TB Radiology for Nurses Garold O. Minns, MD

Transcription

1 TB Nurse Case Management Salina, Kansas March 31-April 1, 2010 TB Radiology for Nurses Garold O. Minns, MD April 1, 2010 TB Radiology for Nurses Highway Patrol Training Center Salina, KS April 1, 2010 Garold O. Minns, MD Professor and Program Director Department of Internal Medicine KU School of Medicine-Wichita Radiology Page 1 of 32

2 Frontal Technique Lateral Posteroanterior (PA) view of the chest Film Radiology Page 2 of 32

3 Anteroposterior (AP) view of the chest Film Items closer to film appear smaller! Object Film Radiology Page 3 of 32

4 Items closer to film appear smaller! Object Film PA View of the Chest Radiology Page 4 of 32

5 Anteroposterior (AP) view of the chest Film AP view of the chest Radiology Page 5 of 32

6 Lateral view of the chest Film Lateral View of the Chest Radiology Page 6 of 32

7 LLL pneumonia Pleural effusions Radiology Page 7 of 32

8 Other views Decubitus Apical lordotic Suspected pleural effusion Radiology Page 8 of 32

9 Apical TB Radiology Page 9 of 32

10 Apical lordotic Film Radiology Page 10 of 32

11 Assess CXR Technical Quality Inspiratory effort 9-10 posterior ribs Penetration thoracic intervertebral disc space just visible Positioning / rotation medial clavicle heads equidistant from spinous process Inspiration: ( 10 posterior ribs) Radiology Page 11 of 32

12 1st rib 3rd rib 2nd rib 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th Radiology Page 12 of 32

13 Poor inspiration Good inspiration Radiology Page 13 of 32

14 Overexposure Exposure Proper Exposure Intervertebral Disks Penetration Radiology Page 14 of 32

15 Over-penetrated Rotated (Oblique) Radiology Page 15 of 32

16 Apicesp Worth a Second Look Retrocardiac areas (left and right) Hilar regions Below diaphragm Radiology Page 16 of 32

17 Lobar anatomy RUL LUL RML RLL LLL Left Lung Right Lung Silhouette sign Heart RML RLL Dome of Right Hemidiaphragm Radiology Page 17 of 32

18 RML opacity obscures heart border RML RLL opacity obscures diaphragm RLL Obscured Diaphragm Clear Heart Border Radiology Page 18 of 32

19 Classification of lung pathology Alveolar Interstitial Airways Radiology Page 19 of 32

20 Alveolar Disease Consolidation Confluent opacity Fluffy around the periphery Air bronchograms Ill-defined nodules Diff dx depends on: Focal Diffuse Radiology Page 20 of 32

21 Consolidation / Air Space Opacity Caused by filling of alveoli with fluid, pus, blood, cells (tumor), etc. May be diffuse, or isolated to segments or lobes of the lung May be associated with air bronchograms (air-filled bronchus surrounded by opacified lung) Pneumonia Radiology Page 21 of 32

22 Interstitial Opacity Disease localized to pulmonary interstitium, i.e., the alveolar septae and connective tissues that support the alveoli Hallmarks: Lines and/or reticulation Small, well-defined nodules Miliary pattern DDX: Pulmonary edema, interstitial lung diseases (ex. idiopathic pulmonary fibrosis), sarcoidosis, infection, tumor (lymphangitic spread), etc. Interstitial Opacity: Lines & Reticulation Radiology Page 22 of 32

23 Nodules and Masses Nodule: discrete pulmonary lesion, sharply defined, nearly circular opacity cm Mass: larger than 3 cm Describe with qualifiers: Single or multiple Size Border characteristics Presence or absence of calcification Location Well-Defined Calcification Ill-Defined Mass Radiology Page 23 of 32

24 Lymphadenopathy (LAN) Non-specific terms: Mediastinal widening Hilar prominence Specific patterns: Particular station enlargement Important to know what normal should look like in order to recognize abnormal Radiology Page 24 of 32

25 Right Paratracheal & Bilateral LAN Right Hilar LAN Radiology Page 25 of 32

26 Cysts & Cavities Abnormal pulmonary parenchymal spaces ( holes ), filled with air and/or fluid, with a definable wall (>1 mm) Cyst: congenital or acquired Cavity: caused by tissue necrosis, (inflammatory and/or neoplastic) Characterize: Wall thickness at thickest portion Inner lining Presence/absence of air/fluid level Number and location TB or Not TB? Cysts and Cavities Are there radiographic features that suggest benign vs. malignant diagnoses? 45 yo man from China with cough, wt. loss A B C D Radiology Page 26 of 32

27 Pleural Disease: Basic Patterns Effusion Angle blunting to massive Thickening Mass Air Calcification Pleural Effusion Radiology Page 27 of 32

28 Can this be TB? Typical Pattern : Post-primary TB Distribution Apical / posterior segments of upper lobes Superior segments of lower lobes Isolated anterior segment involvement unusual for M.tb (think M. avium complex) Radiology Page 28 of 32

29 Typical pattern : Post-Primary TB Patterns of disease Air-space consolidation Cavitation, cavitary nodule Endobronchial spread Miliary Bronchostenosis Tuberculoma Pleural effusions (empyema most likely in post-primary disease) Can this be TB? Atypical pattern : Primary TB Distribution : any lobe involved (slight lower lobe predominance) Air-space consolidation Cavitation is uncommon (<10%) Adenopathy is common (esp. children and HIV), predilection for right side Miliary pattern Pleural effusions Radiology Page 29 of 32

30 Miliary TB Insidious in onset, with general malaise, fever, weight loss, and sweats Typical diffuse miliary pattern often appears in the chest x-ray Sputum smear for AFB are only positive in 30% of cases Other organ involvement is not uncommon Miliary TB Radiology Page 30 of 32

31 Active pulmonary TB: HIV vs. Non-HIV Patients with HIV and TB: Normal chest x-ray, or with infiltrates in any lobes and any location No radiological appearance is pathognomonic of TB Pediatric TB Usually progression from primary TB Lower lobes Bulky lymphadenopathy LAD compression of bronchi Non-apical cavities Miliary forms Extrapulmonary Head and neck LAD (60%) Meningeal (10%) Radiology Page 31 of 32

32 Pediatric TB Pleural TB Peripheral subpleural lesions pleural cavity tubercles effusion and empyema Pleural fluid: exudate with lymphocyte predominance Pleural fluid smear and culture is only positive in 1/3 Pleural tissue culture and granulomatous histology: diagnostic yield >70% Radiology Page 32 of 32

33 Radiographic Patterns: Pulmonary TB TB Pattern Infiltrate Typical (Post-Primary) 85% upper Atypical (Primary) Upper : Lower 60 : 40 Usually upper in children Cavitation Common Uncommon Adenopathy Uncommon Children common Adults ~30% Unilateral > bilateral Effusion May be present May be present CXR Pattern: Early vs. Advanced HIV Pattern Infiltrate Early HIV (CD4>200) Typical (Post-primary) Upper lobes Advanced HIV (CD4<200) Atypical (Primary) Lower lobes, multiple sites, or miliary Cavitation Common Uncommon Adenopathy Uncommon Common Effusion Uncommon More common Radiology Page 33 of 32

34 Can this be TB? Old / healed TB Ca ++ granuloma - Ghon lesion Ca ++ granuloma and hilar node calcification - Ranke complex Apical pleural thickening Fibrosis and volume loss26 Conclusions Primary TB usually involves lower lobes Reactivation TB usually involve upper lobes TB-HIV co-infected can present with normal chest x-ray, or with infiltrates in any lobes and any location No radiological appearance is pathognomonic of TB CT scan can improve chest X-ray evaluation Other image modalities such as MRI can be helpful Radiology Page 34 of 32