Extraordinary Patterns of Tuberculosis

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1 Extraordinary Patterns of Tuberculosis E. Kadakovska Infectology Center of Latvia, Clinic of Tuberculosis and Lung Diseases, Diagnostics and Radiology Department 1

2 Target Importance of recognizing of tuberculosis (TB) Identify the clinical and radiological findings in lung: common, uncommon, Identify TB of extrapulmonary sites. 2

3 Tuberculosis (TB) airborne, contagious disease with chronic course the most common cause of infectious disease related mortality worldwide. definitive diagnosis of TB can only be made by culturing M. Tuberculosis or histology. 3

4 Epidemiology 2 billion people, 1/3 of the world s population, are infected with TB bacilli someone in the world is newly infected every second 3 million people worldwide die each year there were ~ 9.4 million new TB cases in 2008, ~ lethal cases every day, ~ 2 3 million deaths per year UNAIDS, WHO. AIDS Epidemic Update, December 2009 WHO. Global Tuberculosis Control, A short update to the 2009 report 4

5 Epidemiology 5

6 HOT SPOTS of TB 95 % of new TB cases 6

7 Case notification of TB in Latvia years Infectology centre of Latvia, 2010 /

8 Prevalence of TB in Baltic States Data collected from TB control programmes and estimates generated by WHO,

9 TB treatment success rate in Baltic States Data collected from TB control programmes and estimates generated by WHO,

10 Clinical manifestations variable and depend on a number of factors. before global epidemic of HIV, ~ 85% - limited to the lungs, ~ 15% nonpulmonary or both pulmonary and nonpulmonary sites Farer, L. S., L. M. Lowell, and M. P. Meador Extrapulmonary tuberculosis in the United States. Am. J. Epidemiol. 109:

11 Pulmonary tuberculosis classically divided: Primary TB lymphadenopathy and parenchymal disease primary postprimary (reactivation) tuberculosis. MaherD, Raviglione M. Global epidemiology of tuberculosis. Clin Chest Med 2005;26(2): McAdamsHP, Erasmus J, Winter JA. Radiological manifestations of pulmonary tuberculosis. Radiol Clin North Am 1995;33(4): Postprimary TB parenchymal disease 11

12 Primary tuberculosis parenchymal disease lymphadenopathy pleural effusion Lymphadenopathy and parenchymal disease miliary disease atelectasis (compression of airways) Lymphadenopathy and parenchymal disease Woodring JH, Vandiviere HM, Fried AM, Dillon ML, Williams TD, Melvin IG. Update: the radiographic features of pulmonary tuberculosis. AJR Am J Roentgenol 1986;146(3):

13 Postprimary tuberculosis Parenchymal disease with cavitation parenchymal disease with cavitation: S1/2,S6, patchy, poorly defined consolidation, airway involvement, pleural extension other complications Parenchymal disease with airway involvement Andreu J, Cáceres J, Pallisa E, Martinez-Rodriguez M. Radiological manifestations of pulmonary tuberculosis. Eur J Radiol 2004;51(2):

14 Postprimary tuberculosis TB, parenchymal disease with cavitation Most challenging issue - differentiate severe posttb changes, new onset Tb. TB scars, bronchopneumonia TB, parenchymal disease & HIV 14

15 Typical CT finding tree in bud : TB, tree in bud 5 10 mm centrilobular nodules branching linear structures lobular consolidation cavitation bronchial wall thickening TB, parenchymal disease with cavitation COPD, bronchiectasis, bronchopneumonia 15

16 MDR TB ordinary or extraordinary? The imaging patterns of MDR (multidrug resistant) Tb are similar to those of non-mdr Tb. TB, parenchymal disease with cavitation 16

17 Causes of a missed diagnosis TB with predominantly l/n + airways involvement failure to recognize hilar and mediastinal lymphadenopathy as a manifestation of primary or postprimary disease in adults, TB with predominantly l/n + airways involvement 17

18 Causes of a missed diagnosis Chest plain film, without pathology overlooking of mild parenchymal abnormalities in patients with reactivation disease, Miliary pattern of TB 18

19 Causes of a missed diagnosis TB, parenchymal disease failure to recognize that an upper lobe nodule or mass surrounded by small nodular opacities or scarring may represent Tb. TB, parenchymal disease 19

20 Causes of a missed diagnosis TB, parenchymal disease right lobe Squamous cell carcinoma left lobe any image of lung pathology can mimic an image of Tb and vice versa, clinical examination and etiology are of paramount importance. 20

21 Causes of a missed diagnosis TB, parenchymal disease both lungs, squamous cell carcinoma left lobe One of the biggest challenges in differential diagnosis of chest imaging remains single pulmonary nodule (SPN). 21

22 Causes of a missed diagnosis TB, parenchymal disease like SPN Multiple mieloma, same patient CT has had a major influence on the evaluation of SPNs and/or Tb with regard to defining morphological features, detecting calcification, planning and performing diagnostic FNA or biopsy, evaluation of chest pathology at all. 22

23 Extraordinary patterns TB, with galaxy sign like sarcoidosis Recently we face a new complexity as presentations of Tb become change constantly. TB, with ground glass opacity 23

24 Extraordinary patterns TB, miliary pattern with diffuse bilateral areas of GGO single or multiple nodules or masses, basilar infiltrates, miliary TB with diffuse bilateral areas of ground glass opacity reversible multiple cysts. TB, parenchymal disease described as reversible multiple cysts Lee JY, Lee KS, Jung KJ, Han J, Kwon OJ, Kim J, Kim TS.J Pulmonary tuberculosis: CT and pathologic correlation. Comput Assist Tomogr Sep-Oct;24(5):

25 weakest links Lymphadenopathy and severe parenchymal disease, 9 month Mild parenchymal disease HIV infection immunosuppressant therapy: steroid therapy, chemotherapy, diabetics, elderly people, alcohol abuse, malnutrition, children without vaccination. 25

26 Immunocompromised patients TB, parenchymal disease with cavitation higher prevalence of multiple cavities in a tuberculous lesion with nonsegmental distribution compared to patients without underlying disease. TB, sever parenchymal disease with cavitation 26

27 Immunocompromised patients the incidence of Tb in patients with idiopathic pulmonary fibrosis (IPF) is 4x higher. atypical manifestations subpleural nodules lobar or segmental airspace consolidation may mimic lung cancer or bacterial pneumonia. IPF + TB, subpleural nodules & airspace consolidation 27

28 Epidemiology HIV/TB 28

29 HIV/TB: Profound Effect on Individuals The annual risk of TB in HIV infected approximates the lifetime risk of HIV uninfected Small and Fujiwara, N Eng J Med 343:189,

30 HIV/TB: extraordinary patterns of TB TB, parenchymal disease and miliary pattern, ground glass opacity Paradoxical worsening of TB lymphadenitis HIV is fueling the TB epidemics, the presence of other infections, including TB, may allow HIV to multiply more quickly result in more rapid progression of HIV disease HAART may result in paradoxical worsening or TB manifestations, may become typical as immune system repairs. 30

31 Clinical presentation and CD4 Mild immunosuppression (CD4 > 500) are more likely to present with signs and symptoms of pulmonary TB. 31

32 Clinical presentation and CD4 TB, lymphadenopathy with no parenchymal changes Advanced stages of HIV (CD4 < 500): pulmonary cavities absent infiltrates in middle and lower lobes nodular infiltrates effusions can be pleural and pericardial mediastinal lymphadenopathy with no pulmonary infiltrates normal CXR 10 % 32

33 Immunocompromised patients TB, parenchymal disease described as lymphoproliferative type pattern of disease is different, have a higher prevalence of extrapulmonary involvement. 38% of immunocompromised patients with Tb had pulmonary involvement only, 30% had extrapulmonary involvement only, 32% had both pulmonary and extrapulmonary involvement Small PM, Schecter GF, Goodman PC, Sande MA, Chaisson RE, Hopewell PC. Treatment of tuberculosis in patients with advanced human immunodeficiency virus infection. ;(5):

34 Extrapulmonary involvement diagnosis of TB some times becomes a dilemma delay in diagnosis and immunocompromised patients increase number of cases of extrapulmonary tuberculosis. negative smear for AFB, a lack of granuloma on histopathology, and negative culture do not exclude the diagnosis of tuberculosis. 34

35 Diagnosis of TB some times becomes a dilemma Miliary TB Plain film due to pain MR ankylosis due to posttb changes Chest CT without changes Chest CT miliary TB Bone destructions and abscesses 35

36 Miliary TB widespread hematogenous may be the only pulmonary abnormality 1- to 3-mm diameter nodules randomly distributed throughout both lungs thickening of interlobular septa and fine intralobular networks localized ground-glass opacity Chest CT miliary TB 36

37 Complications and Sequelae of Tuberculosis airways, vessels, mediastinum, pleura, or chest wall Chest CT pleural and chest wall TB 37

38 Airway Tuberculosis Chest CT bronchial deformity the most common cause of inflammatory stricture bronchial stenosis circumferential wall thickening and luminal narrowing, with involvement of a long segment of the bronchi airways are irregularly narrowed in their lumina and have thick walls Chest CT TB bronchiolithiasis 38

39 Lymphadenopathy and extrapulmonary involvement US supraclavicular, axillar l/n enlarged necrotic lymph nodes, central areas of low attenuation and peripheral enhancement Chest CT intea & rxtrathoracic l/n & abscess 39

40 TB of larynx, throat Chest CT throat TB result of direct extension from tuberculous lymph nodes, endobronchial spread of infection, lymphatic dissemination, patients: y., elderly. Chest CT larynx TB 40

41 Skeletal TB pulmonary involvement < 50 % spine is the most frequent site, CT spinal TB the most frequent - vl1, 1< vertebra is typically affected, vertebral body is more commonly involved than the posterior elements paravertebral abscesses MR spinal TB 41

42 TB of mammary glands Mammography spiculated mass infrequent occurrence types: nodular mimics carcinoma, diffuse sclerosing. spread: direct, lymphatic, haematogenous. Ultrasound untypical cystic mass 42

43 Diagnosis of TB some times becomes a dilemma biopsy or culture specimens are required to make the definitive diagnosis, radiologists and clinicians have to understand distribution, patterns, imaging manifestations. 43

44 Diagnosis of TB some times becomes a dilemma TB cannot be confidently diagnosed on the basis of chest radiographic or CT findings alone technical parameters are important. 44

45 Tuberculosis (TB) WHO future plans WHO is working to dramatically reduce the burden of TB, halve TB deaths and prevalence by 2015, through its Stop TB Strategy and supporting the Global Plan to Stop TB. 45

46 WHO: The Global Plan to Stop TB access to quality (individual) TB diagnosis and treatment for all TB/HIV, MR TB EU: morbidity of TB (65/ / ) mortality of TB (8/ / ) TM+ (46% 70% 2015.) to cure 85% of TB patients (in Latvia 75% 2009.) 46

47 take home message 1. Tb exists. 2. Tb has lots of faces. 3. Diagnosis of Tb is teamwork. 4. Technical parameters of exams are very important. 47

48 Conclusion I 1. TB is the most common cause of infectious disease related mortality worldwide 2. It can sometimes be difficult to differentiate between primary and postprimary TB both clinically and radiologically, since their features can overlap. 3. There are not actually just TB specific clinical or radiological signs. 48

49 Conclusion II 4. Tuberculosis may simulate many other diseases. 5. Tuberculosis can affect virtually any organ system in the body 6. Diagnostic of tuberculosis is complex action and result of team - work. 49

50 References 1. D. Olivieri, Interstitial Lung Diseases, Karger, A.Nour-Eldin, Practical approach to Interstitial Lung Diseases 3. U.Costabel, B.M. du Bois, J.J. Egan, Diffuse Parenchymal Lung Disease, Karger, M. Maffessanti, G. Dalpiaz, Diffuse Lung Diseases, Clinical Features, Pathology, HRCT, Springer, W. Richard Webb et al., High-Resolution CT of the Lung, Second Edition, Lippincott Raven, 6. S. Raoof, A. Amchentsev et al, Multinodular Disease: A HRCT Scan Diagnostic Algorithm, Chest 2006, 129, E.Eisenhuber, The Tree in Bud Sign, Radiology 2002, 222, Jud W. Gurney et al., Diagnostic Imaging: Chest, 2006, Amirsys, V1/ O.N. Hatipoglu, E Osama et al, High resolution computed tomographic findings in pulmonary tuberculosis, Thorax 1996, 51,

51 References 10. Jung-Gi Im, Harumi Itoh et al, Pulmonary Tuberculosis: CT Findings Early Active Disease and Sequential Change with Antituberculous Therapy, Radiology 1993, 186, Fumito Okada, Yumiko Ando, Clinical/Pathologic Correlations in 533 Patients With Primary Centrilobular Findings on High- Resolution CT 12. K.S.Ko et al, Reverible Cystic Disease Associated with Pulmonary Tuberculosis, Radiology, 1997, 204, M.I. Najjar et al, Case of Miliary Tuberculosis With Cystic CT Scan Changes, Chest,

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