Radiological spectrum of Thoracic Sequelae and Complications of Tuberculosis

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1 Radiological spectrum of Thoracic Sequelae and Complications of Tuberculosis Poster No.: P-0013 Congress: ESTI 2014 Type: Educational Poster Authors: B. Alami, O. Addou, M. Jaffal, M. Y. Alaoui Lamrani, M. Boubbou, I. Kamaoui, M. Maaroufi, N. H. Sqalli, S. Tizniti; Fes/MA Keywords: Thorax, CT-High Resolution, Conventional radiography, Diagnostic procedure, Complications, Infection, Pathology DOI: /esti2014/P-0013 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 34

2 Learning objectives - To be aware of the thoracic sequelae and complications of pulmonary tuberculosis. - To demonstrate the role of cross sectional imaging in the diagnosis and management of sequelae and complications of pulmonary tuberculosis. Page 2 of 34

3 Background We report a retrospective study that evaluates 81 verified cases of pulmonary tuberculosis presenting with variety of sequelae and complications involving airways, vessels, mediastinum, pleura, and chest wall, seen during the four year- period from January 2010 to December All Our patients underwent chest radiograph and CT scan. Page 3 of 34

4 Imaging findings OR Procedure details The results that were obtained : Parenchymal lesions: residual thin-walled cavities (n=11), Cicatrization atelectasis(n=9),destruction of lung (n=7), aspergilloma (n=5), and bronchogenic carcinoma (n=2); Airway lesions: bronchiectasis broncholithiasis (n=3); (n=15), tracheobronchial stenosis (n=3), and Vascular lesions: hypertrophied bronchial arteries (n=2), Rasmussen aneurysm presenting with haemoptysis (n=1), secondary pulmonary hypertension (n=1); Mediastinal lesions: lymph node calcification (n=8), esophagobronchial fistula (n=2),, and fibrosing mediastinitis (n=1); Pleural lesions: chronic empyema (n=3), fibrothorax (n=2),, and pneumothorax (n=1); Chest wall lesions: tuberculous spondylitis (n=4), and osteomyelitis (n=1). Parenchymal lesions: residual Thin-walled Cavity Residual thin-walled cavities may be seen in both active and inactive disease. After antituberculous chemotherapy, the tuberculous cavity may disappear; occasionally, the wall becomes paperthin and an air-filled cystic space remains (Fig. 1). The wall of a chronic cavity varies from 1 cm to less than 1 mm in thickness and may be smooth, sometimes simulating an emphysematous bulla. It can be difficult to distinguish true cavities from bullae, cysts, or pneumatoceles (Fig. 2). Cicatrization and Destruction of lung Cicatrization atelectasis is a common finding after postprimary tuberculosis. Up to 40% of patients with postprimary tuberculosis have a marked fibrotic response, which manifests as atelectasis of the upper lobe, retraction of the hilum, compensatory lower lobe hyperinflation, and mediastinal shift toward the fibrotic lung (Fig. 3). A nonspecific Page 4 of 34

5 radiologic pattern of fibrosis consisting of parenchymal bands, fibrotic nodules and cavities, or traction bronchiectasis is occasionally encountered (Fig. 4). Complete destruction of a whole lung or a major part of a lung is not uncommon in the end stages of tuberculosis. Such damage results from a combination of parenchymal and airway involvement. It may result from a progressive primary infection or from postprimary tuberculosis with a prolonged process of cavitation, spread to new areas, and subsequent fibrosis (Fig. 5). Aspergilloma The prevalence of aspergilloma associated with chronic tuberculosis has been reported to be 11%. Although aspergilloma may exist for years without symptoms, hemoptysis is the most common clinical complication, with a prevalence of 50%-90%. Aspergilloma is usually located within a cavity or ectatic bronchus and consists of masses of fungal hyphae admixed with mucus and cellular debris. At radiography, a mobile, rounded mass surrounded by a crescentic air shadow is noted inside a lung cavity (Air-crescent sign or Monod sign) (Fig. 6A). CT demonstrates a mobile fungus ball, usually with air interspersed between the masses of mycelia (Fig. 6B, 7). Calcification of the mycelial ball occurs in some cases. Thickening of the walls of tuberculous cavities or of the adjacent pleura is reported to be an early radiographic sign. Bronchogenic carcinoma Bronchogenic carcinoma and pulmonary tuberculosis often coexist, creating a difficult diagnostic problem. Manifestations of carcinoma may be obscured or misinterpreted as progression of tuberculosis. Tuberculosis may favor the development of bronchogenic carcinoma by local mechanisms (scar cancer), or tuberculosis and carcinoma may be coincidentally associated. In addition, carcinoma may lead to reactivation of tuberculosis, both by eroding into an encapsulated focus and by decreasing the patient's resistance. Therefore, any predominant or growing nodule should be suspicious for coexisting lung cancer in patients with tuberculosis (Fig. 8). Airway Lesions Page 5 of 34

6 Bronchiectasis Bronchiectasis may develop as a result of tuberculous involvement of the bronchial wall and subsequent fibrosis. Bronchiectasis is seen in 30%- 60% of patients with active postprimary tuberculosis and in 71%-86% of patients with inactive disease at highresolution CT. Commonly it occurs by destruction and fibrosis of the lung parenchyma with secondary bronchial dilatation (traction bronchiectasis) (Fig. 3,5,9). Bronchiectasis located in the apical and posterior segments of the upper lobe is highly suggestive of a tuberculous origin. When multiple cavities are encountered, the possibility that cystic bronchiectasis is present in addition to necrotic cavities must be considered (Fig. 10). Tracheobronchial stenosis Tracheobronchial stenosis is not a frequent complication of pulmonary TB. Factors in pathogenesis include implantation of mycobacteria in the airway from a parenchymal lesion, direct infiltration from an adjacent node, and peribronchial extension through lymphatic drainage or haematogenous spread. Stenosis may arise from extrinsic compression, from enlarged peribronchial lymph nodes or from excessive inflammatory and fibrous reaction affecting the airway wall The CT findings include concentric narrowing of the lumen, uniform thickening of the wall, and involvement of a long bronchial segment in the fibrotic stage (Fig. 11). Broncholithiasis Broncholithiasis is an uncommon complication of pulmonary tuberculosis and is defined as the presence of calcified or ossified material within the lumen of the tracheobronchial tree. Presenting symptoms may include cough, hemoptysis, wheezing, or evidence of recurrent pneumonia. Broncholithiasis is strongly suggested at CT-scan when endobronchial or peribronchial calcified node is associated with findings of bronchial obstruction, such as atelectasis, obstructive pneumonitis, or bronchiectasis(fig. 12, 13 ). Vascular lesions: Page 6 of 34

7 Hypertrophied bronchial arteries Bronchial arteries may be enlarged in bronchiectasis associated with tuberculosis or in parenchymal tuberculosis itself. In patients with bronchiectasis, nodular and tubular structures with an appearance unlike that of lymph nodes or normal vessels in the mediastinum and around the central airway on high-resolution CT scans are suggestive of hypertrophied bronchial arteries (Fig. 14). Recognition of this finding is important so that the bronchoscopist will not biopsy the hypertrophied bronchial arteries protruding into the airway lumen. Rasmussen aneurysm presenting with haemoptysis Rasmussen aneurysm is a rare phenomenon caused by weakening of the pulmonary artery wall from adjacent cavitary tuberculosis (Fig. 15). Hemoptysis is the usual presenting symptom and may be life-threatening when it is massive. There is progressive weakening of the arterial wall occurs as granulation tissue replaces both the adventitia and the media. This is then gradually replaced by fibrin, resulting in thinning of the arterial wall, pseudoaneurysm formation, and subsequent rupture with haemorrhage. Secondary pulmonary hypertension (Fig. 16). Mediastinal lesions: Lymph Node Calcification Tuberculous mediastinal lymphadenitis is a frequent manifestation of primary pulmonary tuberculosis. It is caused by the formation of tuberculous caseating granulomas in lymph nodes, which more commonly involves the right side. In the active stage, the nodes have central low attenuation and peripheral rim enhancement at CT, which correspond to caseation or liquefaction necrosis and granulation tissue with inflammatory hypervascularity, respectively, at pathologic analysis. With treatment, the nodes change in appearance, first becoming homogeneous and finally disappearing or resulting in a residual mass composed of fibrotic tissue and calcifications without low-attenuation areas (Fig. 17). Page 7 of 34

8 Esophagobronchial fistula Esophageal involvement by tuberculosis is rare. The most common cause of esophageal tuberculosis is secondary involvement from adjacent tuberculous lymphadenitis. Presenting symptoms may include fever, cough, weight loss, dysphagia, chest discomfort, or back pain. When tuberculous lymph nodes erode the adjacent esophageal or bronchial wall, an esophagonodal or esophagobronchial fistula may be formed, which manifests as a localized gaseous collection within the mediastinum (Fig. 18). Fibrosing mediastinitis Is a non malignant acellular collagen and fibrous tissue proliferative condition occurring within the mediastinum. Tuberculous mediastinitis is rare; it progresses insidiously and may result in mild symptoms, including cough and low-grade fever, and symptoms due to compression of the superior vena cava, esophagus, and tracheobronchial tree. The CT findings include a mediastinal or hilar mass, calcification in the mass, tracheobronchial narrowing, pulmonary vessel encasement, superior vena cava obstruction, and pulmonary infiltrates (Fig. 19). Pleural lesions: Chronic empyema Pleural infection is usually caused by rupture of a subpleural caseous focus into the pleural space; less commonly, it is caused by hematogenous dissemination and contamination by adjacent infected lymph nodes. Tuberculous pleurisy progresses to become chronic tuberculous empyema, which may be defined as persistent, grossly purulent pleural fluid containing tubercle bacilli. In chronic tuberculous empyema, CT scans show a focal fluid collection with pleural thickening and calcification and with or without extrapleural fat proliferation (Fig. 20). Fibrothorax Page 8 of 34

9 Fibrothorax is defined as fibrosis within the pleural space. It is characterised by relatively smooth pleural thickening that may be calcified. There is usually marked volume loss in the affected hemithorax(fig. 20, 21). Pneumothorax Pneumothorax secondary to tuberculosis often heralds severe and extensive pulmonary involvement by the infectious process and the onset of bronchopleural fistula and empyema. It occurs in approximately 5% of patients with postprimary tuberculosis. The pathogenesis involves pleural caseous infiltrates that undergo liquefaction, resulting in pleural necrosis and rupture. If any apical abnormality is seen after reexpansion of a spontaneous pneumothorax, active tuberculosis should be considered(fig. 20, 22). Chest wall lesions: Chest Wall Tuberculosis Tuberculosis occasionally involves the sternum, the sternoclavicular joint, or a rib, leading to osseous destruction and localized abscess formation. Such involvement may occur by direct extension from a pleuropulmonary tuberculous lesion or by hematogenous spread from a distant focus. Tuberculosis of the chest wall is characterized by bone or costal cartilage destruction and softtissue masses that may demonstrate calcification or rim enhancement with or without evidence of underlying lung or pleural disease at CT (Fig. 23). Bone or cartilage may be intact in chest wall tuberculosis Tuberculous Spondylitis Tuberculous spondylitis is caused primarily by hematogenous spread of pulmonary infection and most commonly affects the lower thoracic and upper lumbar spine. The early radiographic manifestations of spinal involvement consist of irregularity of the vertebral end plates, decreased height of the intervertebral disk space, and sclerosis of the adjacent bone. With progression of disease, there is a tendency toward anterior wedging of the vertebral body, leading to kyphosis and development of a paravertebral abscess. Page 9 of 34

10 Cross-sectional imaging is required to better assess the extent of involvement and particularly for the presence of an epidural component and cord compression. MRI is the modality of choice for this, with CT with contrast being a distant second. Features include irregularity of both the endplate and anterior aspect of the vertebral bodies, with bone marrow oedema and enhancement seen on MRI. The collections are typically well circumscribed, with fluid centers and well defined enhancing margins (Fig. 24, 25). Page 10 of 34

11 Images for this section: Fig. 1: Axial CT scan shows a thin-walled cavity in the both upper lobe; stable for 2 years Page 11 of 34

12 Fig. 2: High-resolution CT scan shows a thin-walled cavity in the right lower lobe; wich was stable for 3 years Page 12 of 34

13 Fig. 3: High-resolution CT scan shows atelectasis of the right upper lobe (blue arrow), with retraction of the hilum and traction bronchiectasis (red arrow). Page 13 of 34

14 Fig. 4: High-resolution CT scan shows parenchymal bands (blue arrow) with traction bronchiectasis (red arrow). Page 14 of 34

15 Fig. 5: Contrast-enhanced CT scan shows marked shifting of the mediastinum toward the left side. The left lung is destroyed and contains cavitie (blue arrow), with traction bronchiectasis (red arrow). Page 15 of 34

16 Fig. 6: Aspergilloma within a cavity in a 45-year-old man. (A) Frontal scout view of the chest shows a mass of soft-tissue opacity (red arrow) with an air-crescent sign (blue arrow) in the left upper lobe. (B) Contrast-enhanced CT scan shows a low-attenuation soft-tissue mass (red arrow) within the cavity, along with the air-crescent sign (blue arrow). Page 16 of 34

17 Fig. 7: Aspergilloma within a cavity in a 53-year-old man. Axial and coronal CT scan show cavity with a central soft tissue attenuating rounded mass (red arrow) surrounded by a Monod sign (blue arrow). Page 17 of 34

18 Fig. 8: Bronchogenic carcinoma with postprimary tuberculosis Contrast-enhanced CT scan shows a lobulated mass in the apical segment of the right lower lobe (red arrow). Page 18 of 34

19 Fig. 9: Traction bronchiectasis in a 69-year-old man. Axial CT scan shows dilatation of bronchi (red arrow) within the right upper lobe with diffuse parenchymal fibrosis (blue arrows) and calcified pleural plaques (white arrow). Page 19 of 34

20 Fig. 10: Traction bronchiectasis in a 49-year-old man. Axial CT scan shows cystic bronchiectasis (red arrows) within the right upper lobe. Page 20 of 34

21 Fig. 11: Tracheobronchial stenosis in a 45-year-old man. Contrast-enhanced CT scan shows concentric narrowing of the left main bronchus (red arrow) with uniform thickening of the wall. Page 21 of 34

22 Fig. 12: Broncholithiasis in a 48-year-old man. Axial CT scan (mediastinal windowing) shows a broncholiths (red arrows) within bronchus in the right lower lobe. Page 22 of 34

23 Fig. 13: Broncholithiasis in a 45-year-old man. Axial and coronal CT scan (lung windowing) show a broncholith in segmental bronchus(red arrow) within the right upper lobe Fig. 14: Hypertrophied bronchial artery in a 53-year-old man who presented with hemoptysis. (A) Nonenhanced CT scan shows nodular structures in the subcarinal region (arrows). Atelectasis with traction bronchiectasis (arrowheads) is noted in the superior segment of the right lower lobe. (B) Bronchial arteriogram shows a dilated and tortuous right bronchial artery (arrows). Kim HY et al. Thoracic sequelae and complications of tuberculosis. Radiographics Jul-Aug; 21(4): Page 23 of 34

24 Fig. 15: Rasmussen aneurysm in a 43-year-old man who presented with a mild fever and a cough. (A) Contrastenhanced CT scan shows an enhancing, ovoid, cm nodular lesion (arrow) arising from a branch of the pulmonary artery (arrowhead). A left pleural effusion is noted. There is a large cavity with an air-fluid level in the right middle lobe. (B) Contrast-enhanced CT scan obtained after 9 months of treatment with antituberculous medication shows that the aneurysm has disappeared. The extent of the left pleural effusion is slightly increased. Kim HY et al. Thoracic sequelae and complications of tuberculosis. Radiographics Jul-Aug; 21(4): Fig. 16: Secondary pulmonary hypertension in a 44-year-old man who was treated for pulmonary tuberculosis. Axial CT scan shows dilatation of the pulmonary artery with interlobular septal thickening (red arrows) and pleural effusion (blue arrow). Page 24 of 34

25 Fig. 17: Lymph node calcification in a 39-year-old man who was treated for primary pulmonary tuberculosis. Unenhanced CT scan shows a hilar (white arrows) and subcarinal (red arrow) lymph nodes with calcification. Page 25 of 34

26 Fig. 18: Esophagobronchopleural fistula in a 63-year-old woman who presented with dysphagia and fever. Contrast-enhanced CT scan shows pleural thickening with calcification and extrapleural fat proliferation and foci of air (arrowheads) within the pleural cavity. There is a communication (short arrows) between the area of parenchymal consolidation and the pleural cavity. Esophageal air is noted (long arrow). Kim HY et al. Thoracic sequelae and complications of tuberculosis. Radiographics Jul-Aug; 21(4): Page 26 of 34

27 Fig. 19: Fibrosing mediastinitis in a 47-year-old woman. Axial contrast-enhanced CT scan shows a soft-tissue infiltration adjacent to the trachea and the aorta (red arrow), containing calcification (white arrow). Page 27 of 34

28 Fig. 20: Chronic empyema, fibrothorax and pneumothorax in a 42-year-old man. Axial contrast-enhanced CT scan shows a fluid collection (red arrows) in the left hemithorax with visceral and parietal pleural thickening and calcification (blue arrow) relevant to Chronic empyema and fibrothorax. There is pleural thickening with calcification and pneumothorax in the left hemithorax (white arrow). Page 28 of 34

29 Fig. 21: Fibrothorax in a 50-year-old man. Axial contrast-enhanced CT scan shows visceral and parietal pleural thickening with calcification in the left hemithorax (red arrows). There is mediastinal lymph nodes (blue arrow). Page 29 of 34

30 Fig. 22: Hydropneumothorax in a 50-year-old man After antituberculous chemotherapy. Axial CT scan shows areas of consolidation in left upper lobe (red arrow). A hydropneumothorax is noted in the left hemithorax (blue arrow) and was treated with insertion of a thoracostomy tube (white arrow). Page 30 of 34

31 Fig. 23: Chest wall abscess in a 47-year-old man. Contrast-enhanced CT scan shows a mass with low attenuation and peripheral enhancement in the anterior chest wall (red arrow). The abscess has an intracostal portion (blue arrow). Excision of the mass was performed Page 31 of 34

32 Fig. 24: Tuberculous Spondylitis in a 37-year-old man. Contrast-enhanced CT scan demonstrates collapse of T10 vertebral body (blue arrow) with paraspinal abscess (red arrow). Fig. 25: Tuberculous spondylodiscitis in a 47-year-old man. MRI shows a partiel destruction of T3-T4 vertebral bodies (blue arrows) with heterogeneous enhancement after gadolinium administration. Abscess is present in T3-4 disk space (red arrow) extending to paraspinal (yellow arrow) and anterior epidural spaces (green arrow). Page 32 of 34

33 Conclusion Various forms of thoracic sequelae and complications may result from pulmonary tuberculosis. It is imperative that radiologists and clinicians understand the spectrum of these sequelae and complications to to facilitate diagnosis. Page 33 of 34

34 References 1) P. Van Dycket al. Imaging of pulmonary tuberculosis. Euro rad August 2003, Volume 13, pp ) Wormanns D et al. Radiological imaging of pulmonary tuberculosis. Radiologe Feb;52(2): ) Eisenhuber E et al. Radiologic diagnosis of lung tuberculosis.radiologe May;47(5): ) Kim HY et al. Thoracic sequelae and complications of tuberculosis. Radiographics Jul-Aug; 21(4): ) Winer-Muram HT et al. Thoracic complications of tuberculosis. J Thorac Imaging Apr; 5(2): Page 34 of 34