The Dr. Jae Yang Lecture: An Overview of the Radiographic Picture of TB

Transcription

1 The Dr. Jae Yang Lecture: An Overview of the Radiographic Picture of TB Harvey H. Wong, MD FRCPC MScCH Assistant Professor Department of Medicine Division of Respirology University of Toronto

2 Financial Interest Disclosure (over the past 24 months) Harvey H. Wong I have no conflict of interest.

3 Learning Objectives 1. Review lung anatomy, chest x-ray orientation, and common radiographic terminology 2. Gain an understanding of typical and atypical TB radiographic findings 3. Understand the radiographic presentations for diseases that can present similarly to TB

4 TB the great mimicker

5 What is normal?

6

7 Left Descending Pulmonary Atery SVC Aortic Arch Right Descending Pulmonary Artery

8 Cardiac Anatomy: Right Sided Chambers

9 Cardiac Anatomy: Left Sided Chambers

10 Retrosternal Airspace Hilum Scapula Lungs posteriorly should get darker as you go down more inferiorly IVC Pulmonary Vessels

11 TB or not TB Let s play

12 TB or not TB

13 TB or not TB Pulmonary tuberculosis Streptococcus pneumonia

14 Consolidation Airspace pattern fluffy

15 Consolidation Airspace pattern Air bronchograms

16 Consolidation Airspace pattern Silhouette sign

17 Differential diagnosis Anything that fills alveoli Pus infection (pneumonia), aspiration Fluid pulmonary edema (CHF, ARDS) Inflammatory cells organizing pneumonia (COP), eosinophilic pneumonia (CEP, AEP) Malignant cells lymphoma, adenocarcinoma Blood alveolar hemorrhage Protein pulmonary alveolar protenosis Fat lipoid pneumonia

18 Case 1 82 year old gentleman PMHx CLL transformed to prolymphocytic leukemia Osteoporosis Meds Alemtuzumab Vit D Calcium HPI Admitted to hospital on oncology service for presumed community acquired pneumonia and treated with moxifloxacin 1 month prior Patient was still short of breath, so a CT was ordered, so I was paged for non-resolving pneumonia

19 CXRs

20 CXRs 4 months ago 1 month ago (during admision)

21 CT

22 CT report Worsening right upper lobe consolidation with low-density areas within. This is suggestive of necrotizing pneumonia. Recommend continued followup to resolution on plain films.

23 Differential diagnosis Anything that fills alveoli Pus infection (pneumonia), aspiration Fluid pulmonary edema (CHF, ARDS) Inflammatory cells organizing pneumonia (COP), eosinophilic pneumonia (CEP, AEP) Malignant cells lymphoma, adenocarcinoma Blood alveolar hemorrhage Protein pulmonary alveolar protenosis Fat lipoid pneumonia

24 Clinical course Seen urgently in TB clinic the next day Further history revealed remote exposure to household TB contact (wife with TB adenitis who never completed treatment) Patient immediately isolated Induced sputum - AFB 3+ (AMTD +ve) Immediately started on quadruple therapy Grew fully sensitive MTB

25 Pre and Post Treatment

26 TB or not TB?

27 TB or not TB? Pulmonary TB Squamous cell lung cancer

28 Fibronodular pattern Interstitial pattern Reticular ( lace pattern )

29 Fibronodular pattern Interstitial pattern Nodular

30 The secondary pulmonary lobule

31 Tree-in-Bud

32 Fibronodular pattern Interstitial pattern differential (anything that highlights interlobular septum/ secondary lobule or causes scarring) Fibrosis ILD, radiation, bronchiectasis Infections TB, NTM, Fungal Cancer lymphangitic spread

33 Case 2 53 yo gentleman referred for TST conversion PMHx Alcohol abuse Previous cocaine abuse TBRF Refugee from Mexico 12 years prior Mother had TB Incarcerated 7 times Previously lived in homeless shelter HIV RF Multiple tattoos Multiple sexual partners (including men)

34 Further history 5 pound weight loss x 1 month Drenching night sweats x 6 months Productive cough of green sputum x 6 months Shortness of breath on exertion x 6 months Volunteers at community center

35 CXR

36 Fibronodular pattern Interstitial pattern differential (anything that highlights interlobular septum/ secondary lobule or causes scarring) Fibrosis ILD, radiation, bronchiectasis Infections TB, NTM, Fungal Cancer lymphangitic spread

37 Clinical course CT scan to rule out other disease Patient immediately told to self-isolated Induced sputum AFB 2+, AMTD +ve Started on quadruple therapy

38 CT Thorax

39 CT Thorax

40 Clinical course Fully sensitive Continue to drink and miss doses Increased liver enzymes Completed a total of 9 months of treatment

41 Pre and Post treatment

42 TB or not TB

43 TB or not TB Sarcoidosis TB lymphadenitis

44 Case 3 30 yo woman PMHx Unremarkable Meds None HPI Had an abnormal CXR on immigration CXR Completely asymptomatic TB RF Born in Nigeria BCG vaccination status unknown

45 CXR

46 Lymphadenopathy

47 Donut sign

48 Clinical course TBST 12mm induration Referred to TB clinic in Toronto Negative induced sputum x2 Organized a CT scan

49 CT

50 Differential diagnosis Infection TB Fungal Malignancy Lymphoma Inflammatory Sarcoidosis

51 EBUS

52 EBUS Video

53 Clinical course 1 st EBUS procedure Cytology and AFB negative Referred to me for second procedure 2 nd EBUS procedure (+ cores Wang needle biopsy) Cytology negative (mainly blood) Fully sensitive MTB isolated Started on treatment

54 Pre and Post treatment

55 TB or not TB?

56 TB or not TB? Pleural TB Adenocarcinoma

57 Case 4 37 yo gentleman PMHx Scolosis Medications Nil HPI 1 month history of cough, shortness of breath, subjective fever Given course of antiobiotics by walk-in CXR performed found to be abnormal (previous normal 2 years ago) Referred to respirology TB RF Born in Eritrea, came to Canada 10 years ago

58 CXR

59 Pleural effusion

60 Differential diagnosis of an exudative effusion Malignancy Primary (i.e. mesothelioma) Metastatic disease (lung, breast, colon, kidney, lymphoma, etc.) Infections Bacterial TB Viral Inflammatory Lupus Rheumatoid arthritis Mixed connective tissue disease Pulmonary embolism

61 Clinical course Attempted thoracentesis Patient became vasovagal and decline further attempts Induced sputum x1, then referred to me in TB clinic TB clinic Patient was isolated based on CXR and another induced sputum ordered CT scan also ordered

62 CT Thorax

63 Clinical Course Taken off isolation after CT scan Induced sputums negative x2 EBUS of sucarinal lymph node - negative Underwent pleuroscopy Chronic necrotizing granulomatous inflammation Started empirically on quadruple therapy MTb isolated fully sensitive

64 Pre and Post treatment

65 TB or not TB Pulmonary TB Pulmonary aspergillosis

66 Case 5 84 yo woman from a nursing home PMHx HTN DM2 Dementia Gout Dyslipidemia OA Pulmonary fibrosis Remote TB (18 years old treated in Hong Kong)

67 Further history Referred to me in my general respirology clinic for cavitary lesion Saw my colleague 2 years ago for mild pulmonary fibrosis lost to follow up CT showed 1 cm cavitary lesion CXR report from GP 1 year ago showed 4cm cavitary lesion possible TB CT scan 2 months ago showed 5cm cavitary lesion possible TB

68 CXR

69 Differential diagnosis C cancer (especially squamous cell) A autoimmune (GPA, RA) V vascular (septic emboli) I infectious (bacterial, TB, NTM, fungal) T trauma (pneumatocele) Y young/ congenital (cystic adenomatoid malformation)

70 Clinical course Admitted directly to respirology under negative pressure isolation Induced sputum AFB 3+ AMTD +ve Started on quadruple therapy Transferred to West Park Contact tracing

71 Some take home points TB has many faces CXR is an important screening tool, but you miss a lot

72 Now, you should have 1. Better knowledge in lung anatomy, chest x-ray orientation, and common radiographic terminology 2. Greater understanding of typical and atypical TB radiographic findings 3. Increased appreciation for the radiographic presentations for diseases that can present similarly to TB

73 Thank you