The Dr. Jae Yang Lecture: An Overview of the Radiographic Picture of TB Harvey H. Wong, MD FRCPC MScCH Assistant Professor Department of Medicine Division of Respirology University of Toronto
Financial Interest Disclosure (over the past 24 months) Harvey H. Wong I have no conflict of interest.
Learning Objectives 1. Review lung anatomy, chest x-ray orientation, and common radiographic terminology 2. Gain an understanding of typical and atypical TB radiographic findings 3. Understand the radiographic presentations for diseases that can present similarly to TB
TB the great mimicker
What is normal?
Left Descending Pulmonary Atery SVC Aortic Arch Right Descending Pulmonary Artery
Cardiac Anatomy: Right Sided Chambers
Cardiac Anatomy: Left Sided Chambers
Retrosternal Airspace Hilum Scapula Lungs posteriorly should get darker as you go down more inferiorly IVC Pulmonary Vessels
TB or not TB Let s play
TB or not TB
TB or not TB Pulmonary tuberculosis Streptococcus pneumonia
Consolidation Airspace pattern fluffy
Consolidation Airspace pattern Air bronchograms
Consolidation Airspace pattern Silhouette sign
Differential diagnosis Anything that fills alveoli Pus infection (pneumonia), aspiration Fluid pulmonary edema (CHF, ARDS) Inflammatory cells organizing pneumonia (COP), eosinophilic pneumonia (CEP, AEP) Malignant cells lymphoma, adenocarcinoma Blood alveolar hemorrhage Protein pulmonary alveolar protenosis Fat lipoid pneumonia
Case 1 82 year old gentleman PMHx CLL transformed to prolymphocytic leukemia Osteoporosis Meds Alemtuzumab Vit D Calcium HPI Admitted to hospital on oncology service for presumed community acquired pneumonia and treated with moxifloxacin 1 month prior Patient was still short of breath, so a CT was ordered, so I was paged for non-resolving pneumonia
CXRs
CXRs 4 months ago 1 month ago (during admision)
CT
CT report Worsening right upper lobe consolidation with low-density areas within. This is suggestive of necrotizing pneumonia. Recommend continued followup to resolution on plain films.
Differential diagnosis Anything that fills alveoli Pus infection (pneumonia), aspiration Fluid pulmonary edema (CHF, ARDS) Inflammatory cells organizing pneumonia (COP), eosinophilic pneumonia (CEP, AEP) Malignant cells lymphoma, adenocarcinoma Blood alveolar hemorrhage Protein pulmonary alveolar protenosis Fat lipoid pneumonia
Clinical course Seen urgently in TB clinic the next day Further history revealed remote exposure to household TB contact (wife with TB adenitis who never completed treatment) Patient immediately isolated Induced sputum - AFB 3+ (AMTD +ve) Immediately started on quadruple therapy Grew fully sensitive MTB
Pre and Post Treatment
TB or not TB?
TB or not TB? Pulmonary TB Squamous cell lung cancer
Fibronodular pattern Interstitial pattern Reticular ( lace pattern )
Fibronodular pattern Interstitial pattern Nodular
The secondary pulmonary lobule
Tree-in-Bud
Fibronodular pattern Interstitial pattern differential (anything that highlights interlobular septum/ secondary lobule or causes scarring) Fibrosis ILD, radiation, bronchiectasis Infections TB, NTM, Fungal Cancer lymphangitic spread
Case 2 53 yo gentleman referred for TST conversion PMHx Alcohol abuse Previous cocaine abuse TBRF Refugee from Mexico 12 years prior Mother had TB Incarcerated 7 times Previously lived in homeless shelter HIV RF Multiple tattoos Multiple sexual partners (including men)
Further history 5 pound weight loss x 1 month Drenching night sweats x 6 months Productive cough of green sputum x 6 months Shortness of breath on exertion x 6 months Volunteers at community center
CXR
Fibronodular pattern Interstitial pattern differential (anything that highlights interlobular septum/ secondary lobule or causes scarring) Fibrosis ILD, radiation, bronchiectasis Infections TB, NTM, Fungal Cancer lymphangitic spread
Clinical course CT scan to rule out other disease Patient immediately told to self-isolated Induced sputum AFB 2+, AMTD +ve Started on quadruple therapy
CT Thorax
CT Thorax
Clinical course Fully sensitive Continue to drink and miss doses Increased liver enzymes Completed a total of 9 months of treatment
Pre and Post treatment
TB or not TB
TB or not TB Sarcoidosis TB lymphadenitis
Case 3 30 yo woman PMHx Unremarkable Meds None HPI Had an abnormal CXR on immigration CXR Completely asymptomatic TB RF Born in Nigeria BCG vaccination status unknown
CXR
Lymphadenopathy
Donut sign
Clinical course TBST 12mm induration Referred to TB clinic in Toronto Negative induced sputum x2 Organized a CT scan
CT
Differential diagnosis Infection TB Fungal Malignancy Lymphoma Inflammatory Sarcoidosis
EBUS
EBUS Video
Clinical course 1 st EBUS procedure Cytology and AFB negative Referred to me for second procedure 2 nd EBUS procedure (+ cores Wang needle biopsy) Cytology negative (mainly blood) Fully sensitive MTB isolated Started on treatment
Pre and Post treatment
TB or not TB?
TB or not TB? Pleural TB Adenocarcinoma
Case 4 37 yo gentleman PMHx Scolosis Medications Nil HPI 1 month history of cough, shortness of breath, subjective fever Given course of antiobiotics by walk-in CXR performed found to be abnormal (previous normal 2 years ago) Referred to respirology TB RF Born in Eritrea, came to Canada 10 years ago
CXR
Pleural effusion
Differential diagnosis of an exudative effusion Malignancy Primary (i.e. mesothelioma) Metastatic disease (lung, breast, colon, kidney, lymphoma, etc.) Infections Bacterial TB Viral Inflammatory Lupus Rheumatoid arthritis Mixed connective tissue disease Pulmonary embolism
Clinical course Attempted thoracentesis Patient became vasovagal and decline further attempts Induced sputum x1, then referred to me in TB clinic TB clinic Patient was isolated based on CXR and another induced sputum ordered CT scan also ordered
CT Thorax
Clinical Course Taken off isolation after CT scan Induced sputums negative x2 EBUS of sucarinal lymph node - negative Underwent pleuroscopy Chronic necrotizing granulomatous inflammation Started empirically on quadruple therapy MTb isolated fully sensitive
Pre and Post treatment
TB or not TB Pulmonary TB Pulmonary aspergillosis
Case 5 84 yo woman from a nursing home PMHx HTN DM2 Dementia Gout Dyslipidemia OA Pulmonary fibrosis Remote TB (18 years old treated in Hong Kong)
Further history Referred to me in my general respirology clinic for cavitary lesion Saw my colleague 2 years ago for mild pulmonary fibrosis lost to follow up CT showed 1 cm cavitary lesion CXR report from GP 1 year ago showed 4cm cavitary lesion possible TB CT scan 2 months ago showed 5cm cavitary lesion possible TB
CXR
Differential diagnosis C cancer (especially squamous cell) A autoimmune (GPA, RA) V vascular (septic emboli) I infectious (bacterial, TB, NTM, fungal) T trauma (pneumatocele) Y young/ congenital (cystic adenomatoid malformation)
Clinical course Admitted directly to respirology under negative pressure isolation Induced sputum AFB 3+ AMTD +ve Started on quadruple therapy Transferred to West Park Contact tracing
Some take home points TB has many faces CXR is an important screening tool, but you miss a lot
Now, you should have 1. Better knowledge in lung anatomy, chest x-ray orientation, and common radiographic terminology 2. Greater understanding of typical and atypical TB radiographic findings 3. Increased appreciation for the radiographic presentations for diseases that can present similarly to TB
Thank you