tuberculosis- what is essential to know? jk amorosa
TRANSCRIPT
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Tuberculosis- Tuberculosis- what is essential what is essential
to know?to know?JK AmorosaJK Amorosa
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23 m23 m LLL, L pl eff, LLL, L pl eff,
endobronchial endobronchial spreadspread
June October
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23 m23 m
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23 m23 m
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TB - Endobronchial TB - Endobronchial spreadspread
Müller, N.L et al. Diseases of the Lung Radiologic and Pathologic Correlations 2003
granuloma
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22 m fever22 m fever
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RUL atelectasis, RUL atelectasis, endobronchial TB diff: endobronchial TB diff:
squamous cell casquamous cell ca
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Airway TBAirway TB
Bronchial stenosis - lobar collapse or Bronchial stenosis - lobar collapse or hyperinflation, obstructive hyperinflation, obstructive pneumonia, mucoid impaction pneumonia, mucoid impaction
Long segment narrowing with Long segment narrowing with irregular wall thickening, luminal irregular wall thickening, luminal obstruction, and extrinsic obstruction, and extrinsic compression compression
Tree-in-bud opacities and traction Tree-in-bud opacities and traction bronchiectasis - upper lobes bronchiectasis - upper lobes
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TB mediastinal TB mediastinal adenopathyadenopathy
19 f19 f
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Young patient with fever Young patient with fever and chest painand chest pain
Harisinghani,MGRadiographics ’00
TB mediastinaladenopathy
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51 yo immigrant with 51 yo immigrant with feverfever
TB mediastinal abscess
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Intrathoracic- Intrathoracic- LymphadenopathyLymphadenopathy
96% of children and 43% of adults 96% of children and 43% of adults Unilateral and right sided, involving Unilateral and right sided, involving
the hilum and right paratracheal -the hilum and right paratracheal -bilateral in about one-third of casesbilateral in about one-third of cases
Low-attenuation center secondary to Low-attenuation center secondary to necrosis CT – active necrosis CT – active
Calcified hilar nodes and a Ghon Calcified hilar nodes and a Ghon focus (Ranke complex) - previous focus (Ranke complex) - previous tuberculosistuberculosis
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12 yo with fever and cough
RUL cavity & RUL cavity & atelectasisatelectasis
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RUL consolidation, minimal RUL consolidation, minimal atelectasis and R hilar atelectasis and R hilar
adenopathyadenopathy 29 f pregnant 29 f pregnant
fatiguefatigue
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TB – lung parenchymaTB – lung parenchyma
Dense, homogeneous parenchymal Dense, homogeneous parenchymal consolidation in any lobe, consolidation in any lobe, predominance in the lower and predominance in the lower and middle lobes - especially in adults middle lobes - especially in adults
Looks like bacterial pneumonia Looks like bacterial pneumonia except for except for lymphadenopathylymphadenopathy and and the lack of response to conventional the lack of response to conventional antibiotics antibiotics
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29 29 m m
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Miliary patternMiliary pattern
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32 m32 m
R hilar adenopathyR hilar adenopathy Miliary patternMiliary pattern Focal RUL Focal RUL
opacitiesopacities
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Pattern? Pattern? Miliary
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45 yo f asymptomatic SARCOIDOSISSARCOIDOSIS, , ddx:lymphomaddx:lymphoma
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Calcified bilat nodules Calcified bilat nodules Ddx: chicken pox, histo, Ddx: chicken pox, histo,
TBTB
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TB Lung parenchyma TB Lung parenchyma MiliaryMiliary
1% to 7% of patients 1% to 7% of patients elderly, infants, immunocompromised elderly, infants, immunocompromised manifestation within 6 months of initial exposure manifestation within 6 months of initial exposure Chest X-ray normal or hyperinflated Chest X-ray normal or hyperinflated evenly distributed diffuse small 2–3-mm nodules, evenly distributed diffuse small 2–3-mm nodules,
with a slight lower lobe predominance - 85% of with a slight lower lobe predominance - 85% of cases cases
CT is more sensitive than Chest X-ray CT is more sensitive than Chest X-ray The nodules usually resolve - 2–6 months with The nodules usually resolve - 2–6 months with
treatment, without scarring or calcification, treatment, without scarring or calcification, rare: coalescence c focal or diffuse consolidationrare: coalescence c focal or diffuse consolidation
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37 yo m with 37 yo m with cough and chest cough and chest
painpain
Diff Dx: TB pleuritis, Malignancy Hemothorax Chylothorax
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Intrathoracic - Intrathoracic - Pleural Pleural EffusionEffusion
one-fourth of patients with primary one-fourth of patients with primary tuberculosis tuberculosis
sole manifestation of tuberculosis, 3–7 sole manifestation of tuberculosis, 3–7 months after initial exposure months after initial exposure
very uncommon in infants very uncommon in infants UnilateralUnilateral empyema , fistulae, bone erosion rare empyema , fistulae, bone erosion rare Residual pleural thickening /calcification Residual pleural thickening /calcification Ultrasonography (US) often demonstrates Ultrasonography (US) often demonstrates
a complex septated effusiona complex septated effusion Sequalae: pleural thickening, calcification Sequalae: pleural thickening, calcification
(calcified fibrothorax(calcified fibrothorax
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Tuberculoma RATuberculoma RA TB pericarditisTB pericarditis
Harisinghani
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Cardiac TBCardiac TB
0.5% of cases of extrapulmonary 0.5% of cases of extrapulmonary tuberculosis tuberculosis
Pericardial Pericardial immunocompromised patients immunocompromised patients Myocardial involvement – rare, Myocardial involvement – rare,
asymptomatic asymptomatic Thickened, irregular pericardium with Thickened, irregular pericardium with
associated mediastinal associated mediastinal lymphadenopathylymphadenopathy
IVC distentionIVC distention
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40 yo m with 40 yo m with coughcough RUL cavity; Ddx: TB, abscess, CA
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55 f with fever, 55 f with fever, cough & wt losscough & wt loss
RUL cavity, atelectasis Ddx: TB, abscess, CA
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66 m cough 66 m cough LUL cavity, Ddx: TB, abscess, CA
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62 m c 62 m c coughcough
LUL cavities and bilateral endobronchial spreadDdx: TB, CA
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69 m with 69 m with worsening worsening
COPDCOPD LUL cavitary lung opacity; TB Ddx:CA, abscess
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Morbidly obese f in her 50’s with persistent post-op fever
R apical cavity, TB; Ddx: CA
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Müller, N.L et al. Diseases of the Lung Radiologic and Pathologic Correlations 2003
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Parenchymal Parenchymal manifestation-manifestation-cavitycavity
50% of patients 50% of patients thick, irregular walls, which become thick, irregular walls, which become
smooth and thin with successful smooth and thin with successful treatment treatment
multiple, occur within areas of multiple, occur within areas of consolidation Resolution : consolidation Resolution : emphysematous change or scarringemphysematous change or scarring
air-fluid levels: uncommonair-fluid levels: uncommon
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Fibrosis, cavity and … Fibrosis, cavity and … fungus ballfungus ball
DX: SARCOIDOSIS STAGE IV
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Single CavitySingle Cavity
TBTB HistoHisto CACA AbscessAbscess
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69 yo pre-op
Calcified granulomatouscomplex
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AsymptomaticAsymptomatic
Calcified granulomas
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Pulmonary nodule, Pulmonary nodule, metabolically activemetabolically active dx: dx:
tuberculomatuberculoma
Harlsinghani
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TB bronchiectasis c atelectasis RUL, LLL TB bronchiectasis c atelectasis RUL, LLL pneumoniapneumonia
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TB bronchiectasis c TB bronchiectasis c atelectasisatelectasis
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62 yo f chronic 62 yo f chronic coughcough
Total left lung atelectasis with bronchiectasis
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TuberculosisTuberculosis Resurgence in nonendemic populations due Resurgence in nonendemic populations due
to 1.increased migration 2. HIV to 1.increased migration 2. HIV Respiratory, cardiac, CNS, musculoskeletal, Respiratory, cardiac, CNS, musculoskeletal,
GI, GU systems GI, GU systems History of infection or exposure to TB ca History of infection or exposure to TB ca
50% 50% Tuberculin skin test does not in exclude Tuberculin skin test does not in exclude
infection infection Mimics other diseases Mimics other diseases Biopsy or culture specimens are required to Biopsy or culture specimens are required to
make the definitive diagnosismake the definitive diagnosis
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PulmonaryPulmonary TuberculosisTuberculosis
PrimaryPrimary Childhood and Childhood and
30% in adults 30% in adults because of lack of because of lack of unexposed adult unexposed adult populationspopulations
LymphadenopathyLymphadenopathy Mid and lower Mid and lower
lungslungs Self-limitingSelf-limiting
PostprimaryPostprimary Adults and adolescentsAdults and adolescents Reinfection Reinfection
with/reactivationwith/reactivation ProgressiveProgressive CavitationCavitation Upper>Lower lungsUpper>Lower lungs Hematogenous and Hematogenous and
endobronchial spreadendobronchial spread Airway and pleural invAirway and pleural inv Heals with fibrosis and Heals with fibrosis and
calcificationcalcification
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LeungLeung
‘‘In 1993, the World Health In 1993, the World Health Organization declared TB to be a Organization declared TB to be a global emergency global emergency
At current control levels, it is At current control levels, it is estimated that between 1997 and estimated that between 1997 and 2020, nearly 1 2020, nearly 1 billionbillion people will people will become newly infected and 70 become newly infected and 70 million people will die from the million people will die from the disease “disease “
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Increase, esp multidrug-Increase, esp multidrug-resistant (MDR) TBresistant (MDR) TB
AfricaAfrica Asia Asia EuropeEurope
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TB in Immunocompromised TB in Immunocompromised patientspatients
Higher prevalenceHigher prevalence More MDR More MDR Higher prevalence of Higher prevalence of
extrapulmonary extrapulmonary Normal chest radiographic findingsNormal chest radiographic findings
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TB Differential Dx “the TB Differential Dx “the mimicker”mimicker”
Primary:Primary: Focal opacity: pneumonia, histoFocal opacity: pneumonia, histo Adenopathy: lymphoma, sarcoid, histo, Adenopathy: lymphoma, sarcoid, histo,
metsmets Pleural eff: malignancy, hemothorax, histoPleural eff: malignancy, hemothorax, histo Reactivation:Reactivation: Cavity: lung ca, abscessCavity: lung ca, abscess Healed (fibrotic):Healed (fibrotic): radiation fibrosisradiation fibrosis
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REFERENCESREFERENCES
Tuberculosis: A Radiologic ReviewTuberculosis: A Radiologic Review
Joshua BurrillJoshua Burrill,, Radiographics 2007; 27: 1255-73 Radiographics 2007; 27: 1255-73 Tuberculosis from Head to Toe1 (RSNA Link) Tuberculosis from Head to Toe1 (RSNA Link) Mukesh G. Harisinghani, MD , Theresa C. Mukesh G. Harisinghani, MD , Theresa C.
McLoud, MD, Jo-Anne O. Shepard, MD, Jane McLoud, MD, Jo-Anne O. Shepard, MD, Jane P. Ko, MD, ‘00P. Ko, MD, ‘00
Radiology.Radiology. 1999;210:307-322.) 1999;210:307-322.)State of the ArtState of the Art
Pulmonary Tuberculosis: The Essentials Ann Pulmonary Tuberculosis: The Essentials Ann N. Leung, MD1 N. Leung, MD1