Experiencing technical difficulties? Please call Adobe Connect for technical assistance at 1-800-422-3623 Pediatric TB Radiology: It s Not Black and White Part 2 June 18, 2018 A National Webinar June 18, 2018 1
Faculty Ann M. Loeffler, MD Thienkhai Vu, MD, PhD June 18, 2018 2
Pediatric TB Radiology: Too bad it s not actually black and white Thienkhai Vu, MD, PhD Ann M. Loeffler, MD June 18, 2018 3
normal neonate cardiothoracic ratio < 65% June 18, 2018 4
normal neonate June 18, 2018 5
normal thymus configuration June 18, 2018 6
normal thymus configuration June 18, 2018 7
normal thymus configuration June 18, 2018 8
normal thymus configuration June 18, 2018 9
normal thymus configuration: lateral projection June 18, 2018 10
normal thymus configuration: Wavy thymus sign June 18, 2018 11
14-month-old child June 18, 2018 12
2-year-old child June 18, 2018 13
3-year-old child June 18, 2018 14
5-year-old child June 18, 2018 15
9-year-old child June 18, 2018 16
Pediatric TB Chest Findings atelectasis consolidation adenopathy bronchial narrowing nodules lungs hyperinflation pleural effusion June 18, 2018 17
Comparison of Radiographic Features of Pulmonary TB in Infancy and Childhood: Literature Review Rad Studies 1 2 3 4 5 6 7 8 N = 25 29 Mean Age 5.9 mos 65 days 100 21.5 mos 15 191 32 41 48 2 year 5.9 year 6 year 6 year 7.9 year Med LN 72% 89% 0 92% 63% Consolidation 80% 71% 0 70% Disseminated nodules Airway compression 24% 26% 0 16% 41% 0 June 18, 2018 18
Comparison of CT Features of Pulmonary TB in Infancy and Childhood: Literature Review Rad Studies 1 2 3 4 5 6 7 8 N = 25 29 100 15 191 32 41 48 Mean Age 5.9 mos 65 days 21.5 mos 2 year 5.9 year 6 year 6 year 7.9 year Med LN 100% 92% 60% 84% 83% 73% Consolidation 100% 49% 19% Bronchogenic Nodules Disseminated Nodules Bronchial Narrowing 41% 29% 29% 17% 65% 29% 37% June 18, 2018 19
2-month-old TB case: Rotated study June 18, 2018 20
2-month-old TB case: adenopathy, consolidation, and micronodules June 18, 2018 21
2-month-old TB case: adenopathy, consolidation, and micronodules June 18, 2018 22
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have a systematic approach to interpretation June 18, 2018 28
pulmonary hila June 18, 2018 29
pulmonary hila June 18, 2018 30
Large airway contours June 18, 2018 31
4-year-old TB case: hilar adenopathy June 18, 2018 32
4-year-old TB case: infrahilar adenopathy RPA LPA June 18, 2018 33
34-month-old TB case: June 18, 2018 34
34-month-old TB case: hilar and infrahilar adenopathy and left lower lung nodules June 18, 2018 35
6-year-old TB Case: Left hilar adenopathy and perihilar opacities/nodules June 18, 2018 36
6-year-old TB Case: Left hilar adenopathy and perihilar opacities/nodules June 18, 2018 37
7-year-old TB Case: right hilar/paratracheal adenopathy and right lung consolidation and micronodules June 18, 2018 38
7-year-old TB Case: right hilar adenopathy and right lung consolidation and micronodules June 18, 2018 39
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15-year-old TB Case: Right hilar Adenopathy and lung cavity June 18, 2018 46
15-year-old TB Case: Right hilar Adenopathy and lung cavity June 18, 2018 47
12-month-old patient: with parenchymal consolidation and pleural effusion TB or not TB? June 18, 2018 48
12-month-old patient: with parenchymal consolidation and pleural effusion MRSA Empyema June 18, 2018 49
TB Pleural Effusion Uncommon presenting finding in children with TB Tuberculous pleural effusions are rare in young children but are more frequent in adolescents and in boys Most are unilateral and typically associated with parenchymal disease June 18, 2018 50
CASE 6: 11 year old boy emigrating from Chuuk Presents to care for a tender mass on his thigh. 11 year old from Micronesia He had two weeks of cough / rhinorrhea One week of fever, malaise and anorexia and new onset leg mass. No comparison weights as he had been living with relatives in Chuuk June 18, 2018 51
CASE 6: lateral June 18, 2018 52
CASE 6: CT images at presentation There was a broad differential diagnosis including TB, fungal infections, Nocardia, malignancy The CT scan showed very large, necrotizing lymph nodes (less likely malignant) as well as parenchymal disease June 18, 2018 53
CASE 6: before and after therapy TST was positive. Cultures grew M. tuberculosis. Clinical improvement was initially very slow! He may well have scarring or bronchiectasis given the extensive disease June 18, 2018 54
CASE 7: referred because mother may have tuberculosis 5 month old infant whose mother was screened for TB in jail. Mom had a positive IGRA and reportedly had cough. She was released from jail before a CXR was taken The baby had recurrent viral illnesses TST was 0 mm induration Baby s CXR shows right sided likely adenopathy and airspace disease Siblings (who also lived with mom and baby) were all also TST negative June 18, 2018 55
CASE 7: lateral Case 7: lateral 5 weeks earlier during documented viral bronchiolitis June 18, 2018 56
CASE 7: a few weeks into therapy - more work of breathing Hilar & Subcarinal adenopathy The baby got sicker despite four drug TB therapy and required ICU admission. TB cultures were negative; RSV positive June 18, 2018 57
CASE 7 prior to TB diagnosis (viral bronchiolitis), at the time of TB diagnosis and 3 months into TB treatment. We treated him for presumed TB disease and his radiograph steadily normalized June 18, 2018 58
Teaching point Approximately 20% of children ultimately diagnosed with culture proven tuberculosis have a negative TST or IGRA at the time of dx. Most of these will children (but not all) will eventually have a positive TST / IGRA Gastric aspirates (and other microbiologic specimens for TB ) in children have suboptimal sensitivity. The yield for 3, first morning gastric aspirate cultures is as high as 80% for young infants, but <50% for children in general. Smears are even less often positive Re: Gene Xpert for gastric aspirates: more sensitive than smear, less sensitive than culture. Not FDA approved per my lab: they won t release results The dx of TB disease is often made based on a combination of clinical, radiographic, immunologic, demographic and exposure features. Once TB therapy is started in a child, we often need to finish therapy as it is really hard to prove that another process was causing the illness June 18, 2018 59
CASE 8 3 month old evaluated during contact investigation of potentially contagious adult June 18, 2018 60
CASE 8: lateral 3 month old baby screened several weeks into a contact investigation A former roommate was found to have smear positive TB The baby was symptomatic with work of breathing, noisy breathing, night sweats, and subjective fever On exam no breath sounds heard on the right anteriorly, diminished posteriorly Radiographic interpretation, hyperinflation on the right concerning for airway obstruction, as well as airway opacification and lymphadenopathy. Retrocardiac density suggests left lower lobe June 18, 2018 61
CASE 8 before 2 months into therapy We treated him for TB disease as well as with steroids for symptomatic airway obstruction. His radiograph showed resolution of air trapping June 18, 2018 62
CASE 8 Completion of therapy beautiful normalization of the radiographic abnormalities (unchanged 6 months off therapy) June 18, 2018 63
Teaching points Young children are a high priority during contact investigation of a potentially contagious TB case. Infants less than 1 year of age have a 40% chance of developing TB disease if infected. The risk gradually declines to 5-10% around age 4 yrs. Pre-school aged children should have a high quality two view chest radiograph and history / physical looking for any evidence of TB disease (regardless of TST / IGRA result) If TB disease is ruled out by CXR / H&P in a young child, window prophylaxis is recommended TST / IGRA is repeated 8 10 weeks after contact is broken with source case / or source non-contagious. No need to repeat a chest radiograph unless the child has new symptoms. Infants < 6-12 months may need longer treatment (consult an expert) June 18, 2018 64
Teaching points - continued Children with TB meningitis (TBM) initially have very nonspecific clinical features and the diagnosis is often delayed. Infants and children under 2 years of age are at much risk of disseminated TB and TBM. The diagnosis of TBM should be considered for any child with systemic symptoms and especially for infants. The 2018 AAP RedBook notes that most experts recommend lumbar puncture for any infant < 12 mo of age with TB disease. Symptomatic children with TBM benefit from corticosteroid with their TB treatment as well as consideration of alternate TB medications. Consult a pediatric TB expert with any questions June 18, 2018 65
CASE 9: Immigration screening 13 year old Burmese girl Initial chest radiograph for immigration screening was subtly abnormal? Right hilar adenopathy Subsequent CXR after screening IGRA was positive showed a vague density over the LLL. She was treated for LTBI. She had developed a chest wall fluctuance which was not correlated with the radiographic abnormalities. The mass was drained twice (recurred) and treated for staph without culture June 18, 2018 66
Soft tissue density with bony irregularity of rib cortex 1 1 /1 5 /2 0 0 3 1 1 Y E A R F H C T T RA N SFE R O F O U T SI DE FI LM S R2 Pediatric C oronal 10/1 /2015 4 :50:48 PM 22481140 --- LO C : -5 2.5 0 T H K: 3 FFS R L RD: 2 5 5 T ilt: 0 ma : 9 5 KV p: 1 0 0 A c q no: 3 Z: 1.0 9 C : 4 0 0 W: 2 0 0 0 DFO V :23.4x23.4cm P age: 1 1 of 5 8 F I M : 1 1 SE : 6 CT scan showed cortical rib cm defect and fluid collection, soft tissue swelling. Rib debridement was culture and path negative after INH monotherapy, but sputum culture was positive for pan-susceptible M. tb. June 18, 2018 67
Teaching points Do not start INH monotherapy (or any other LTBI regimen) without good quality chest radiograph, history and physical exam looking for pulmonary AND extrapulmonary TB! Collect AFB cultures from any site possible Collect sputum for AFB, even from patients with only apparent extrapulmonary TB. Sometimes they re positive and exceedingly helpful Unclear connection between parenchymal disease (Positive sputum), lymphadenopathy, bone / soft tissue disease). It would seem that she must have been bacillemic. June 18, 2018 68
CASE 10: 15 year old with hip pain (recent Vietnamese immigrant) June 18, 2018 69
CASE 10: 15 year old with hip pain Chest radiograph obtained when IGRA was strongly positive in anticipation of treatment for presumed autoimmune arthritis Right apex showed small linear abnormalities June 18, 2018 70
CASE 10 after high dose steroids for hip arthritis RUL before and after steroids Marked worsening of right Apical abnormalities -? cavity June 18, 2018 71
CASE 10: before and after 9 months of MDR- TB treatment Sputum cultures grew M. tb resistant to INH, rifampin, ethambutol Joint aspirate / synovial biopsy showed no evidence of TB! June 18, 2018 72
CASE 10: after 27 months of treatment Worst 4/2016 Completion of therapy 4/2018 Completion of therapy CT obtained in case he clinically worsens off TB Therapy. Few right tiny nodules (2 calcified) and left apical blebs noted June 18, 2018 73
Teaching points Chest radiographic abnormalities that look like they may represent old TB disease or scarring should be evaluated by obtaining high quality sputum cultures and repeating the radiograph in 2-3 months. Radiographic stability and negative cultures suggest scarring rather than TB disease. Do not treat for LTBI until these are done. Treat for TB disease instead IF treatment must be initiated before radiographic stability can be documented. A TST and / or IGRA should be obtained before initiating immunosuppression. The result should be reviewed and acted upon before starting immunosuppression. In this case - TB was considered only because of the positive IGRA and then abnormal right apical radiographic findings In our case, the worsening of pulmonary disease was advantageous as he was than able to submit smear and culture positive MDR-TB. June 18, 2018 74