  - Progress of parenchymal involvement -development or enlargement of LN cause Unknown , may be due to: development of hypersensitivity reaction 2-10 weeks after initial infection
  52. 52. Can X-ray play role in assessing treatment response? worsening of the radiographic 1st 3 months of treatment  findings i.e. extension of parenchymal involvement +development or enlargement of LN 6m-2 years of treatmentresolution of parenchymal  abnormalities on X-ray this is seen earlier on CT (15 months) Failure of improvement of radiographic drug resistant findings after 3 months of treatmentorganism superimposed infection
  53. 53. 2ry to 1. Pleural disease +empyema 2. Haematogenous spread of disease Characterized by 1. Destruction of bone or costal cartilage 2. Soft tissue masses may show calcifications + rim enhancement 3. Fistulation
  54. 54. TB of the sternoclavicular J soft-tissue mass Clavical with irregular margin
  55. 55. Rarely involves the heart Tuberculoma of the Rt atrium in a patient with miliary T.B. mass pleural effusion MRI-Axial T2WI
  56. 56. Rarely involves the heart Pericardial involvement may be seen with mediastinal + pulmonary TB pericardial thickening Tuberculous pericarditis in a patient with pleuropulmonary T.B. pleural effusion Axial CT scan tuberculoma
  57. 57. T.B. spondylitis (Pott’s disease): Spine is the comment site of osseous involvement in T.B or Upper lumbar + lower dorsal are most frequently involved Vertebral body is more commonly affected than post. elements Disease process begins in ant. part of the vertebral body extension beneath infection spread to disc space by the ant./ post. L. L. Collapse of disc penetration of subchondral bone plate
  58. 58. T.B. spondylitis (Pott’s disease): Spine is the comment site of osseous involvement in T.B Upper lumbar + lower dorsal are most frequently involved Vertebral body is more commonly affected than post. elements Disease process begins in ant. part of the vertebral body Disease progression vertebral collapse
  59. 59. Oblite ra disk s ted pace T.B. spondylitis (Pott’s disease): Destructed end plates Tuberculous spondylitis. Lateral radiograph
  60. 60. T.B. spondylitis (Pott’s disease): Spine is the comment site of osseous involvement in T.B Upper lumbar + lower dorsal are most frequently involved Vertebral body is more commonly affected than post. elements Disease process begins in ant. part of the vertebral body Disease progression vertebral collapse with ant. wedging  gibbus deformity Extension may be subligamentous to distant vertebra
  61. 61. T.B. spondylitis (Pott’s disease): on erosi Subligamentous spread of spinal T.B. Lateral radiograph
  62. 62. T.B. spondylitis (Pott’s disease): Spine is the comment site of osseous involvement in T.B Upper lumbar + lower dorsal are most frequently involved Vertebral body is more commonly affected than post. elements Disease process begins in ant. part of the vertebral body Disease progression vertebral collapse In the thoracic region Paravertebral abscess =Post.mediastinal mass
  63. 63. T.B. spondylitis (Pott’s disease): s s es c bs a ue s -tis oft lytic destruction Tuberculous spondylitis. Axial CT scan
  64. 64. T.B. spondylitis (Pott’s disease): Spine is the comment site of osseous involvement in T.B Upper lumbar + lower dorsal are most frequently involved Vertebral body is more commonly affected than post. elements Disease process begins in ant. part of the vertebral body Disease progression vertebral collapse In the thoracic region Paravertebral abscess =Post.mediastinal muscles In the lumbar region =Psoas abscess
  65. 65. presacra l abscess erosion Iliopsoas abscess. Axial CT scan s se es sc ab abs ces se s T.B. spondylitis (Pott’s disease):
  66. 66. T.B. spondylitis (Pott’s disease): Spine is the comment site of osseous involvement in T.B Upper lumbar + lower dorsal are most frequently involved Vertebral body is more commonly affected than post. elements Disease process begins in ant. part of the vertebral body Disease progression vertebral collapse In the thoracic region Paravertebral abscess =Post.mediastinal muscles In the lumbar region =Psoas abscess may calcify when healed
  67. 67. T.B. spondylitis (Pott’s disease): s+ scesse ab ation calcific ab ca sce lci ss fic es at + ion Calcified psoas abscess. Axial CT scan
  68. 68. T.B. spondylitis (Pott’s disease): Spine is the comment site of osseous involvement in T.B Upper lumbar + lower dorsal are most frequently involved Vertebral body is more commonly affected than post. elements Disease process begins in ant. part of the vertebral body Disease progression vertebral collapse Paravertebral abscess MR helps in diagnosis = focal area of low T1 + high T2 SI with increased SI of disc
  69. 69. T.B. spondylitis (Pott’s disease): al spin intra sion n exte dis k nar row ing D.D. Tuberculous spondylitis. Sagittal T2WI 1- Pyogenic vertebral osteomyelitis 2- Metastases 3- Sarcoid 4- Tumor = lymphoma, multiple myeloma, chordoma 5- Other infections = brucellosis, fungus, hydatid

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