RADIOLOGIC EVALUATION OF PULMONARY NTM INFECTION. Tilman Koelsch, MD National Jewish Health - Department of Radiology
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1 Pr N op ot e fo rty rr o f ep Pr ro es du en ct te io r n RADIOLOGIC EVALUATION OF PULMONARY NTM INFECTION Tilman Koelsch, MD National Jewish Health - Department of Radiology
2 Disclosures None
3 Goals Identify the imaging features of pulmonary NTM infection on CT and X-ray Understand radiological phenotypes of pulmonary NTM infection Understand the role of other imaging modalities
4 Overview I. CT technique II. NTM imaging signs III. Radiological/Clinical Phenotypes & Secondary Causes and Underlying Disease
5 CT Technique Spiral & Volumetric CT
6 CT Technique Spiral CT Most CTs in US. Quick - One breath hold (10-30 sec) Reconstruct in: Any plane, Any thickness, 3D
7 CT Technique HRCT (1 mm) Why? Fine Details! Subtle bronchiectasis Air trapping/ Semi-Functional Evaluation Subtle interstitial disease (i.e. mild ILD or mild change)
8 CT Technique Our Protocol HRCT for initial eval Low-Dose CT if any follow-up CASE - 83 y/o M with indoor hot tub. + NTM sputum 1.5 mm HRCT 5 mm
9 CT Technique HRCT (1 mm) Often reconstructed from Spiral CT Often also: 1) End expiration (air trapping) 2) Possible Prone
10 Slice Thickness NTM from same CT, with 3 different thickness reconstructions 1.5 mm 3 mm 5 mm
11 CT Technique Contrast? Usually not needed Use for Soft Tissue Mediastinum/Hila? Pleural evaluation?
12 NTM Imaging Signs Tree-In-Bud and Centilobular Nodules Bronchiectasis Cavities Ground-Glass and Consolidation Atelectasis
13 NTM Imaging Signs Example Case - RML and Lingula - Where we are going
14 NTM Imaging Signs Centrilobular Nodules and Tree-In-Bud Typically from Airways Infection, Infection, Mucus Plugs/Aspiration
15
16 NTM Imaging Signs Bronchiectasis
17 Bronchiectasis NTM Imaging Signs
18 Bronchiectasis NTM Imaging Signs
19 figures from Bronchiectasis NTM Imaging Signs
20 Slice Thickens Bronchiectasis? 5 mm 1 mm Maybe? Yes! Bronchi bigger than arteries
21 Slice Thickens Bronchiectasis? 5 mm 1 mm Maybe? Yes! Bronchi bigger than arteries
22 Kim et al AJR 2005; 184: NTM Imaging Signs Cavities - and feeding bronchus sign
23 NTM Imaging Signs Cavities
24 NTM Imaging Signs Cavities
25 NTM Imaging Signs Cavities - and feeding bronchus sign
26 NTM Imaging Signs Cavities - and feeding bronchus sign Kim et al AJR 2005; 184:
27 NTM Imaging Signs Consolidation and Ground-Glass
28 NTM Imaging Signs Consolidation and Ground-Glass
29 Atelectasis NTM Imaging Signs RML
30 Atelectasis NTM Imaging Signs
31 Atelectasis NTM Imaging Signs RML
32 Aside: NTM with Normal CXR
33 Overview I. CT technique II. NTM imaging signs III. Radiological/Clinical Phenotypes & Secondary Causes and Underlying Disease
34 Radiological/Clinical Phenotypes of NTM I. Bronchiectasis/Tree-in-bud - Right middle lobe/lingular bronchiectasis II. Upper Lobe Cavities III. Solitary Pulmonary Nodule IV. NTM superimposed on underlying disease - Chronic Obstructive Pulmonary Disease (COPD) - Idiopathic Pulmonary Fibrosis (IPF) - Cystic Fibrosis (CF) V. Hot Tub Lung
35 Radiological/Clinical Phenotypes of NTM I. Bronchiectasis & Tree-in-Bud - CASE 1 CASE 1 Mild Look for active disease Tree-in-bud, consolidation possible look for stability (& clinical) GGO typically active inflammation
36 Radiological/Clinical Phenotypes of NTM I. Bronchiectasis & Tree-in-Bud - CASE 1 CASE 1 Mild Look for active disease Tree-in-bud, consolidation possible look for stability, (& clinical) GGO typically active inflammation
37 Radiological/Clinical Phenotypes of NTM I. Bronchiectasis & Tree-in-Bud - CASE 1 Inspiratory Expiratory Mild - no significant/minimal air trapping
38 Radiological/Clinical Phenotypes of NTM I. Bronchiectasis & Tree-in-Bud - CASE 2 CASE 2 Note RUL cystic bronchiectasis More severe: Nodules/nodular consolidations Bronchiectasis
39 CASE 2 Progression from
40 Radiological/Clinical Phenotypes of NTM I. Bronchiectasis & Tree-in-Bud - CASE 2 CASE 2 More severe, progressive Cavity formation
41 Radiological/Clinical Phenotypes of NTM II. Upper Lobe Cavities- CASE 3 CASE 3 RUL Cavity. Also bronchiectasis elsewhere Note soft tissue in cavity: Debris? Fungus? Rare cancer? Progressive enlarging solid
42 Radiological/Clinical Phenotypes of NTM II. Upper Lobe Cavities- CASE 3
43 Radiological/Clinical Phenotypes of NTM II. Upper Lobe Cavities- CASE 4 CASE 4 - More severe/ Classic upper lobe cavitary dz.
44 Radiological/Clinical Phenotypes of NTM II. Upper Lobe Cavities- CASE 4
45 Radiological/Clinical Phenotypes of NTM II. Upper Lobe Cavities- CASE Surgical Biopsy 2014 CASE 5 - Upper lobe cavitary dz. Mixed Change. Overall worsening
46 Radiological/Clinical Phenotypes of NTM II. Upper Lobe Cavities- CASE 5 CASE 5 Mixed change with progression Developed bronchocutaneous fistula. Rare. Here after surgery. Broncho-pleural fistula still
47 Radiological/Clinical Phenotypes of NTM III. Solitary Pulmonary Nodule - CASE 6 CASE 6 Solitary nodule. less common. Must still rule out other causes of nodule (i.e neoplasm)
48 Radiological/Clinical Phenotypes of NTM III. Solitary Pulmonary Nodule - CASE 7 CASE 7 Solitary Cavity Not squamous
49 Honda et al Clin Chest Med 2015; 36:1-11 Radiological/Clinical Phenotypes of NTM IV. NTM & underlying lung disease Often underlying lung disease Structural Non-structural Radiology also has role also in Risk factors for pulmonary NTM underlying disease
50 Radiological/Clinical Phenotypes of NTM IV. NTM & underlying lung disease- CASE 8 NTM in COPD/Emphysema Cavities can form: with bronchiectasis OR in preexisting disease Can spill contents
51 Radiological/Clinical Phenotypes of NTM IV. NTM & underlying lung disease- CASE 8
52 Radiological/Clinical Phenotypes of NTM IV. NTM & underlying lung disease- CASE 9 NTM in Chronic Aspiration Nothing Specific with known NTM Few months later Migratory Ground-Glass/Consolidation most suggestive Location? Anywhere, but: lower-posterior - most common. unilateral - sided sleeper? upper - gardening, yoga, cough?
53 Radiological/Clinical Phenotypes of NTM IV. NTM & underlying lung disease- CASE 9 Inspiratory Expiratory
54 Radiological/Clinical Phenotypes of NTM IV. NTM & underlying lung disease- CASE 9 Aspiration Work-up 1. Esophogram Also evaluates dysmotility Only 2 min intermittent for GERD 2. Tailored Barium Swallow with Speech Pathology Oral motility issues 3. Esophageal ph testing
55 Radiological/Clinical Phenotypes of NTM IV. NTM & underlying lung disease- CASE 10 NTM in Adult CF - often NOT specific findings
56 Radiological/Clinical Phenotypes of NTM IV. NTM & underlying lung disease- CASE 10 NTM in Adult CF Fatty Pancreas Replacement Inspiratory Expiratory Dynamic Expiratory - over 70% from Insp. ALSO TBM
57 Radiological/Clinical Phenotypes of NTM IV. NTM & underlying lung disease- CASE 11 NTM in Adult CF - example 2 more classic upper lung adult CF but normal pancreas
58 Radiological/Clinical Phenotypes of NTM IV. NTM & underlying lung disease- CASE 12 NTM in Silicosis
59 Radiological/Clinical Phenotypes of NTM IV. NTM & underlying lung disease- CASE 13 NTM in IPF
60 Radiological/Clinical Phenotypes of NTM IV. NTM & underlying lung disease- CASE 14 NTM in RA with TNF antagonist
61 Radiological/Clinical Phenotypes of NTM IV. NTM & underlying lung disease- CASE 14 NTM in RA/TNF antagonist
62 Radiological/Clinical Phenotypes of NTM IV. NTM & underlying lung disease- CASE 15 NTM in Tracheobronchomegally (aka.mounier-kuhn syndrome) Congenital large central airways
63 Radiological/Clinical Phenotypes of NTM V. Hot Tub Lung- CASE 16 Hot Tub Lung Ground-Glass Centrilobular nodules
64 Radiological/Clinical Phenotypes of NTM V. Hot Tub Lung- CASE 16 Inspiratory Expiratory Hot Tub Lung Air-trapping essentially always present Could be only finding by CT Normal CXR in 20+% Hartman et al. AJR Apr;188(4):1050-3
65 PET/CT and NTM NTM will cause increased uptake (like most infections) SUV typically about 8.5 ( ) So caution in evaluating for cancer with NTM May be useful for disease activity/response (but higher radiation) Hahm et al. Lung Jan-Feb;188(1):25-31 Treglia et al. J Comput Assist Tomogr. 2011;35(3):
66 PET/CT and NTM Lung Cancer with NTM 6/13 1/14 6/15
67 MRI and NTM Cavities - Excellent Good but not perfect for other findings. (may miss small/mild findings and change) NO Radiation Chung et al. Ann Am Thorac Soc Jan;13(1):49-
68 References Martinez S, McAdams HP, Batchu CS. The many faces of pulmonary nontuberculous mycobacterial infection. AJR Am J Roentgenol. 2007;189(1): Ellis SM. The spectrum of tuberculosis and non-tuberculous mycobacterial infection. Eur Radiol. 2004;14 Suppl 3(3):E34-E42. Ellis SM, Hansell DM. Imaging of Non-tuberculous (Atypical) Mycobacterial Pulmonary Infection. Clin Radiol. 2002;57(8): Jeong YJ, Lee KS, Koh W-J, Han J, Kim TS, Kwon OJ. Nontuberculous mycobacterial pulmonary infection in immunocompetent patients: comparison of thin-section CT and histopathologic findings. Radiology. 2004;231(3): Wittram C, Weisbrod GL. Mycobacterium avium complex lung disease in immunocompetent patients: radiography-ct correlation. BJR. 2002;75(892): Erasmus JJ, McAdams HP, Farrell MA, Patz EF. Pulmonary nontuberculous mycobacterial infection: radiologic manifestations. RadioGraphics. 1999;19(6):
RADIOLOGIC EVALUATION OF PULMONARY NTM INFECTION. Tilman Koelsch, MD National Jewish Health - Department of Radiology
Pr N op ot er fo ty r R of ep Pr ro es du en ct te io r n RADIOLOGIC EVALUATION OF PULMONARY NTM INFECTION Tilman Koelsch, MD National Jewish Health - Department of Radiology Disclosures No relevant financial
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