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JK Amorosa. Tuberculosis Primary –selflimiting Infection in patients previously not exposed to M tuberculosis (under age 5 in the past, now common in.

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Presentation on theme: "JK Amorosa. Tuberculosis Primary –selflimiting Infection in patients previously not exposed to M tuberculosis (under age 5 in the past, now common in."— Presentation transcript:

1 JK Amorosa

2 Tuberculosis Primary –selflimiting Infection in patients previously not exposed to M tuberculosis (under age 5 in the past, now common in adults also) Postprimary-progressive Reactivation and reinfection

3 Chest X-ray is normal in TB in 50% 75% 15%

4 Manifestations of Primary TB are: Parenchymal disease Lymphadenopathy Miliary disease Pleural Effusion

5 Manifestations of Postprimary TB are: Upper lobe distribution Cavity Absence of adenopathy Airway involvement

6 Human disease causing mycobacteria are more likely: Slow growing Fast growing

7 Mycobacteria – aerobic rods Categories by disease cause: 1.tuberculosis complex: causes human disease 2.nontuberculous or atypical Categories by rate of growth: 1.rapid growing: 7 days Rapid: M.abscessus, M.fortiutum, M.chelonae Slow: MTB, MAC, M.Kansasii

8 Transmission Respiratory Desiccated bacilli remain airborne for long time – indoor close many months contact is necessary for transmission Laryngeal, transbronchial, cavitary disease produce most bacilli Ventillation reduces infectiousness

9 Lung Parenchymal involvement Primary

10 57 yo f with chronic cough

11 Value of thin section

12 Tuberculous mediastinal adenopathy

13 TB mediastinal adenopathy 19 f

14 TB mediastinal adenopathy is seen as part of Reactivation TB HIV Primary TB usually in children

15 TB mediastinal adenopathy is seen as part of Reactivation TB HIV Primary TB usually in children

16 TB Lymphadenopathy Central low attenuation Active disease Necrosis R hilar is most common

17 Pathogenesis TB bacilli in the body elicit acute inflammatory response – no symptoms Macrophages ingest bacilli and transport them to regional lymph nodes If not contained in local LNs, hematogenous dissemination of bacilli occurs and usually is contained, if not, then: miliary, meningeal, GU, MSK

18 Miliary

19 60 f smoker Langerhans Histiocytosis

20 Miliary Chickenpox pneumonia Tuberculosis, disseminated Blastomycosis, disseminated Coccidioidomycosis, disseminated Cryptococcosis Histoplasmosis, disseminated Melioidosis Blastomycosis Coccidioidomycosis, pulmonary, chronic Cryptococcosis, pulmonary Filariasis Fungal lung infection Histoplasmosis Histoplasmosis, pulmonary Parasitic lung infection Pulmonary larval infestation/nematodes Pulmonary larval migrans Schistosomiasis Chickenpox pneumonia Tuberculosis, disseminated Blastomycosis, disseminated Coccidioidomycosis, disseminatedCryptococcosis Histoplasmosis, disseminated MelioidosisBlastomycosis Coccidioidomycosis, pulmonary, chronicCryptococcosis, pulmonaryFilariasisFungal lung infectionHistoplasmosis Histoplasmosis, pulmonary Parasitic lung infection Pulmonary larval infestation/nematodes Pulmonary larval migrans Schistosomiasis Granulomatous, Inflammatory Disorders Bronchiocentric granulomatosis/lung Granulomatous lung disease Sarcoidosis Sarcoidosis, pulmonary Neoplastic Disorders Lymphomas Metastatic lung lymphatics/carcinoma Alveolar cell carcinoma, lung Carcinoma, thyroid, anaplastic Bronchiocentric granulomatosis/lung Granulomatous lung diseaseSarcoidosis Sarcoidosis, pulmonary LymphomasMetastatic lung lymphatics/carcinoma Alveolar cell carcinoma, lungCarcinoma, thyroid, anaplastic

21 Miliary cont Allergic, Collagen, Auto- Immune Disorders Pulmonary arteritis/vasculitis Rheumatoid lung disease Metabolic, Storage Disorders Histiocytosis, pulmonary Histiocytosis X Hereditary, Familial, Genetic Disorders Tuberous Sclerosis Pulmonary arteritis/vasculitis Rheumatoid lung diseaseHistiocytosis, pulmonaryHistiocytosis X Tuberous Sclerosis Anatomic, Foreign Body, Structural Disorders Atelectasis, pulmonary Reference to Organ System Respiratory distress (newborn) syndrome Pulmonary fibrosis Pulmonary microlithiasis, alveolar Poisoning (Specific Agent) Silicosis Organ Poisoning (Intoxication) Pneumoconiosis Atelectasis, pulmonaryRespiratory distress (newborn) syndromePulmonary fibrosisPulmonary microlithiasis, alveolar Silicosis Pneumoconiosis

22 Pleural Effusion TB

23 TB pleurisy Unilateral Exudative: high protein content, High WBC, low glucose Lymphocyte predominance Complications: B-P fistula, empyema 1/3 negative TB skin test

24 Pleural Effusion exudative Malignancy Pneumonia Tuberculosis Pulmonary embolism Fungal infection Pancreatic pseudocyst Intra-abdominal abscess After coronary artery bypass graft surgery Postcardiac injury syndrome Pericardial disease Meigs syndrome Ovarian hyperstimulation syndrome Rheumatoid pleuritis Lupus erythematosus Drug-induced pleural disease Asbestos pleural effusion Yellow nail syndrome Uremia Trapped lung Chylothorax Pseudochylothorax Acute respiratory distress syndrome Chronic pleural thickening Malignant mesothelioma

25 Pleural Effusion transudate : <3 g protein, low WBC, normal glucose Congestive heart failure (most common) Cirrhosis with hepatic hydrothorax Nephrotic syndrome Peritoneal dialysis/continuous ambulatory peritoneal dialysis Hypoproteinemia Glomerulonephritis Superior vena cava obstruction Fontan procedure Urinothorax CSF leak to the pleural space

26 83 f

27 TB bacilli spread to meninges via: Inhalation to lymphnodes to bloodstrean to meninges Inhalation to lymphnodes to meninges Ingestion to peritoneum to CSF Intravenous introduction to meninges

28 TB bacilli spread to meninges via: Inhalation to lymphnodes to bloodstream to meninges Inhalation to lymphnodes to meninges Ingestion to peritoneum to CSF Intravenous introduction to meninges

29 Manifestations of Postprimary TB are: Upper lobe distribution Cavity Absence of adenopathy Airway involvement

30 53 m

31 37 m

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33 40 m with cough

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37 Cavity vs cyst vs bulla Cavity: Gas-filled space in an area of lung consolidation or mass or nodule produced by the expulsion of a necrotic part of the lesion via the bronchial tree; wall thickness varies Cyst: wall thickness is 4 mm or less Bulla: wall thickness < 4 mm Often difficult to distinguish the 3 Clin Microbiol Rev April; 21(2): 305–333

38 Cavity - causes Abscess TB Ischemic necrosis (infarct) PCP Fungal process Malignancy Wegeners granulomatosis Sarcoidosis – rare COP (Cryptogenic Organizing Pneumonia -rare

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40 38 51

41 Cavity T bacilli grow in cavities which communicate with bronchi and spread infection MDR bacilli grow in cavities exclusively Hydrolytic enzymes break down lung Tuberculosis Volume 89, Issue 4, Pages , July 2009 Volume 89, Issue 4

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43 54 m

44 48 m

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46 Cryptococcus

47 35 f

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49 Aspergillus AML

50 57 f

51 Primary lung ca with mets

52 67 f

53 43 m

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55 34 m

56 43 m

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58 Bronchopneumonia

59 Invasive bronchiolar aspergillosis in a patient who underwent bone marrow transplantation RadioGraphics, Aspergillus

60 Five causes of tree-in-bud are: Bronchopneumonia Fungal Viral ABPA TB

61 Tree –in-bud pattern Rossi, SE et al: May/June 2005 Radiographics 25,3

62 Cocaine 23 m

63 25 m

64 TB in HIV

65 TB & HIV Clinical features depend on the severity immunosuppression Relatively intact cellular immunity = non– HIV-infected individuals- TB remains localized to the lung. HIV (CD4 T-lymphocyte count: <200/mm3), pulmonary TB with extra-pulmonary involvement: lymphadenitis, miliary

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67 46 m

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69 76 m emphysematous pericarditis, streptococcal

70 TB - healing Lung destruction: bronchiectasis Bronchial stenosis

71 LUL atelectasis, bronchiectasis TB

72 77 m

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74 Radical mastectomy & rad Rx

75 80 f

76 The History of Tuberculosis The Hebrew word for phthisis or consumption (schachepheth) means to waste away occurs twice in the Bible: Leviticus 26:16 I, in turn, will do this to you: I will appoint over you a sudden terror, consumption and fever that will waste away the eyes and cause the soul to pine away; also you will sow your seed uselessly, for your enemies will eat it up. Deuteronomy 28:22 The Lord will smite you with consumption and with fever and with inflammation and with fiery heat and with the sword and with blight and with mildew and they will pursue you until you perish.

77 The History of Tuberculosis By 1650 consumption was the leading cause of mortality and became a reference in some of Shakespeare's plays- one of the consumptive lovers, in "Much A Do About Nothing", as well as scrofula in "Macbeth"

78 The History of Tuberculosis Early attempts at treatment can be found throughout history Greeks believed cutting off cool air eventuated in a burning up of the tissues Romans put importance of diet Hebrews control disease from diet to the destruction of clothing Early "cures" from physicians Warm sea air Milk from pregnant women Seaweed placed under the pillow Cold baths Deep breathing

79 The History of Tuberculosis The first breakthrough came when German bacteriologist named Robert Koch isolated the infectious agent known as tuberculosis bacteria or tubercle bacilli in He was later awarded the Nobel Prize for physiology or medicine in 1905

80 The History of Tuberculosis The first sanatorium opened in 1854 in Gorbersdorf, Germany. Sick patients were given wholesome food and plenty of fresh air. This became the modern way to fight the disease. The sanatoriums provided medical care for almost 100 years and became one of the most remarkable and unique periods of medical care in history. By 1889 in the USA the National Tuberculosis Association fully realized that TB was distinctly preventable and not directly inherited No real progress was made until new antibiotics were used between It has taken almost three thousand years to understand the full nature of Tuberculosis

81 58 m

82 References Joshua Burrill, Christopher J. Williams, Gillian Bain, Gabriel Conder, Andrew L. Hine, Rakesh R. Misra RadioGraphics, 2007, Vol.27: , /rg Joshua BurrillChristopher J. WilliamsGillian Bain Gabriel ConderAndrew L. HineRakesh R. Misra RadioGraphics Santiago Enrique Rossi, Tomas Franquet, Mariano Volpacchio, Ana Giménez, Gabriel Aguilar RadioGraphics, 2005, Vol.25: Santiago Enrique RossiTomas FranquetMariano VolpacchioAna GiménezGabriel AguilarRadioGraphics JR Cohen, JK Amorosa, PR Smith –The air-fluid level in cavitary pulmonary TB, Radiology, radiology JK Amorosa, PR Smith, JR Cohen, C Ramsey… - …, Tuberculous mediastinal lymphadenitis in the adult Tuberculous mediastinal lymphadenitis in the adult 1978 – radiology Medscape Tuberculosis (TB), a multisystemic disease ….JK Amorosa….

83 Famous people who had TB Gaius Valerius Catullus (ca. 84 BC – ca. 54 BC), Roman poet Gaius Valerius Catullus Bronte sisters Elizabeth Barrett Browning Elizabeth Barrett Browning Albert Camus Anton Chekhov Maxim Gorky Franz Kafka Eugene O'Neill Molière Robert Louis Stevenson Dylan Thomas Voltaire Paul Gauguin Amedeo Modigliani Frédéric Chopin Niccolò Paganini Igor Stravinsky Cardinal Richelieu Simón Bolívar

84 Opera, Theatre, Novels - TB Puccini: La boheme Verdi: La Traviata Thomas Mann: The Magic Mountain Victor Hugo: Les Miserables Upton Sinclair: The Jungle Johnny Nolan: A Tree Grows in Brooklyn W.Somerset Maugham: Sanatorium Frank McCourt: Angelas Ashes

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