Case presentation of pulmonary tuberculosis x- ray finding

Radiology case

1. CASE PRESENTATION
DR. M. H BHUYAN
DR. P. BORAH
DR. D.J BORPATRAGOHAIN
DR. L. NATH
DR. P.N TAYE
DR. S. S BISWAS (MODERATOR)
PRESENTER-DR. RISHAV SARMAH

2. HISTORY
A 55-year-old male patient
presented to OPD with
chronic cough and
dyspnea at rest for last six
months.
Patient gives history of
working as a sandblaster for
last 20 years
Patient has no history of
any autoimmune
disease,tuberculosis,fever.

3. IMAGING FINDINGS

4. IMAGING FINDINGS: Chest Xray
Chest X-ray: Diffuse reticonodularopacities with coalescence of nodules
leading to conglomerate fibrotic masses.

5. HRCT Thorax Findings
A. Lung window in coronal section shows
upper lobe predominance of large
symmetric opacities bilaterally with
irregular margins
B.Mediastinalwindow in coronal section
shows the presence of egg shell
calcification of bilateral hilar and
mediastinal lymph nodes.

6. C. Axial image in lung window showing the presence of paracicatricial
emphysema (black arrow).The lateral margin of these lesions parallels the
lateral chest wall.

7. DIAGNOSIS
Based on clinical history and
imaging findings the diagnosis
of Silicosis with progressive
massive fibrosis was made.

8. Differential
Diagnosis
-Pulmonary Tuberculosis: Shows
asymmetric nodular opacities without
lobar distinction.
-Sarcoidosis: Nodules show
perilymphatic distribution as opposed to
bronchovascular pattern of silicosis.
Shows icing sugar calcification of nodes.
-Coal Workers' Pneumoconiosis: smaller
ill-defined nodules with central dot
calcification.

9. DISCUSSION

10. Pneumoconiosis
ILO defines pneumoconiosis
as dust accumulation in
lung and subsequent tissue
reaction to its presence.
There are 3 factors on
which development of
pneumoconiosis depends:
An agent capable of inciting
strong tissue reaction.
Size appropriate to be
retained in lung.
Sufficient duration of
exposure.

12. Silicosis
Caused prolonged
inhalation of silica dioxide.
Silica exists in two
morphological forms-
crystalline and amorphous
among which crystalline
silica is highly fibrogenic.
Miners,sandblasters,glass
workers,quarrying and
ceramic workers are at risk.
Silicosis is divided into
acute and chronic or
classical silicosis.
Classical silicosis is further
divided into simple or
complicated.

13. Simple
Silicosis
Most common, seen after 10-20 years of exposure.
Much advanced by the time of presentation.
Chest Xray-Multiple nodules with upper lobe
predominance,along with calcified hilar and mediastinal
nodes.
HRCT Thorax-Multiple well-defined nodules of uniform
size.Initially centrilobular and subpleural,later may become
perilymphatic and miliary.Upper lobe predominance is seen.
Pleural pseudoplaques may be seen due to coalescence of
subpleural nodules. Thickening or effusion may be present.

14. Complicated
silicosis
Denotes the development of fibrosis in
simple silicosis.
Chest Xray-Coalescence of nodules is
noted leading to development of
conglomerate fibrotic masses. (PMF)
HRCT Thorax-Fibrotic masses are large,
irregular,bilaterally
symmetrical.Cavitation and
paracicatricial emphysema may be
present.

15. Acute
Silicosis
Results from heavy exposure to silica dust in
short duration (<3 years) in closed spaces
with little or no personal protection.
Similar to pulmonary alveolar proteinosis
with rapid proliferation of type II
pneumocytes leading to accumulation of
PAS positive lipoproteinaceous exudate.
Chest Xray shows presence of diffuse ground
glass opacities or alveolar opacities.
HRCT shows presence of crazy paving
pattern due to intra and interlobular septal
thickening.More seen in dependent
posterior segments.

16. A.ChestXray shows multiple nodules with upper lobe predominance.
B,C. Egg shell calcification of bilateral hilar and mediastinal lymph nodes.
D. HRCT shows high density centrilobular and subpleural nodules.
E.Pseudoplaqueappearance.
F,G.Fibrotichigh density mass with adjacent pleural thickening.
H.Paracicatricialemphysema.

17. CASE 2
HISTORY
A 46 year old male patient came
with back pain,fever and
progressive kyphotic deformity for
past three months.
History of contact with tuberculosis
patient is present.

18. IMAGING FINDINGS

19. CHEST XRAY
Xray shows collapse of T10,T11 and T12 vertebrae causing gibbus deformity.

20. MRI Dorsolumbarspine findings
T1 and T1 postcontrast images show wedging of T10 with complete collapse of T11
and T12 vertebrae.

21. Sagittal T2 images shows hyperintense
paravertebral collection.
Axial T1 post-contrast image collection
tracking to involve left Psoas muscle

22. DIAGNOSIS
Based on clinical features and
imaging findings diagnosis of
Tuberculous spondylodiscitis
was made.

23. DISCUSSION

24. Tuberculous
spondylodiscitis
Tuberculosis is one of the leading causes of
mortality and morbidity worldwide.
Spondylitis constitutes 50% of musculoskeletal
tuberculosis and rest is constituted by
tenosynovitis,arthritis,osteomyelitis and bursitis.
Tuberculosis mostly affect the thoracolumbar
vertebrae of which thoracic vertebrae are most
commonly involved.
Subchondral or paradiscal part of the vertebral
body acts as nidus of infection.
Intervertebral disc in adults is avascular and does
not act as nidus of infection.

25. Mycobacterium tuberculosis lacks
proteolytic enzymes hence disc is not
involved until late in the disease.
Abscess after breaching the cortex spreads
beneath the ligaments to involve multiple
contiguous vertebrae and laterally to the
paraspinal muscles forming cold abscesses.
Infection may spread via Bateson venous
plexus to involve non-contiguous vertebrae.
Clinical features involve chronic back pain
with less systemic symptoms.

26. Imaging
findings
Radiographs-
Anteroposterior
and lateral
radiographs of
the affected
spine are done.
Earliest finding
is fuzzy margins
with loss of
definitions of
end plate.
Other findings
may include-
Destruction of anterior portions of contiguous
vertebrae.
Birds nest appearance due to lateral
displacement of posteromedial pleural line.
Periosteal reaction is usually absent.

27. A. Lateral radiograph shows end plate
irregularity and sclerosis involving
L4/L5 vertebrae.
B.Whitearrows denote fusiform
paravertebral opacity displacing
the posterior pleural line-bird’s
nest appearance.

28. CT Findings
Aids in surgical
planning.
Detection of osseous
fragment within spinal
canal and aids in
biopsy.

29. A.Mixed lytic sclerotic lesions involving contiguous vertebral bodies.
B.Presence of sequestrum.
C and E. Psoas abscesses.
D. Central lesion causes collapse of single vertebra-Concertina collapse.

30. MRI
Investigation of choice.
4 patterns of vertebral
involvement have been described:
•Paradiscal: Most common.
•Anterior: Due to subligamentous spread.
•Central:Gradually enlarging lesion in
centre.
•Posterior: Isolated involvement is
rare.Facets are spared.

31. Bone marrow edema is the earliest finding on
MRI.Hyperintense signal on STIR images and
hypointense on T1 images is noted.
Vertebral findings are similar to other
modalities.
Paraspinal abscesses are T2 hyperintense and
show thin peripheral hyperenhancement.
Cervical vertebral involvement leads to
retropharyngeal abscesses.
Tubercular abscesses usually heal with
calcification.

32. A.STIR images show contiguous spread with skip lesions in upper vertebral
bodies.Subligamentousspread is also noted.
B.T2W image shows paravertebral collection.
C.L4/L5 shows prevertebral and anterior epidural abscess.
D and E. Peripherally enhancing prevertebral collection in D and similar collection in
right Psoas in E.
F.ImagingPsoas sign.

33. Differential diagnosis

34. THANK YOU