Atypical radiologic appearances of pulmonary tuberculosis in non-hiv adult patients

Transcription

1 Atypical radiologic appearances of pulmonary tuberculosis in non-hiv adult patients Poster No.: R-0200 Congress: RANZCR-AOCR 2012 Type: Educational Exhibit Authors: K. N. Jeon, K. Bae, M. J. Park Keywords: Lung, Respiratory system, Thorax, CT, Computer ApplicationsDetection, diagnosis, Infection DOI: /ranzcraocr2012/R-0200 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 49

2 Learning Objectives To be familiar with typical and atypical radiologic features of pulmonary tuberculosis (TB) in immunocompetent and immunocompromised non-hiv patients. To learn how to differentiate tuberculosis from other infectious or noninfectious disease on the basis of CT findings and clinical settings when radiologic findings show atypical patterns and sputum AFB staining is negative. Page 2 of 49

3 Background Pulmonary TB is a common worldwide infection causing high mortality and morbidity. The most common form of pulmonary tuberculosis in adults is nodular or cavitary lesions involving the apical or posterior segments of the upper lobes, or superior segments of the lower lobes. Unusual radiologic manifestations of TB may be encountered in as many as one third of cases of adult-onset tuberculosis. Page 3 of 49

4 Imaging Findings OR Procedure Details 1. Common Features of Pulmonary TB in Adults Postprimary TB is common form of tuberculosis in adults and occurs in patients previously sensitized to Mycobacterium tuberculosis. Reactivation of dormant bacilli occurs during periods of immunosuppression, malnutrition, and debilitation or as a result of aging. Postprimary TB most commonly involves the apical and posterior segments of the upper lobes and superior segment of lower lobes, often associated with cavitation. The most common route of dissemination in postprimary TB is through the bronchi. The findings of bronchogenic spread are centrilobular lesions appearing nodules or tree-in-bud appearance, bronchial wall thickening and lobular consolidation. Fig. 1: A-44 year-old woman with active TB. Chest CT scans show an irregularly marginated tuberculoma demonstrating central cavitation and associated small satellite nodules in posterior segment of left upper lobe. References: Department of Radiology, Gyeongsang National University - / Page 4 of 49

5 Fig. 2: A-25- year-old woman with active Tb. HRCT scans show an irregularly marginated tuberculoma and associated lobular consolidation, centrilobular nodules with branching, linear structure in posterior segment of right upper lobe and superior segment of right lower lobe. References: Department of Radiology, Gyeongsang National University - / Fig. 3: A-24 year-old man with active TB. HRCT scans show multiple cavitary lesions and consolidation in both upper lobes and lower lobe superior segments. Centrilobular nodules with tree-in-bud appearance and lobular consolidation are noted in both lungs suggesting bronchogenic dissemination. References: Department of Radiology, Gyeongsang National University - / 2. Atypical locations of TB in adults An atypical distribution of disease with parenchymal opacities isolated to anterior segment of the upper lobes or basilar segments of the lower lobes has been reported to occur approximately 5% cases of postprimary TB. Prior reports suggest that patients with diabetes mellitus and the elderly are predisposed to atypical distributions of disease. (1) Basal segments of lower lobes Chronic subsegmental or lobular lesions in the lower lobes are uncommon in tuberculosis. However, in old age, pregnant women and in persons with DM, the lesions are common. Page 5 of 49

6 Fig. 4: A-80-year-old male who visited the hospital with non-resolving pneumonia. (A) Chest PA shows consolidation in basal segment of left lower lobe and pleural effusion. (B-C) Chest CT scans show consolidation with volume loss in basal segments of left lower lobe. Central low-density area is noted within consolidation. Sputum smear for AFB was positive and pathologic specimen obtained by TBLB was consistent with active TB. References: Department of Radiology, Gyeongsang National University - / Page 6 of 49

7 Fig. 5: A-50-year-old male presented with chronic cough. (A) Chest PA shows an illdefined mass with a cavitation in RLL lateral basal segment. (B) Chest CT scan shows a thick walled cavity and satellite nodules. References: Department of Radiology, Gyeongsang National University - / (2) Right middle lobe & anterior segment of upper lobe TB associated with anthracofibrosis and tuberculous endobronchial disease is generally reported more often in women than men. In patients with anthracofibrosis, multiple sites were usually involved, the right lung more often than the left, and the right middle lobe more often than any other lobe, followed by the right upper, left upper, lingular division, right lower, and left lower lobe bronchi, in order of frequency. When more than one segmental or lobar bronchus, including RML, is stenotic, and/or lymph nodes are calcified, and there is associated airway hyperpigmentation, TB should be considered. This association is especially important to recognize in nonsmoking women. CT findings of bronchial tuberculosis and anthracofibrosis include bronchial narrowing or obstruction, thickening of the wall or peribronchial cuffing, endobronchial low-attenuation nodule, and lymphadenitis compressing the bronchi. Page 7 of 49

8 Fig. 6: A-69-year-old woman presented with cough and blood-tinged sputum. Chest radiograph shows ill-defined nodules in right upper lobe. Chest CT scans show a broncholith in RUL anterior segmental bronchus. Centrilobular nodules with tree-in-bud appearance and poorly marginated nodules are noted in RUL anterior segment. At bronchoscopy, luminal irregularity and edema were noted and a hard mass was aspirated. In pathologic examination, the mass was composed of calcification, consistent with broncholith. AFB smear for bronchial aspirate was positive and M. tuberculosis grew in culture. References: Department of Radiology, Gyeongsang National University - / Page 8 of 49

9 Fig. 7: A-64-year-old woman with abnormal findings on chest PA. (A) Chest radiograph shows consolidation in anterior segment of RUL and collapse of right middle lobe. (B-C) Chest CT scans show severe narrowing of segmental bronchi. Luminal narrowing with anthracotic pigmentation of anterior segment of RUL and RML bronchi was noted in bronchoscopy. M. tuberculosis grew in sputum culture. References: Department of Radiology, Gyeongsang National University - / Page 9 of 49

10 Fig. 8: A-76-year-old woman presented with hemoptysis. (A) Chest PA shows collapse of right middle lobe. (B-C) Chest CT scans show calcified lymph nodes around middle lobe bronchus and obliteration of bronchial lumen. Narrowing of right middle lobe bronchus by mucosal edema was observed in bronchoscopy. Pathologic findings of the specimen were consistent with tuberculosis. References: Department of Radiology, Gyeongsang National University - / (3) Lingular segment Page 10 of 49

11 Fig. 9: A-16-year-old woman presented with hemoptysis. (A) Chest PA shows illdefined increased opacity in left upper lobe. (B-C) Chest CT scans show a focal masslike consolidation with ground-glass opacity in lingular segment. Sputum study for AFB was negative. TBLB specimen showed chronic granulomatous inflammation with caseous necrosis, consistent with tuberculosis. References: Department of Radiology, Gyeongsang National University - / 3. Atypical patterns of TB in adults Through effective antituberculosis medication and preventive chemotherapy, we have seen relative increased of primary infection in adults, in whom TB can take an atypical course. Along with the advance of medical science, there has been an increase in immunocompromised hosts, and TB developing in these patients frequently manifests atypical patterns. (1) Lobar or segmental consolidation Segmental or lobar form of tuberculous pneumonia may occur in adults (especially in pregnant women, in persons with diabetes, and in alcoholics) secondarily from the discharge of caseous material containing tubercle bacilli (from caseous lymph nodes or tuberculous cavities) into a large airway. This form of tuberculosis is a hypersensitivity reaction to tuberculous antigen. Multifocal involvement is identified radiographically in 12-24%. Page 11 of 49

12 Radiologically TB pneumonia shows segmental or lobar consolidation similar to nontuberculous pneumonia or carcinoma with obstructive pneumonitis, thus delaying accurate diagnosis. Multiple small cavities maybe shown within a consolidation lesion. Fig. 10: A-19-year-old man presented with hemoptysis. (A) Chest PA shows diffuse consolidation in both lungs. (B-C) Chest CT scans show diffuse, multifocal consolidation without cavitation. Air-bronchogram is not seen. TB was confirmed by transbronchial lung biopsy References: Department of Radiology, Gyeongsang National University - / Page 12 of 49

13 Fig. 11: A-67-year-old diabetic woman with non-resolving pneumonia. (A) Chest radiograph shows multifocal segmental consolidation in left lung. (B-C) Chest CT shows segmental consolidations in lingular segment and superior segment of left lower lobe, similar to nontuberculous pneumonia. Sputum smear was 2+ for Tb and biopsy specimen showed consistent findings with Tb. References: Department of Radiology, Gyeongsang National University - / Page 13 of 49

14 Fig. 12: A-44-year-old man presented with hemoptysis. (A) Chest radiograph shows multifocal consolidation and ill-defined nodules in both lung.(b-c) Chest CT scans show multifocal consolidations and ill-defined nodules in both lungs. Multiple small cavities are noted within lesions. Sputum smear and culture were positive for tuberculosis. References: Department of Radiology, Gyeongsang National University - / (2) Multiple nodules or masses Scattered nodules are unusual with tuberculosis. Histopathologically, each nodule represents a conglomerated granuloma with central caseating necrosis, which is surrounded by mononuclear inflammatory cells. Page 14 of 49

15 Fig. 13: A-62-year-old man with diabetes mellitus. (A) Chest radiograph shows multiple nodules in both lungs and a focal consolidation in left lower lobe. (B-C) Chest CT shows multiple well demarcated nodules without centrilobular nodules in both lungs. Smear of bronchial aspirate was positive for M. tuberculosis. References: Department of Radiology, Gyeongsang National University - / Page 15 of 49

16 Fig. 14: A-44-year-old man presented with fever, chill, right pleuritic chest pain. (A-B) Chest CT shows multiple irregular nodules in both lungs and pleural effusion on the right. Sputum smear was positive for AFB and M. tuberculosis grew in sputum culture. References: Department of Radiology, Gyeongsang National University - / 4. Paradoxical response to TB medication Paradoxical response refers to enlargement of old lesions or unexpected appearance of new lesions during adequate antituberculous therapy. Various types of paradoxical response have been reported, including increase in size of lymph nodes and areas of pulmonary infiltration in patients with tuberculous lymphadenitis, development of new pulmonary infiltrates in patients with extrapulmonary tuberculosis, and development of tuberculous pleural effusion and progression of pulmonary infiltrates in patients with pulmonary tuberculosis, development of contralateral pleural effusion and increase in the amount of effusion in patients with tuberculous pleural effusion. Paradoxical response generally occurs 3-12 weeks after the beginning of antituberculous therapy that includes rapid bactericidal drugs like isoniazid and rifampin, and it usually regresses without a change of the initial drug regimen. Page 16 of 49

17 Fig. 15: A-31-year-old woman presented with pleuritic chest pain. (A) Chest radiograph shows infiltrates in both upper lobes and large amount of pleural effusion on the right. (B-C) CT scans show an irregular mass in right upper lobe and loculated pleural effusion with even pleural enhancement on the right. (D) Frontal chest radiograph obtained 4 months after TB medication demonstrates decreased amount of pleural effusion. However, a peripheral mass lesion is developed in right lower lobe. (E-F) CT scans show decreased size of the nodule in right upper lobe. Note a newly developed well-enhancing peripheral lung mass with central low attenuation. It abuts the thickened pleura. The mass disappeared 16 months later with use of the same medication. References: Department of Radiology, Gyeongsang National University - / Page 17 of 49

18 5. Cystic change in TB Cystic changes associated with pulmonary TB have described in several reports. It has also been reported that the cysts occurred after isoniazid treatment. The cysts may have developed from bronchiolar distributions of granuloma and consequent check-valve mechanism and excavation of excavation of caseous necrotic material by draining bronchi. Fig. 16: A-47-year-old man presented with fever. (A-C) Chest radiograph and CT shows multifocal consolidation in both upper lobes and right lower lobe. Sputum smear for AFB was positive and anti-tb medication was started.(d-f) Chest radiograph Page 18 of 49

19 and CT obtained 2 &1/2 months after initial CT reveals cystic lesions at the previous consolidation area. References: Department of Radiology, Gyeongsang National University - / 6. Peribronchial lymphadenopathy and fibrosis Intrathoracic lymphadenopathy is an uncommon manifestation in of tuberculosis in white adult, but it is relatively common in Asian or blacks with a preponderance of female subjects. In addition, intrathoracic lymph nodes are often anthracotic in aged individuals. Severe peribronchial fibrosis is a common pathologic finding in biopsy specimen. The exact etiologic factors of the fibrosis are unknown, it can be inferred that seepage of the antigen from the caseous focus stimulates fibrogenesis in hypersensitive patients. In this aspect, anthracofibrosis might be a less severe form of diffuse mediastinal fibrosis. Page 19 of 49

20 Fig. 17: A-68-year-old woman presented with voice change. (A-C) Chest CT scans show multiple lymphadenopathy and soft tissue in mediastinum and hila.(d-f) Peribronchial soft tissue with calcific foci are noted in unenhanced CT images. Mediastinoscopic biopsy was done. Pathologic specimen showed granulomatous inflammation with reactive fibrosis and anthracosis. References: Department of Radiology, Gyeongsang National University - / 7. TB mimicking lung cancer Endobronchial involvement occurs in approximately 2-4% of persons with pulmonary TB. On CT endobronchial TB typically manifests as irregular or smooth circumferential bronchial narrowing associated with mural Page 20 of 49

21 thickening. Endobronchial TB sometimes may mimic lung cancer, with segmental collapse and/or endobronchial mass. Pulmonary tuberculosis sometimes appears as an ill-defined mass at CT, simulating a primary lung cancer. Fig. 18: A-43-year-old man presented with hemoptysis. Initial chest radiograph (A) shows patchy consolidation in left upper lobe. (B)After two days left upper lobe is collapsed.(c-d) Chest CT scans obtained at the same time with (A) show soft tissue mass, obstructing left upper lobe bronchus. Patchy consolidation and ground-glass opacities are seen in both upper lobes. Sputum smear for AFB was negative. Bronchoscopic impression was lung cancer and biopsy was done. The result was consistent with tuberculosis. References: Department of Radiology, Gyeongsang National University - / Page 21 of 49

22 Fig. 19: A-76 year-old female presented with chronic cough. (A) Chest radiograph shows consolidation with volume loss of right upper lobe. (B-C) Chest CT scans show circumferential soft tissue thickening of the bronchus and consolidation in right upper lobe. Satellite nodules or cavitary lesions are not found. Sputum smear for AFB was positive and M. tuberculosis grew in sputum culture. References: Department of Radiology, Gyeongsang National University - / Fig. 20: A-51-year-old man presented with incidentally found mass. (A-B) Chest CT scans show about 3cm sized mass in left lower lobe. The margin is lobulated with some spiculation and a small eccentric calcification is noted at the periphery. CT- Page 22 of 49

23 guided needle biopsy was done. Pathologic specimen showed chronic granulomatous inflammation with caseation necrosis, consistent with Tuberculosis. References: Department of Radiology, Gyeongsang National University - / Fig. 21: A-83-year-old man presented with dyspnea. (A) Chest CT scans show a large mass in right lower lobe and pleural effusion on the right. (B-D) Chest CT scans show about 8cm size heterogeneous mass with lobulated margin in RLL. Satellite nodules are not seen. CT-guided needle biopsy was done. Pathologic specimen showed chronic granulomatous inflammation with caseation necrosis, consistent with active tuberculosis. References: Department of Radiology, Gyeongsang National University - / 8. Coexisting TB and lung cancer Lung cancer and pulmonary TB often coexist, creating a difficult diagnostic problem. Manifestation of cancer may be obscured or misinterpreted as progression of tuberculosis. Tuberculosis may favor the development of lung cancer by local mechanisms (scar cancer), or tuberculosis and cancer may be coincidentally associated. In addition, carcinoma may lead to reactivation Page 23 of 49

24 of tuberculosis. Therefore, any predominant or growing nodule should be suspicious for coexisting lung cancer in patients with tuberculosis. Fig. 22: A-48-year-old man presented with abnormal findings on chest PA. (A) Chest radiograph shows a mass lesion in left upper lobe. Multiple calcification, fibrosis and lung volume loss is associated. (B-C) CT shows a heterogeneous mass in left upper lobe with multiple calcification at the periphery. Left upper paratracheal lymph node is enlarged. USG-guided biopsy was done twice and the results were consistent with tuberculosis. The patient underwent VATS biopsy. In pathologic specimen, TB and nonsmall cell cancer was intermingled within the mass. References: Department of Radiology, Gyeongsang National University - / 9. TB in patients with DM Diabetic patients are considered a high-risk population for the development of pulmonary tuberculosis. CT findings of active tuberculosis in diabetic adult patients differ from those in patients without underlying disease. Radiological disparities in diabetic patients have been attributed to cellmediated immunological abnormalities and to polymorphonuclear cell dysfunction. Patients with diabetes mellitus have a higher prevalence of multiple cavities within any given lesion and of multilobar, nonsegmental distribution than do patients without underlying disease. In patients with diabetes, the Page 24 of 49

25 prevalence of TB in lower lung zone and anterior segments of upper lobes reportedly is higher than that in nondiabetic patients. Fig. 23: A-40-year-old man with diabetes mellitus. (A) Chest radiograph shows diffuse consolidation in both lungs. (B-D) CT shows multiple cavities in confluent consolidations in both lungs. Consolidation is nonsegmental and multiple ill-defined nodules and ground-glass opacities are seen as satellite lesions. Sputum smear for AFB was strongly positive. References: Department of Radiology, Gyeongsang National University - / 10. TB in SLE patients Patients with SLE are particularly prone to infections as a consequence of either the disease or the immunosuppressive therapies used in this illness. Infections in SLE encompass a wide range of presentations, invariably involving defects in any of the components of the immune response, particularly T-cell processes. A study of 54 patients with TB and SLE illustrates the spectrum of tuberculous infection in SLE patients, highlighting the propensity to develop middle to lower lung field and extrapulmonary TB, including arthritis, soft tissue abscesses, and genitourinary involvement. Page 25 of 49

26 Fig. 24: A-45-year-old woman with SLE. (A-B) Chest radiograph and CT shows a small cavitary lesion with smooth margin in right upper lobe. The patient had no subjective symptoms and sputum smear for AFB was negative. (C-E) Chest radiograph and CT scans obtained 20 days after initial CT, when the patient presented with dyspnea and productive cough, show multifocal consolidation with ground-glass opacities in the right lung and left lower lobe. Sputum smear for AFB was positive. References: Department of Radiology, Gyeongsang National University - / Page 26 of 49

27 Images for this section: Fig. 1: A-44 year-old woman with active TB. Chest CT scans show an irregularly marginated tuberculoma demonstrating central cavitation and associated small satellite nodules in posterior segment of left upper lobe. Department of Radiology, Gyeongsang National University - / Fig. 2: A-25- year-old woman with active Tb. HRCT scans show an irregularly marginated tuberculoma and associated lobular consolidation, centrilobular nodules with branching, linear structure in posterior segment of right upper lobe and superior segment of right lower lobe. Department of Radiology, Gyeongsang National University - / Page 27 of 49

28 Fig. 3: A-24 year-old man with active TB. HRCT scans show multiple cavitary lesions and consolidation in both upper lobes and lower lobe superior segments. Centrilobular nodules with tree-in-bud appearance and lobular consolidation are noted in both lungs suggesting bronchogenic dissemination. Department of Radiology, Gyeongsang National University - / Fig. 4: A-80-year-old male who visited the hospital with non-resolving pneumonia. (A) Chest PA shows consolidation in basal segment of left lower lobe and pleural effusion. (BC) Chest CT scans show consolidation with volume loss in basal segments of left lower Page 28 of 49

29 lobe. Central low-density area is noted within consolidation. Sputum smear for AFB was positive and pathologic specimen obtained by TBLB was consistent with active TB. Department of Radiology, Gyeongsang National University - / Fig. 5: A-50-year-old male presented with chronic cough. (A) Chest PA shows an illdefined mass with a cavitation in RLL lateral basal segment. (B) Chest CT scan shows a thick walled cavity and satellite nodules. Department of Radiology, Gyeongsang National University - / Page 29 of 49

30 Fig. 6: A-69-year-old woman presented with cough and blood-tinged sputum. Chest radiograph shows ill-defined nodules in right upper lobe. Chest CT scans show a broncholith in RUL anterior segmental bronchus. Centrilobular nodules with tree-inbud appearance and poorly marginated nodules are noted in RUL anterior segment. At bronchoscopy, luminal irregularity and edema were noted and a hard mass was aspirated. In pathologic examination, the mass was composed of calcification, consistent with broncholith. AFB smear for bronchial aspirate was positive and M. tuberculosis grew in culture. Department of Radiology, Gyeongsang National University - / Page 30 of 49

31 Fig. 7: A-64-year-old woman with abnormal findings on chest PA. (A) Chest radiograph shows consolidation in anterior segment of RUL and collapse of right middle lobe. (BC) Chest CT scans show severe narrowing of segmental bronchi. Luminal narrowing with anthracotic pigmentation of anterior segment of RUL and RML bronchi was noted in bronchoscopy. M. tuberculosis grew in sputum culture. Department of Radiology, Gyeongsang National University - / Page 31 of 49

32 Fig. 8: A-76-year-old woman presented with hemoptysis. (A) Chest PA shows collapse of right middle lobe. (B-C) Chest CT scans show calcified lymph nodes around middle lobe bronchus and obliteration of bronchial lumen. Narrowing of right middle lobe bronchus by mucosal edema was observed in bronchoscopy. Pathologic findings of the specimen were consistent with tuberculosis. Department of Radiology, Gyeongsang National University - / Page 32 of 49

33 Fig. 9: A-16-year-old woman presented with hemoptysis. (A) Chest PA shows ill-defined increased opacity in left upper lobe. (B-C) Chest CT scans show a focal mass-like consolidation with ground-glass opacity in lingular segment. Sputum study for AFB was negative. TBLB specimen showed chronic granulomatous inflammation with caseous necrosis, consistent with tuberculosis. Department of Radiology, Gyeongsang National University - / Page 33 of 49

34 Fig. 10: A-19-year-old man presented with hemoptysis. (A) Chest PA shows diffuse consolidation in both lungs. (B-C) Chest CT scans show diffuse, multifocal consolidation without cavitation. Air-bronchogram is not seen. TB was confirmed by transbronchial lung biopsy Department of Radiology, Gyeongsang National University - / Page 34 of 49

35 Fig. 11: A-67-year-old diabetic woman with non-resolving pneumonia. (A) Chest radiograph shows multifocal segmental consolidation in left lung. (B-C) Chest CT shows segmental consolidations in lingular segment and superior segment of left lower lobe, similar to nontuberculous pneumonia. Sputum smear was 2+ for Tb and biopsy specimen showed consistent findings with Tb. Department of Radiology, Gyeongsang National University - / Page 35 of 49

36 Fig. 12: A-44-year-old man presented with hemoptysis. (A) Chest radiograph shows multifocal consolidation and ill-defined nodules in both lung.(b-c) Chest CT scans show multifocal consolidations and ill-defined nodules in both lungs. Multiple small cavities are noted within lesions. Sputum smear and culture were positive for tuberculosis. Department of Radiology, Gyeongsang National University - / Page 36 of 49

37 Fig. 13: A-62-year-old man with diabetes mellitus. (A) Chest radiograph shows multiple nodules in both lungs and a focal consolidation in left lower lobe. (B-C) Chest CT shows multiple well demarcated nodules without centrilobular nodules in both lungs. Smear of bronchial aspirate was positive for M. tuberculosis. Department of Radiology, Gyeongsang National University - / Page 37 of 49

38 Fig. 14: A-44-year-old man presented with fever, chill, right pleuritic chest pain. (A-B) Chest CT shows multiple irregular nodules in both lungs and pleural effusion on the right. Sputum smear was positive for AFB and M. tuberculosis grew in sputum culture. Department of Radiology, Gyeongsang National University - / Fig. 15: A-31-year-old woman presented with pleuritic chest pain. (A) Chest radiograph shows infiltrates in both upper lobes and large amount of pleural effusion on the right. (B-C) CT scans show an irregular mass in right upper lobe and loculated pleural effusion with even pleural enhancement on the right. (D) Frontal chest radiograph obtained 4 months after TB medication demonstrates decreased amount of pleural effusion. However, a peripheral mass lesion is developed in right lower lobe. (E-F) CT scans show Page 38 of 49

39 decreased size of the nodule in right upper lobe. Note a newly developed well-enhancing peripheral lung mass with central low attenuation. It abuts the thickened pleura. The mass disappeared 16 months later with use of the same medication. Department of Radiology, Gyeongsang National University - / Fig. 16: A-47-year-old man presented with fever. (A-C) Chest radiograph and CT shows multifocal consolidation in both upper lobes and right lower lobe. Sputum smear for AFB was positive and anti-tb medication was started.(d-f) Chest radiograph and CT obtained 2 &1/2 months after initial CT reveals cystic lesions at the previous consolidation area. Department of Radiology, Gyeongsang National University - / Page 39 of 49

40 Fig. 17: A-68-year-old woman presented with voice change. (A-C) Chest CT scans show multiple lymphadenopathy and soft tissue in mediastinum and hila.(d-f) Peribronchial soft tissue with calcific foci are noted in unenhanced CT images. Mediastinoscopic biopsy was done. Pathologic specimen showed granulomatous inflammation with reactive fibrosis and anthracosis. Department of Radiology, Gyeongsang National University - / Page 40 of 49

41 Fig. 18: A-43-year-old man presented with hemoptysis. Initial chest radiograph (A) shows patchy consolidation in left upper lobe. (B)After two days left upper lobe is collapsed.(cd) Chest CT scans obtained at the same time with (A) show soft tissue mass, obstructing left upper lobe bronchus. Patchy consolidation and ground-glass opacities are seen in both upper lobes. Sputum smear for AFB was negative. Bronchoscopic impression was lung cancer and biopsy was done. The result was consistent with tuberculosis. Department of Radiology, Gyeongsang National University - / Page 41 of 49

42 Fig. 19: A-76 year-old female presented with chronic cough. (A) Chest radiograph shows consolidation with volume loss of right upper lobe. (B-C) Chest CT scans show circumferential soft tissue thickening of the bronchus and consolidation in right upper lobe. Satellite nodules or cavitary lesions are not found. Sputum smear for AFB was positive and M. tuberculosis grew in sputum culture. Department of Radiology, Gyeongsang National University - / Fig. 20: A-51-year-old man presented with incidentally found mass. (A-B) Chest CT scans show about 3cm sized mass in left lower lobe. The margin is lobulated with some spiculation and a small eccentric calcification is noted at the periphery. CT-guided needle Page 42 of 49

43 biopsy was done. Pathologic specimen showed chronic granulomatous inflammation with caseation necrosis, consistent with Tuberculosis. Department of Radiology, Gyeongsang National University - / Fig. 21: A-83-year-old man presented with dyspnea. (A) Chest CT scans show a large mass in right lower lobe and pleural effusion on the right. (B-D) Chest CT scans show about 8cm size heterogeneous mass with lobulated margin in RLL. Satellite nodules are not seen. CT-guided needle biopsy was done. Pathologic specimen showed chronic granulomatous inflammation with caseation necrosis, consistent with active tuberculosis. Department of Radiology, Gyeongsang National University - / Page 43 of 49

44 Fig. 22: A-48-year-old man presented with abnormal findings on chest PA. (A) Chest radiograph shows a mass lesion in left upper lobe. Multiple calcification, fibrosis and lung volume loss is associated. (B-C) CT shows a heterogeneous mass in left upper lobe with multiple calcification at the periphery. Left upper paratracheal lymph node is enlarged. USG-guided biopsy was done twice and the results were consistent with tuberculosis. The patient underwent VATS biopsy. In pathologic specimen, TB and non-small cell cancer was intermingled within the mass. Department of Radiology, Gyeongsang National University - / Page 44 of 49

45 Fig. 23: A-40-year-old man with diabetes mellitus. (A) Chest radiograph shows diffuse consolidation in both lungs. (B-D) CT shows multiple cavities in confluent consolidations in both lungs. Consolidation is nonsegmental and multiple ill-defined nodules and groundglass opacities are seen as satellite lesions. Sputum smear for AFB was strongly positive. Department of Radiology, Gyeongsang National University - / Page 45 of 49

46 Fig. 24: A-45-year-old woman with SLE. (A-B) Chest radiograph and CT shows a small cavitary lesion with smooth margin in right upper lobe. The patient had no subjective symptoms and sputum smear for AFB was negative. (C-E) Chest radiograph and CT scans obtained 20 days after initial CT, when the patient presented with dyspnea and productive cough, show multifocal consolidation with ground-glass opacities in the right lung and left lower lobe. Sputum smear for AFB was positive. Department of Radiology, Gyeongsang National University - / Page 46 of 49

47 Conclusion The radiologic presentation of Pulmonary TB is changing, with fading of classical distinction between primary and postprimary disease. Atypical patterns are more frequent, especially in elderly and immunocompromised patients. The radiologist must be able not only to recognize the classical feature of primary and postprimary tuberculosis but also to be familiar with the atypical patterns found in elderly and immunocompromised patients, since an early diagnosis is generally associated with a greater therapeutic efficacy. Page 47 of 49

48 Personal Information Page 48 of 49

49 References 1. Leung AN. Pulmonary tuberculosis: the essentials. Radiology. 1999;210: Lee JY, Lee KS, Jung KJ, Han J, Kwon OJ, Kim J, et al. Pulmonary tuberculosis: CT and pathologic correlation. J Comput Assist Tomogr. 2000;24: Lee KM, Choe KH, Kim SJ. Clinical investigation of cavitary tuberculosis and tuberculous pneumonia. Korean J Intern Med 2006; 21: Lee JH, Han DH, Song JW, Chung HS. Diagnostic and therapeutic problems of pulmonary tuberculosis in elderly patients. J Korean Med Sci 2005; 20(5): Kim HY, Im JG, Goo JM, Kim JY, Han SK, Lee JK, et al. Bronchial Anthracofibrosis (Inflammatory Bronchial Stenosis with Anthracotic Pigmentation): CT findings AJR 2000;174: Pérez-Guzmán C., Torres-Cruz A, Villarreal-Velarde H, Salazar-Lezama M. A, Vargas M. H. Atypical radiological images of pulmonary tuberculosis in192 diabetic patients: a comparative study Int J Tuberc Lung Dis 2001; 5: Victorio-Navarra ST, Dy EE, Arroyo CG, Torralba TP. Tuberculosis among Filipino patients with systemic lupus erythematosus. Semin Arthritis Rheum. 1996;26: Lee KS, Kim YH, Kim WS, Hwang SH, Kim PN, Lee BH. Endobronchial tuberculosis: CT features. J Comput Assist Tomogr. 1991;15: Choi YW, Jeon SC, Seo HS, Park CK, Park SS, Hahm CK, et al. Tuberculous Pleural Effusion: New Pulmonary Lesions during Treatment. Radiology : Takemura T, Akiyama O, Yanagawa T, Ikushima S, Ando T, Oritsu M. Pulmonary tuberculosis with unusual cystic change in an immunocompromised host. Pathol Int ;50: Chung MP, Lee KS, Han J, Kim H, Rhee CH, Han YC, et al. Bronchial stenosis due to anthracofibrosis. Chest 1998 ;113: Page 49 of 49