David E. Griffith, MD has the following disclosures to make:

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1 Diagnosis of TB: Radiology David E. Griffith, MD March 13, 2015 TB for Pulmonologist March 13, 2015 Phoenix, AZ EXCELLENCE EXPERTISE INNOVATION David E. Griffith, MD has the following disclosures to make: No conflict of interests No relevant financial relationships with any commercial companies pertaining to this educational activity 1

2 Diagnosis of TB: Radiology David E. Griffith, M.D. Professor of Medicine UTHSCT Assistant Medical Director Heartland National TB Center Primary Tuberculosis usually asymptomatic: most common radiographic appearance normal Ghon lesion calcified nodule with parenchymal scar. Ranke complex Ghon lesion & calcified hilar node. may have hematogenous spread, which also calcifies as immunity develops. in 5-10% the infection is poorly controlled, resulting in progressive primary tuberculosis. 4 2

3 Primary Tuberculosis Most commonly in children, immune compromised patients (HIV seropositive, TNFα blockers) Opacities are seen in middle and lower lungs Most frequently unilateral, right middle lobe, lower lobes focal pneumonitis, with caseous necrosis and lymphatic spread to ipsilateral hilar and mediastinal nodes. Primary Tuberculosis Hilar or paratracheal lymphadenopathy with or without a infiltrates is characteristicand may cause bronchial compression. Bilateral lymphadenopathy in up to 15% Lymphadenopathy may result in lobar atelectasis due to bronchial compression. 6 3

4 Lymph nodes associated with the lungs /richtlijn/item/pagina.php&id=22056&richtlijn_id=396 Lymphadenopathy more common in primary TB than post primary TB central necrosis particularly high incidence in AIDS, associated with rim enhancement (85%) 8 4

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7 Where s the Adenopathy? Courtesy: Dr. Santiago R 7

8 18 M with HIV Courtesy: Dr. Santiago R Progressive primary tuberculosis extensive cavitation of tuberculous pneumonia with endobronchial spread rupture of necrotic nodes into bronchi results in further endobronchial spread, as well as hematogenous spread pleural effusion (25%) hypersensitivity reaction. 16 8

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10 Reactivation tuberculosis characteristically have apical abnormalities.(up to 90%) usually posterior segment upper lobe. 19 Reactivation tuberculosis Radiographic findings patchy consolidation with streaky opacities (100%) primarily apical posterior upper lobes (90%) cavitation 45% bronchogenic spread of disease with ill-defined nodules (20-25%) fibrosis (30%) pleural effusion (20%) 20 10

11 Post primary or reactivation tuberculosis Post primary or reactivation tuberculosis 11

12 Post primary or reactivation tuberculosis Tuberculous cavities usually have thick, irregular walls with treatment, walls thin and cavity shrinks and usually collapse 24 12

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14 Consumption Courtesy: Dr. Santiago Re 14

15 primary TB (25%) Pleural effusions hypersensitivity reaction to TB proteins organisms uncommonly isolated from fluid may be unassociated with obvious parenchymal disease on CXR 29 15

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17 Pleural effusion post primary TB (20%) caused by rupture of a tuberculous cavity into the pleural space, causing empyema may cause bronchopleural fistula with air fluid levels often results in irreversible pleural thickening and calcification 33 17

18 Diagnosis? xxxxxx 18

19 Empyema Necessitatis xxxxxx CT / HRCT findings airspace consolidation cavitation ill defined air space nodules (endobronchial spread) small diffuse nodules (miliary) due to hematogenous dissemination 38 19

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21 Tree in bud represents solid caseous material filling or surrounding terminal bronchioles or alveolar ducts. may coalesce, resulting in focal areas of bronchopneumonia usually reversible, resolving within 5-9 months of treatment 41 Tree in Bud Courtesy: Dr. Santiago R 21

22 CT/ HRCT findings pleural effusion lymph node enlargement with central necrosis interlobular septal thickening bronchovascular distortion and impaction 44 22

23 CT / HRCT more sensitive than chest radiography in detection and characterization of parenchymal and mediastinal disease, particularly in primary tuberculosis more accurately defines and characterizes lymphadenopathy 45 Miliary TB fine nodular or reticulonodular pattern, evenly distributed distinguished from endobronchial spread by uniform size of nodules and even distribution can occur with reactivation of progressive Primary TB 46 23

24 Millet Seeds Slender plant, 1-15 feet Maize like kernels: ~ 2 mm in diameter 1/6 of world grain 1/3 of grain for 3 rd world Africa and India Producer: India 24

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26 Reactivation TB complications pneumothorax due to cavity rapture into pleural space can also occur due to formation of subpleural blebs Endobronchial stenosis 52 26

27 Mycetomas (fungus balls) common in patients with cavitary tuberculosis colonization of cavities by aspergillus best shown by CT 53 Mycetoma intracavitary mass with an air-crescent sign changes position in cavity with prone/ decubitus scans not specific to tuberculous cavities (sarcoid, bulla, etc.) 54 27

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29 TB and AIDS TB reported in up to 10% of AIDS patients radiographic appearance is more similar to primary TB, although reactivation is the most likely mechanism non cavitary consolidation in upper & lower regions associated with hilar / mediastinal lymphadenopathy 57 TB: Lymphadenopathy in AIDS Courtesy of Dr. Diane Strollo 29

30 TB: Lymphadenopathy in AIDS Central necrosis Peripheral enhancement Courtesy of Dr. Sandy Rubin Tuberculosis and HIV 30

31 TB and AIDS if CD4 count greater than 200, tuberculosis is indistinguishable from non-hiv patients (upper lobe cavitary infiltrates) if CD4 count less than 200, radiographic findings are similar to primary tuberculosis (80%) Dissemination is also more common in patients with greater degrees of immunocompromise, with miliary and extrapulmonary disease 62 31

32 TB and AIDS Normal CXR reported in up to 15% of AIDS / HIV patients with isolated TB CT much more sensitive in these cases 64 32

33 TB and AIDS 30-60% with tuberculosis have extra pulmonary foci, and only half of these have identifiable concomitant pulmonary infection abscesses of multiple organs including prostate, liver, spleen, chest and abdominal wall, and pancreas 65 Extrapulmonary manifestations of Tuberculosis exposure of superficial mucosal surfaces to infected respiratory secretions contiguous spread lymphohematogenous dissemination (especially in immunocompromised hosts) 66 33

34 Extrapulmonary Tuberculosis can affect any organ Cardiac: pericarditis, pericardial effusion, myocarditis CNS: meningitis, tuberculomas, tuberculous abscesses, cerebritis, and miliary TB Head and neck: lymphadenitis (scrofula), less common sinonasal, thyroid, skull base Musculoskeletal: spinal column, pelvis, hip, and knee (spondilytis, osteomyelitis, arthritis) Abdominal: lymphadenopathy, peritonitis, ileocecal region, hepatosplenic, adrenal Genitourinary: renal, ureters, bladder, genital (fallopian tubes in women and seminal or prostate gland in men) 34

35 Hematogenous dissemination involves organ systems in proportion to blood flow spleen,liver,lungs, bone marrow, kidneys, adrenals, eyes splenomegaly or hepatomegaly with small abscesses meningitis, choroid plexus, pericarditis 69 Hematogenous dissemination tuberculous meningitis thought to occur via rupture of a subependymal tubercle into the subarachroid space basal meninges most commonly involved Secondarily results in cortical and lacunar brain infarction, and spinal cord infarction 70 35

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38 Bone involvement Potts disease Tuberculous spondylitis destructive lesions in spine primarily centered in vertebral discs, and secondarily involving vertebral end plates, resulting in kyphosis. May result in paravertebral abscess Cold abscess. Extends under anterior longitudinal ligament, involving multiple vertebra

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40 Bone involvement also involves other joints hip, knee, tarsal joints cartilage destruction with articular defects 79 GI involvement increased incidence in AIDS ingestion of tuberculous sputum ileocecal area, ascending colon, most common sites 80 40

41 Tuberculous peritonitis complication of GI involvement ascites low density lymphadenopathy adhesions with bowel obstruction 81 41

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43 1 year old child with pneumonia year old mother of child with pneumonia 86 43

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