An Introduction to Radiology for TB Nurses Garold O. Minns, MD September 14, 2017 TB Nurse Case Management September 12 14, 2017 EXCELLENCE EXPERTISE INNOVATION Garold O. Minns, MD has the following disclosures to make: No conflict of interests No relevant financial relationships with any commercial companies pertaining to this educational activity Radiology Page 1 of 32
TB Radiology for Nurses Heartland National TB Center San Antonio, TX September 14, 2017 Garold O. Minns, MD Dean & Professor Department of Internal Medicine KU School of Medicine-Wichita 3 Posteroanterior (PA) view of the chest Film 4 Radiology Page 2 of 32
Frontal Technique Lateral 5 Anteroposterior (AP) view of the chest Film 6 Radiology Page 3 of 32
Items further from film appear larger! Object Film 7 PA View of the Chest 8 Radiology Page 4 of 32
AP view of the chest 9 Other views Decubitus Apical lordotic 10 Radiology Page 5 of 32
Suspected pleural effusion 11 12 Radiology Page 6 of 32
Apical TB 13 Apical lordotic Film 14 Radiology Page 7 of 32
15 Causes of Poor Quality Chest X-Rays Over or under penetration Rotation of chest Poor inspiration Angulation Scapula overlying lung fields Foreign bodies in field of view Patient ID inaccurate 16 Radiology Page 8 of 32
Overexposure Exposure Proper Exposure 17 Apices Worth a Second Look Retrocardiac areas (left and right) Hilar regions Below diaphragm 18 Radiology Page 9 of 32
Classification of lung pathology Alveolar Interstitial Airways 19 20 Radiology Page 10 of 32
Alveolar Disease 21 Consolidation Confluent opacity Fluffy around the periphery Air bronchograms Ill-defined nodules Diff dx depends on: Focal Diffuse 22 Radiology Page 11 of 32
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) 23 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. 24 Radiology Page 12 of 32
Interstitial Opacity: Lines & Reticulation 25 Nodules and Masses Nodule: discrete pulmonary lesion, sharply defined, nearly circular opacity 0.2-3 cm Mass: larger than 3 cm Describe with qualifiers: Single or multiple Size Border characteristics Presence or absence of calcification Location 26 Radiology Page 13 of 32
Well-Defined Calcification Ill-Defined Mass 27 Lymphadenopathy (LAN) Non-specific terms: Mediastinal widening Hilar prominence Specific patterns: Particular lymph node station enlargement Important to know what normal should look like in order to recognize abnormal 28 Radiology Page 14 of 32
Right Paratracheal & Bilateral LAN 29 Right Hilar LAN 30 Radiology Page 15 of 32
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 31 TB or Not TB? Cysts and Cavities Cysts and Cavities Are there radiographic features that suggest benign vs. malignant diagnoses? A C 45 yo man from China with cough, wt. loss B D 32 Radiology Page 16 of 32
Pleural Disease: Basic Patterns Effusion Angle blunting to massive Thickening Mass Air Calcification 33 34 Radiology Page 17 of 32
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) 35 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) 36 Radiology Page 18 of 32
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 37 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 38 Radiology Page 19 of 32
Miliary TB 39 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 40 Radiology Page 20 of 32
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%) 41 Pediatric TB 42 Radiology Page 21 of 32
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% 43 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 44 Radiology Page 22 of 32
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 45 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 loss 46 Radiology Page 23 of 32
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 47 Radiology Page 24 of 32