Pulmonary Tuberculosis นพ. ชัชชัย หอมเกตุ

Pulmonary Tuberculosis Primary Tuberculosis Secondary Tuberculosis

Primary tuberculosis Clinical feature Asymtomatic 65% Non specific symptom when present Progressive primary complex Fever, cough,hemoptysis,weightloss

Primary tuberculosis 1. Parenchymal consolidation 2. Lymphadenopathy 3. Pleural effusion 4. Atelectasis

Primary tuberculosis Consolidation • Pneumonic type common • Unilobar > multilobar • Lobar pneumonia almost always associated with lymphadenopathy - Infiltrate + ipsilateral adenopathy–think TB • Cavitation is rare

Consolidation in primary tuberculosis Consolidation in primary tuberculosis. Frontal chest radiograph demonstrates consolidation in the right middle lobe (straight arrow) with right hilar adenopathy (curved arrow).

Primary pulmonary tuberculosis Lymphadenopathy • Mostly ipsilateral hilar and/or paratracheal. Bilat. up to 31 % • Usually right-sided • Much more common in children (95%), adult (43%) • CT: peripheral enhancement , central low-attenuation

Primary tuberculosis Atelectasis and pleural effusion • Pleural effusion very common in young children

Primary tuberculosis Atelectasis • Classically affects anterior segments of upper lobes, or medial segment of the RML

Secondary tuberculosis Synonyms Reactivation TB Reinfection TB Postprimary TB Site of involvement Lung parenchyma - classically the apical and posterior segments of the upper lobes, superior segments of the lower lobes Trachea and major bronchi - endobronchial TB Pleura - tuberculous pleuritis

Secondary tuberculosis 1. Consolidation 50-70% 2. Cavitation 40-45% 3. Nodule 4. Airway involvement

Primary tuberculosis Consolidation • Heterogenous, nodular, linear • calcified primary complex may be identified • Apico, posterior of upper lobe 85% Superior segment of lower lobe 14%

Primary tuberculosis Cavity Tuberculous cavitation most commonly occurs within areas of consolidation and indicates a high likelihood of activity. Cavities are often multiple and demonstrate thick, irregular walls. Air-fluid levels are rare, but when present they suggest the possibility of superinfection

Cavitary postprimary tuberculosis. Frontal radiograph demonstrates a thick-walled cavity with smooth inner margins in the left upper lobe (arrow). Pulmonary tuberculosis with cavity

Primary tuberculosis Nodule -Tuberculoma -SPN:variable borders, satellite lesions Upper lobe -Endobronchial -Centrilobular nodule, tree in bud (CT) -Hematogenous spread -Miliary , 1-3 mm, random

Endobronchial spread of tuberculosis Endobronchial spread of tuberculosis. Axial CT scan shows severe changes of bronchiolar dilatation and impaction. Bronchiolar wall thickening (straight arrows) and mucoid impaction of contiguous branching bronchioles produce a tree-in-bud appearance (curved arrows).

Primary tuberculosis Airway involvement -Bronchiectasis -Bronchitis -Air way narrowing

HIV and TB CD4 count < 200/mm3 , primary TB pattern CD4 count > 200/mm3 , secondary TB pattern

Primary tuberculosis Delayed hypersensitivity 6-10 wks after initial exposure, then +PPD Clinical infection following first exposure Ghon focus : local infection Ranke complex : local infection with lymph node spread Often asymptomatic in children Adults : wt. loss, fever, cough, hemoptysis Radiography may be normal Air space consolidation maybe lobar : often slow to clear Atelectasis in child Cavitation and miliary spread uncommon Lymphadenopathy common in children, uncommon in adults Pleural effusion maybe seen without lung dz

Postprimary tuberculosis Immediate hypersensitivity Reactivation of latent infection Most often involve apical and posterior segment of upper lobe and superior segment of lower lobe Often asso. with progressive disase Cavitation is common, endobrochial spread may occur. Fatigue, night sweat, wt loss,low grade fever Radiographic finding Poorly defined area of consolidation Cavitation visible 20-45% Tree in bud on HRCT Lymphadenopathy and effusion uncommon Miliary spreading Airway stenosis Tuberculoma

The end