Tuberculosis- what is essential to know? JK Amorosa

23 m LLL, L pl eff, endobronchial spread JuneOctober

23 m

TB - Endobronchial spread Müller, N.L et al. Diseases of the Lung Radiologic and Pathologic Correlations 2003 granuloma

22 m fever

RUL atelectasis, endobronchial TB diff: squamous cell ca

Airway TB Bronchial stenosis - lobar collapse or hyperinflation, obstructive pneumonia, mucoid impaction Bronchial stenosis - lobar collapse or hyperinflation, obstructive pneumonia, mucoid impaction Long segment narrowing with irregular wall thickening, luminal obstruction, and extrinsic compression Long segment narrowing with irregular wall thickening, luminal obstruction, and extrinsic compression Tree-in-bud opacities and traction bronchiectasis - upper lobes Tree-in-bud opacities and traction bronchiectasis - upper lobes

TB mediastinal adenopathy 19 f 19 f

Young patient with fever and chest pain Harisinghani,MG Radiographics ’00 TB mediastinal adenopathy

51 yo immigrant with fever TB mediastinal abscess

Intrathoracic- Lymphadenopathy 96% of children and 43% of adults 96% of children and 43% of adults Unilateral and right sided, involving the hilum and right paratracheal -bilateral in about one- third of cases Unilateral and right sided, involving the hilum and right paratracheal -bilateral in about one- third of cases Low-attenuation center secondary to necrosis CT – active Low-attenuation center secondary to necrosis CT – active Calcified hilar nodes and a Ghon focus (Ranke complex) - previous tuberculosis Calcified hilar nodes and a Ghon focus (Ranke complex) - previous tuberculosis

12 yo with fever and cough RUL cavity & atelectasis RUL cavity & atelectasis

RUL consolidation, minimal atelectasis and R hilar adenopathy 29 f pregnant fatigue 29 f pregnant fatigue

TB – lung parenchyma Dense, homogeneous parenchymal consolidation in any lobe, predominance in the lower and middle lobes - especially in adults Dense, homogeneous parenchymal consolidation in any lobe, predominance in the lower and middle lobes - especially in adults Looks like bacterial pneumonia except for lymphadenopathy and the lack of response to conventional antibiotics Looks like bacterial pneumonia except for lymphadenopathy and the lack of response to conventional antibiotics

29 m

Miliary pattern

32 m R hilar adenopathy Miliary pattern Focal RUL opacities

Pattern? Miliary

45 yo f asymptomatic SARCOIDOSIS, ddx:lymphoma

Calcified bilat nodules Ddx: chicken pox, histo, TB

TB Lung parenchyma Miliary 1% to 7% of patients 1% to 7% of patients elderly, infants, immunocompromised elderly, infants, immunocompromised manifestation within 6 months of initial exposure manifestation within 6 months of initial exposure Chest X-ray normal or hyperinflated Chest X-ray normal or hyperinflated evenly distributed diffuse small 2–3-mm nodules, with a slight lower lobe predominance - 85% of cases evenly distributed diffuse small 2–3-mm nodules, with a slight lower lobe predominance - 85% of cases CT is more sensitive than Chest X-ray CT is more sensitive than Chest X-ray The nodules usually resolve - 2–6 months with treatment, without scarring or calcification, The nodules usually resolve - 2–6 months with treatment, without scarring or calcification, rare: coalescence c focal or diffuse consolidation rare: coalescence c focal or diffuse consolidation

37 yo m with cough and chest pain Diff Dx: TB pleuritis, Malignancy Hemothorax Chylothorax

Intrathoracic - Pleural Effusion one-fourth of patients with primary tuberculosis one-fourth of patients with primary tuberculosis sole manifestation of tuberculosis, 3–7 months after initial exposure sole manifestation of tuberculosis, 3–7 months after initial exposure very uncommon in infants very uncommon in infants Unilateral Unilateral empyema, fistulae, bone erosion rare empyema, fistulae, bone erosion rare Residual pleural thickening /calcification Residual pleural thickening /calcification Ultrasonography (US) often demonstrates a complex septated effusion Ultrasonography (US) often demonstrates a complex septated effusion Sequalae: pleural thickening, calcification (calcified fibrothorax Sequalae: pleural thickening, calcification (calcified fibrothorax

Tuberculoma RA Tuberculoma RA TB pericarditis Harisinghani

Cardiac TB 0.5% of cases of extrapulmonary tuberculosis 0.5% of cases of extrapulmonary tuberculosis Pericardial Pericardial immunocompromised patients immunocompromised patients Myocardial involvement – rare, asymptomatic Myocardial involvement – rare, asymptomatic Thickened, irregular pericardium with associated mediastinal lymphadenopathy Thickened, irregular pericardium with associated mediastinal lymphadenopathy IVC distention IVC distention

40 yo m with cough RUL cavity; Ddx: TB, abscess, CA

55 f with fever, cough & wt loss RUL cavity, atelectasis Ddx: TB, abscess, CA

66 m cough LUL cavity, Ddx: TB, abscess, CA

62 m c cough LUL cavities and bilateral endobronchial spread Ddx: TB, CA

69 m with worsening COPD LUL cavitary lung opacity; TB Ddx: CA, abscess

Morbidly obese f in her 50’s with persistent post-op fever R apical cavity, TB; Ddx: CA

Müller, N.L et al. Diseases of the Lung Radiologic and Pathologic Correlations 2003

Parenchymal manifestation-cavity 50% of patients 50% of patients thick, irregular walls, which become smooth and thin with successful treatment thick, irregular walls, which become smooth and thin with successful treatment multiple, occur within areas of consolidation Resolution : emphysematous change or scarring multiple, occur within areas of consolidation Resolution : emphysematous change or scarring air-fluid levels: uncommon air-fluid levels: uncommon

Fibrosis, cavity and … fungus ball DX: SARCOIDOSIS STAGE IV

Single Cavity TB TB Histo Histo CA CA Abscess Abscess

69 yo pre-op Calcified granulomatous complex

Asymptomatic Calcified granulomas

Pulmonary nodule, metabolically active dx: tuberculoma Harlsinghani

TB bronchiectasis c atelectasis RUL, LLL pneumonia

TB bronchiectasis c atelectasis

62 yo f chronic cough Total left lung atelectasis with bronchiectasis

Tuberculosis Resurgence in nonendemic populations due to 1.increased migration 2. HIV Resurgence in nonendemic populations due to 1.increased migration 2. HIV Respiratory, cardiac, CNS, musculoskeletal, GI, GU systems Respiratory, cardiac, CNS, musculoskeletal, GI, GU systems History of infection or exposure to TB ca 50% History of infection or exposure to TB ca 50% Tuberculin skin test does not in exclude infection Tuberculin skin test does not in exclude infection Mimics other diseases Mimics other diseases Biopsy or culture specimens are required to make the definitive diagnosis Biopsy or culture specimens are required to make the definitive diagnosis

Pulmonary Tuberculosis Primary Primary Childhood and Childhood and 30% in adults because of lack of unexposed adult populations 30% in adults because of lack of unexposed adult populations Lymphadenopathy Lymphadenopathy Mid and lower lungs Mid and lower lungs Self-limiting Self-limiting Postprimary Adults and adolescents Reinfection with/reactivation Progressive Cavitation Upper>Lower lungs Hematogenous and endobronchial spread Airway and pleural inv Heals with fibrosis and calcification

Leung ‘In 1993, the World Health Organization declared TB to be a global emergency ‘In 1993, the World Health Organization declared TB to be a global emergency At current control levels, it is estimated that between 1997 and 2020, nearly 1 billion people will become newly infected and 70 million people will die from the disease “ At current control levels, it is estimated that between 1997 and 2020, nearly 1 billion people will become newly infected and 70 million people will die from the disease “

Increase, esp multidrug-resistant (MDR) TB Africa Africa Asia Asia Europe Europe

TB in Immunocompromised patients Higher prevalence Higher prevalence More MDR More MDR Higher prevalence of extrapulmonary Higher prevalence of extrapulmonary Normal chest radiographic findings Normal chest radiographic findings

TB Differential Dx “the mimicker” Primary: Primary: Focal opacity: pneumonia, histo Focal opacity: pneumonia, histo Adenopathy: lymphoma, sarcoid, histo, mets Adenopathy: lymphoma, sarcoid, histo, mets Pleural eff: malignancy, hemothorax, histo Pleural eff: malignancy, hemothorax, histo Reactivation: Reactivation: Cavity: lung ca, abscess Cavity: lung ca, abscess Healed (fibrotic): Healed (fibrotic): radiation fibrosis radiation fibrosis

REFERENCES Tuberculosis: A Radiologic Review Tuberculosis: A Radiologic Review Joshua Burrill, Radiographics 2007; 27: Tuberculosis from Head to Toe1 (RSNA Link) Tuberculosis from Head to Toe1 (RSNA Link) Mukesh G. Harisinghani, MD, Theresa C. McLoud, MD, Jo-Anne O. Shepard, MD, Jane P. Ko, MD, ‘00 Mukesh G. Harisinghani, MD, Theresa C. McLoud, MD, Jo-Anne O. Shepard, MD, Jane P. Ko, MD, ‘00 Radiology. 1999;210: ) State of the Art Radiology. 1999;210: ) State of the Art Pulmonary Tuberculosis: The Essentials Ann N. Leung, MD1 Pulmonary Tuberculosis: The Essentials Ann N. Leung, MD1