radiology case 1 final
DESCRIPTION
radio case 1 of section cTRANSCRIPT
RADIOLOGYCase Discussion 1
JACINTO, Ma. TheresaJEONG, Kyung Sun
JOSE, NiñaJUNIA, Christine Joy
KING KAY, Caroline BernadetteLAO, Eugene
LAO, Kriselle MarisLAO, Lawrence Edeniño
LAO, Sharlene MarieLAUS, Lady Diana Rose
III - C
CASE
RR, 70 years old, male, seaman Chief complaint: Cough
History of Present Illness
3 years PTC Productive cough with whitish phlegmAccompanied by fever and body malaiseSelf-medicated with paracetamol and
amoxicillin (unrecalled dosage)
History of Present Illness
2 years PTCPersistence of cough, now blood tingedSought consult, was advised to have chest x-
ray. Was given anti-TB regimen but unable to
comply with the full course of treatment
History of Present Illness
1 year PTCOccasional cough and febrile episodes No medications taken
3 days PTCExpectorated bloodAdvised to have chest CT scan
Review of Systems
(+) weight loss (+) loss of appetite (+) body malaise (+) night sweats
Past Medical History
(+) Hypertension
Physical Examination
Hyposthenic Normal Vital Signs Lagging of the left lung Diminished breath sounds on the left
Normal Patient
Chest PA Lateral
Learning Issues
Radiographic signs of PTB What is a tuberculoma? Distinguish between primary vs re-infection
tuberculosis Explain the presence of atelectasis, cavitations
and bronchiectasis in PTB What is the role of follow-up chest x-ray? Radiographic findings of healed PTB What is the role of CT scan?
OUTLINE
Pathophysiology of Tuberculosis Radiographic Signs of PTB
Tuberculoma Bronchiectasis Cavitation Atelectasis
Primary vs. Re-infection PTB Active vs. Healed PTB Role of Chest X-Ray in Follow-up Role of CT Scan
OUTLINE
Pathophysiology of Tuberculosis Radiographic Signs of PTB
Tuberculoma Bronchiectasis Cavitation Atelectasis
Primary vs. Re-infection PTB Active vs. Healed PTB Role of Chest X-Ray in Follow-up Role of CT Scan
Infection with M. tuberculosis
Alveolar macrophage ingestion of bacilli
Unchecked bacillary multiplication
Lysis of the macrophage
Activated monocytes ingest the bacilli from lysed
macrophage
Alveolar macrophages secrete cytokines
IL1
IL6
TNF-ά
Fever
Hyperglobulinemia
• Killing of Mycobacteria• Granuloma formation• Fever• Weight loss
Activation of more hostresponses
Tissue-damagingresponse
Macrophage-activatingresponse
Formation of solid necrosis in the center of the
tubercle
• Development of specific immunity• Accumulation of activated macrophage
Caseating granuloma Tubercle formation
Some lesions heal byfibrosis and calcification
• Lagging of the left lung• Breath sounds
Treatment failure
Intensified DTH
Tissue-damagingresponse
Caseous materialliquefies
Invasion & destructionOf BV and bronchial walls
Cavity formation
Drained throughbronchi
Multiplication &spread of thebacilli into the
airways
• Cough• Hemoptysis
OUTLINE
Pathophysiology of Tuberculosis Radiographic Signs of PTB
Tuberculoma Bronchiectasis Cavitation Atelectasis
Primary vs. Re-infection PTB Active vs. Healed PTB Role of Chest X-Ray in Follow-up Role of CT Scan
Tuberculoma Primary, post-primary
tuberculosis Form of lesion commonly
seen in TB Well circumscribed,
round/oval opacities caused by acid-fast bacilli
1-4 cm or more in diameter
mostly in upper lobe, right more than the left
Tuberculoma
OUTLINE
Pathophysiology of Tuberculosis Radiographic Signs of PTB
Tuberculoma Bronchiectasis Cavitation Atelectasis
Primary vs. Re-infection PTB Active vs. Healed PTB Role of Chest X-Ray in Follow-up Role of CT Scan
Bronchiectasis
Localized, irreversible dilatation of the bronchial tree
Associated with acute, chronic or recurrent infection (bacteria and mycobacteria)
Bronchiectasis
Tram line Ring shadows with thickened bronchial walls Mucus plugs
Bronchiectasis
Air fluid levels Watch for dextrocardia Diffuse lung fibrosis
Due to recurrent infections
Bronchiectasis
Bronchial dilatation Tram lines Thickened bronchial walls Mucus plugs
OUTLINE
Pathophysiology of Tuberculosis Radiographic Signs of PTB
Tuberculoma Bronchiectasis Cavitation Atelectasis
Primary vs. Re-infection PTB Active vs. Healed PTB Role of Chest X-Ray in Follow-up Role of CT Scan
Robbins and Kutran. Pathologic basis of disease. 7th ed pp. 384-386
Cavitations
Cavitation, usually in the apices of the lungs, occurs readily in the secondary form of PTB, resulting in dissemination of mycobacteria along the airways
Robbins and Kutran. Pathologic basis of disease. 7th ed pp. 384-386
Expansion in the area of caseation erosion into a bronchus evacuation of the caseous center (cough) irregular cavity lined by caseous material and fibrous tissue
Radiology of the chest. Regional roentgen pathology. pp. 358-364
Early stages Cavity is usually irregular, often showing air-fluid level
Radiology of the chest. Regional roentgen pathology. pp. 358-364
Early stages Small areas of infiltration, consolidation adjacent to a
cavity is highly suggestive of PTB (differentiate from lung abcess)
Early lesions: posterior portion of upper lobe, below level of the clavicle
CAVITY
CAVITY
OUTLINE
Pathophysiology of Tuberculosis Radiographic Signs of PTB
Tuberculoma Bronchiectasis Cavitation Atelectasis
Primary vs. Re-infection PTB Active vs. Healed PTB Role of Chest X-Ray in Follow-up Role of CT Scan
Radiology of the chest. Regional roentgen pathology. pp. 365-367
Thoracic Imaging: Pulmonary and Cardiology. pp. 47-65
Atelectasis “Incomplete
stretching”, loss of volume of lung tissue because of decreased amount of gas
Destructive process in the walls of the bronchi and plugging of the lumina by exudate
Radiology of the chest. Regional roentgen pathology. pp. 365-367
Thoracic Imaging: Pulmonary and Cardiology. pp. 47-65
Direct Signs ( due to lobar volume loss) Displacement of interlobular fissures: best sign of
atelectasis Crowding of vessels, bronchi or air bronchograms
Radiology of the chest. Regional roentgen pathology. pp. 365-367
Thoracic Imaging: Pulmonary and Cardiology. Pp. 47-65
Indirect Signs Diaphragmatic elevation: due to ipsilateral volume
loss: more common lower lobe Juxtaphrenic Peak (upper lobe atelectasis)
Radiology of the chest. Regional roentgen pathology. pp. 365-367
Thoracic Imaging: Pulmonary and Cardiology. pp. 47-65
Indirect Signs Mediastinal shift:
more common upper lobe collapse (Trachea); more common lower lobe collapse (heart)
Thoracic Imaging: Pulmonary and Cardiology. Pp 47-65
Indirect signs Compensatory overinflation of normal lung on the same side;
increased volume with decreased density of lung Hilar displacement: Hilum ELEVATED with ULA; Hilum
DEPRESSED with LLA
Radiology of the chest. Regional roentgen pathology. pp. 365-367
Thoracic Imaging: Pulmonary and Cardiology. pp. 47-65
Indirect signs Reorientation of
hilum or bronchi ULA: hilum rotates
outward and descending pulmonary artery is less vertical and easily seen
LLA: hila are depressed and bronchi appear more vertical
Radiology of the chest. Regional roentgen pathology. pp. 365-367
Thoracic Imaging: Pulmonary and Cardiology. pp. 47-65
Indirect Signs Approximation of the ribs: ipsilateral ribs appear
closer together Flat waist sign: flattening of the left heart border due
to rotation of heart and great vessels
Radiology of the chest. Regional roentgen pathology. pp. 365-367
Thoracic Imaging: Pulmonary and Cardiology. pp. 47-65
Indirect Signs Increased lung opacity: reflects replacement of
alveolar air with fluid or compressed airless tissue Absence of air bronchograms
Radiology of the chest. Regional roentgen pathology. pp. 365-367
Thoracic Imaging: Pulmonary and Cardiology. pp. 47-65
Indirect signs Absence of air bronchograms suggests central
bronchial obstruction Mucus bronchograms Shifting granuloma sign: parenchymal lesions of prior
film shifts in location
OUTLINE
Pathophysiology of Tuberculosis Radiographic Signs of PTB
Tuberculoma Bronchiectasis Cavitation Atelectasis
Primary vs. Re-infection PTB Active vs. Healed PTB Role of Chest X-Ray in Follow-up Role of CT Scan
Primary Tuberculosis Pulmonary imaging findings in individuals with
primary tuberculosis are nonspecific Note that chest radiographic findings may be
normal in as many as 15% of patients with primary pulmonary tuberculosis
Primary Tuberculosis
Parenchymal consolidationPredilection for the lower lobes, middle lobe
and lingula, and anterior segments of the upper lobes
Homogeneous, with ill-defined marginsCaseous necrosis occurs centrally within the
lung parenchymal opacity, decreasing its sizeBecome rounded with healing, continues to
shrink until only a small nodule remains → calcified or ossified → calcified granuloma
(Lee KS et al, 1003)
PTB with bronchogenic spread in 34 y/o woman CXR: Nodules, right lower lobe HRCT: Peribronchial (arrows) and large acinar (arrowheads) nodules CT: Lobular consolidations (arrows) and acinar nodules (arrowheads)
Tuberculoma may be a manifestation of either primary or postprimary tuberculosis
(Lee KS et al, 1003)
Primary Tuberculosis
Lymphadenopathy Distinguishing feature of primary TB vs.
recurrent TBMore common with immune incompetent hostsMost common in the ipsilateral hilar regionMay involve the airways Indistinguishable from that of sarcoid or
lymphoma
Tuberculosis, lymphadenopathy in a 19 y/o male CXR: Bilateral widening of superior mediastinum and
enlargement of right hilum CT: Extensive mediastinal adenopathy with central low
density and peripheral rim enhancement
Primary Tuberculosis
Airway involvement Airway compression with resultant atelectasisMucosal infectionBroncholithiasis Endobronchial spread of infectionBronchiectasis
Traction bronchiectasis in a 52 y/o male HRCT: Dilatation of right upper lobe bronchi and
granuloma in left upper lobe
(Hyae Young Kim, 2001)
Tracheobronchial stenosis in a 40 y/o female Contrast-enhanced CT: narrowing of left main
bronchus(Hyae Young Kim, 2001)
Broncholithiasis in a 58 y/o male Contrast-enhanced CT: broncholith within lateral segmental
bronchus of right middle lobe Distal obstructive atelectasis and calcified lymph nodes Right pleural effusion
(Hyae Young Kim, 2001)
Re-infection Tuberculosis
Often on the apical and posterior segments of the upper lobes or superior segments of the lower lobes
Associated with progressive disease
Re-infection Tuberculosis
Most common clinical finding is poorly defined areas of consolidation in involved segments
Re-infection Tuberculosis
There may be cavitation, with visible endobronchial spread
Re-infection Tuberculosis
In 20-45% of patients with active post-primary TB, cavitation is visible on chest radiographs, with numerous small nodules
Re-infection Tuberculosis
Pleural involvement Uncommon in children, seen more frequently
in adultsMore frequently identified in post-primary
tuberculosis
(Lee KS et al, 1003)
Tuberculosis with pleural effusion in a 38 y/o female CT: Pleural effusion in anterior and lateral pleural spaces
and right major fissure Parenchymal tuberculous focus in right middle lobe
Re-infection Tuberculosis
Miliary TB is a disseminated systemic infection from a pulmonary nidus spread hematogenously
May also be seen in primary TB
OUTLINE
Pathophysiology of Tuberculosis Radiographic Signs of PTB
Tuberculoma Bronchiectasis Cavitation Atelectasis
Primary vs. Re-infection PTB Active vs. Healed PTB Role of Chest X-Ray in Follow-up Role of CT Scan
Active PTB
Infiltrate or consolidation Cavitary lesion Nodule with poorly defined margins Pleural effusion Hilar or mediastinal lymphadenopathy Linear, interstitial disease (in children only) Miliary findings
Healed PTB
Discrete fibrotic scar or linear opacity Discrete nodule(s) without calcification Discrete fibrotic scar with volume loss or
retraction Discrete nodule(s) with volume loss or
retraction Upper lobe bronchiectasis
OUTLINE
Pathophysiology of Tuberculosis Radiographic Signs of PTB
Tuberculoma Bronchiectasis Cavitation Atelectasis
Primary vs. Re-infection PTB Active vs. Healed PTB Role of Chest X-Ray in Follow-up Role of CT Scan
ROLE OF FOLLOW-UP CHEST X-RAY To determine presence of late complications
at completion of therapyRelapseAspergillomaBronchiectasisBroncholithiasisFibrothoraxCarcinoma
eMedicine: Tuberculosis by Thomas Herchline, MD
OUTLINE
Pathophysiology of Tuberculosis Radiographic Signs of PTB
Tuberculoma Bronchiectasis Cavitation Atelectasis
Primary vs. Re-infection PTB Active vs. Healed PTB Role of Chest X-Ray in Follow-up Role of CT Scan
ROLE OF CT SCAN Better define abnormalities in patients with vague
findings on chest radiography More sensitive in the detection of:
Cavitation Hilar and mediastinal lymphadenopathies Endobronchial spread Malignancy Complications in the course of the disease
eMedicine: Tuberculosis by Thomas Herchline, MD; Eisenhuber E, et al. Radiologic Diagnosis of Lung Tuberculosis (abstract), Der Radiologe Vol.37 No.5 May 2007
ROLE OF CT SCAN
Valuable technique in the assessment of tuberculosis activity, especially in patients where M. tuberculosis has not been detected in the sputum or in patients with multi drug-resistant tuberculosis
eMedicine: Tuberculosis by Thomas Herchline, MD; Eisenhuber E, et al. Radiologic Diagnosis of Lung Tuberculosis (abstract), Der Radiologe Vol.37 No.5 May 2007
THANK YOU FOR YOUR KIND ATTENTION