Morphological features of tuberculosis

A case based understanding of Tuberculosis, clinical and gross mimicker of tuberculosis.

1. MORPHOLOGICAL FEATURES OF TUBERCULOSIS – case based understanding Dr. Manan Shah

2. Contents Introduction of tuberculosis Case based discussion of Tuberculosis of different organs Diagnostic difficulties Clinical differential diagnosis Gross features Conclusion

3. Case 1 45 yr/ Male C/C: Cough with expectoration x 3-4 weeks Fever x 3-4 week Haemoptysis x 1 week Family History: Not significant Personal History: H/O Smoking since 10 years (8-10/day) H/O Alcohol since 7 years (Occasional) H/O Weight Loss

4. Case 1- Investigations CBC: Normocytic Normochromic Anemia ESR: High

5. Chest X-ray Peripheral solitory nodule Mediastinal lymph node enlargement

6. CT Scan: Peripheral solitory nodule with speculated margins

7. CT Scan: 2-3 mediastinal lymphnode causing widening of mediastinum

8. Clinical Diagnosis ..?

9. Case 2 50 yr/ Male C/C: Cough with expectoration x 2-3 weeks Fever x 2-3 week Haemoptysis x 3 days Family History: Not significant Personal History: No H/O Smoking or Alcohol H/O Weight Loss

10. Case 2- Investigations CBC: Normocytic Normochromic Anemia ESR: High

11. Chest X-ray Peripheral solitory nodule Mediastinal lymph node enlargement

12. CT Scan & PET Scan: Peripheral solitory nodule with speculated margins Increased Uptake in PET Scan

13. Clinical Diagnosis ..?

14. Gross Case 1 Case 2

15. Diagnosis Case 1 Carcinoma Lung Case 2 Tuberculosis of Lung

16. Tuberculosis Tuberculosis is the second leading infectious cause of death in the world after HIV, affecting 1.7 billion people worldwide and killing 1.7 million each year Tuberculosis is caused by, Mycobacterium tuberculosis hominis Most common cause of human infection M. tuberculosis bovis Other less common- M. africanum , M. microti , M. pinnipedii etc.

17. Pulmonary tuberculosis Lung is one of the main organ affected in tuberculosis Depending upon the type of tissue response, the infection is of two main types: Primary tuberculosis Secondary tuberculosis

18. Primary Pulmonary tuberculosis The infection of an individual who has not been previously infected or immunized is called primary tuberculosis. It is characterized by Ghon’s complex Ghon’s Complex consists of 3 components Ghon’s focus: 1-2 cm solitary area, located peripherally, most common in subpleural focus Lymphatic component: lymphatics draining the lesion contain phagocytes containing bacilli Lymphnode component: Enlarged and matted hilar and tracheao -bronchial lymphnode

19. X-Ray of primary pulmonary Tuberculosis

20. Gross Ghon’s focus: Grey white firm solitary nodule Hilar lymphadenopathy: matted multiple lymphnode, also shows grey w hite cut surface

21. Gross

22. Sequelae of primary tuberculosis Healing with fibrosis and calcification Progressive primary tuberculosis Miliary spread Fibrocaseous tuberculosis

23. Healed Primary Tuberculosis

24. Progressive primary tuberculosis

25. Miliary pulmonary tuberculosis The miliary lesions are millet seed-sized, approximately 1-3 mm in size, yellowish, firm areas without gross necrosis

26. Secondaries to Lung

27. Fibrocaseous tuberculosis Spherical cavity Thick fibrous wall Contains, caseous necrotic material. Thickned overlying pleura

28. Case 3 40/M C/C: vague right-sided abdominal pain x 6 months diarrhoea , and weight loss. Family history: Not significant Personal History: H/o Alcohol (Occasional)

29. Case 3 Clinical Examination : Pallor No Lymphadenopathy No fever Palpable mobile mass in the right hypochondrium which was non-tender and measured 7x5cm Investigations: Microcytic Hypochromic anemia X-Ray (Chest) : Normal CT Scan (Abdomen) : Large polypoid mass In the right colon extending from the ileo-caecal junction Narrowing of lumen Enlarged pericolic lymph nodes Colonoscopy Colonoscopy revealed a polypoidal mass in the proximal part of the ascending colon

30. Case 3- CT Scan IC Junction Shows thickening of the wall of the intestine and mass protruding in side the lumen

31. Clinical Diagnosis ..?

32. Gross

33. Diagnosis ..? Intestinal tuberculosis

34. Tuberculosis of intestine The most common site of intestinal tuberculosis is   ileum Intestinal tuberculosis can occur in three forms Ulcerative (Most common) Hypertrophic/hyperplastic Ulcero-hypertrophic

35. Pathogenesis of Intestinal tuberculosis

36. Tuberculosis of intestine Gross Small ulcerative lesion which later enlarges  to form a large  transverse ulcer. The serosal surfaces can show the presence of   tubercles which is a small elevation or protuberance on the serosal surface .  Later stages strictures of the small intestines are seen which is due to fibrosis . Long standing lesions may even show Napkin-ring constriction !

37. Tuberculosis of intestine

38. Tuberculosis of intestine

39. Tuberculosis of intestine

40. Intestine TB vs Cancer Tuberculosis More common near ileo-caecal junction Transverse ulcer. Tubercles Cancer Any site Not specific No tubercles Right: Polypoidal mass Left: Circumferential/ Napkin-ring constriction

41. D/D of mass in intesine Tuberculosis Cancer Crohn’s Disease Appendicular mass Hernia Intussusception Intestinal obstruction

42. TB vs Crohn’s disease

43. Tuberculosis of lymphnode Lymphadenitis is the most common clinical presentation of extrapulmonary tuberculosis Tuberculous lymphadenitis most frequently involves the cervical lymph nodes followed in frequency by mediastinal , axillary, mesenteric, hepatic portal, perihepatic and inguinal lymph nodes. It present as a unilateral single or multiple slow growing mass mostly located in the posterior cervical and less commonly in supraclavicular region. They are usually matted, firm on digital examination and painless

44. Tuberculosis of lymphnode Large multinodular mass that resembles carcinoma with multiple foci of caseous necrosis

45. Case 4 27/F Pain in right wrist x 3 months No H/o trauma, fever, surgery, Weight loss On examination, swelling 4-5 cms away from the right wrist measuring 3x2 cm. ESR: 25

46. Case 4

47. DDs? Solitary bone cyst Aneurysmal bone cyst Metastasis Infection Giant cell Tumour

48. Microscopy

49. Tuberculous osteomyelitis 1-3% of individuals with pulmonary or extrapulmonary tuberculosis have osseous infection Blood born > Direct extension C/F: Localized pain Low grade fever Chills Weight loss Solitary except immunocompromised patient Most common: Spine( Pott disease)

50. Pott's disease: Involvement of spine (thoracic / lumbar) Extensive necrosis of intervertebral discs with extension into soft tissue May produce significant deformities or neurologic deficits Difficult to treat

51. Case 5 6yr/M Fever x 8 months weakness of right side of body x 3 months Headache x 2 weeks Vomiting x 1 week Convulsions x 1week (3-4 episodes) On history: Recurrent B/L purulent ear discharge x 3 years Multiple neck swellings

52. Case 5 On Examination: Pallor Right cervical lymphadenopaty One of the lymph node were showing discharge Right sided hemiparesis Patient was conscious, obeying simple commands Investigations Chest X-ray: Normal Normocytic normochromic anemia ESR: 130

53. CT Brain CT brain showed large heterogenous , enhancing, ill-defined intracranial SOL with marked surrounding edema

54. Clinical Diagnosis ..? Astrocytoma / glioblastoma multiforme

55. Pathological investigations Lymph node FNAC : Tuberculous lymphadenitis X-ray of right Hip : X-Ray right hip joint showed areas of rarefaction with increased joint space, capsular enhancement, with displaced fat planes suggestive of tuberculosis CSF: PCR Study of CSF was done for detecting mycobacterial DNA which was positive.

56. Diagnosis Extrapulmonary tuberculosis involving Brain ( Neurotuberculosis ) Lymph node ( Tuberculous lymphadenitis) Hip Joint ( Tuberculous osteomyelitis )

57. Case 5

58. Tuberculosis of brain Tubercular meningitis is the most common presentation of CNS tuberculosis. Other presentations are, intracranial space occupying lesions such as tuberculoma and tubercular abscess tubercular encephalopathy tubercular vasculopathy

59. Tubercular meningitis

60. Tubercular meningitis

61. Renal Tuberculosis Tuberculosis may involve the kidney as part of generalized disseminated infection or as localized genitourinary disease Tuberculosis can cause renal failure by two mechanisms that involve intrinsic infection within the renal parenchyma or obstructive uropathy The kidney frequently is involved in miliary tuberculosis The site of preference is the renal medulla, where caseous necrosis occurs, leading to local tissue destruction

62. Gross Tuberculous infection involving renal papillae with associated papillary necrosis. There is also the dilation and irregularity of the ureter , which also is involved

63. Gross Putty Kidney Diffuse, uniform, extensive parenchymal calcification.

64. Cutaneous Tuberculosis Cutaneous tuberculosis (CTB) is the result of a chronic infection by Mycobacterium tuberculosis, M. ovis and occasionally by the Calmette -Guerin bacillus The clinical manifestations are variable and depend on the interaction of several factors including the site of infection and the host's immunity

65. Cutaneous Tuberculosis Factors involved in disease progression Infected person's cellular immunity state Infection route Bacilli resistance Virulence factors Individual's inherent factors (age, sex, race) Environmental factors (climate, geography)

66. Cutaneous Tuberculosis Classification

67. Tuberculous chancre It is a rare form of TB Also called primary TB inoculation chancre Occurs most often in children in endemic areas of low vaccination coverage On Examination it is firm painless, reddish-brown, slowgrowing papule or nodule arises, which may develop into an ulcer. The ulcer is friable, has a tendency to bleeding and a base with coarse granular surface

68. Tuberculous chancre

69. Tuberculosis verrucosa cutis (TVC) TVC, the most common form of exogenous TB It is the result of primary inoculation in previously sensitized individuals who maintain moderate to high immunity against  M. tuberculosis Lesions are usually solitary, painless and predominate in anatomical locations that are prone to traumas, such as fingers and toes Initially it is erythematous papules surrounded by a purplish inflammatory halo & evolve to verrucous plaques, with 1 to 5 cm in diameter. Growth happens through peripheral extension, sometimes accompanied by central atrophy. They may rarely ulcerate

70. Tuberculosis verrucosa cutis (TVC)

71. Tuberculosis verrucosa cutis (TVC)

72. Tuberculosis verrucosa cutis (TVC)

73. Scrofuloderma It occurs in children and young people he infection route is always endogenous, usually secondary to bone or lymph node TB Clinical lesions appear as nodules, gumma and ulcerations due to fistulae Patients may have active pulmonary or pleural disease with systemic symptoms

74. Lupus Vulgaris It is a form of cutaneous TB that occurs in previously sensitized individuals, with delayed hypersensitivity reaction strongly positive to tuberculin, secondary to TB verrucosa cutis, scrofuloderma or BCG inoculation It is a papulo -tuberous lesion of slow evolution I can coalesce into a plaque May found on the face or mucosae . It is classically defined as “apple jelly nodules”

75. Lupus Vulgaris Dermatoscopy reveales peculiar characteristics consisting of linear telangiectasias on a yellow to golden background and whitish reticular streaks which is characteristic finding.

76. Ocular tuberculosis The eye can become infected with tuberculosis through several different mechanisms. The most common form of ocular involvement is from hematogenous spread. Primary exogenous infection of the eye Secondary infection of the eye Some forms of ocular tuberculosis, such as Eales ' disease, thought to be the result of a hypersensitivity reaction.

77. TB Male genital tract Associated with tuberculosis of the kidney and prostate Seminal vesicle, epididymis , testes as well as scrotum may occasionally be affected The sites most commonly involved are epididymis , followed by the prostate,testicular involvement is less common and usually is the result of direct extension from the epididymis

78. TB Male genital tract Tubercular prostatitis usually results from antegrade infection within the urinary tract Many theories have been postulated to define the precise route of infection to the epididymis . These include – Infected urine theory spread via lymphatic system and metastatic spread through the blood stream. Female to male transmission (venereal transmission of TB) is very rare.

79. TB Male genital tract Testicular involvement is usually as a result of local invasion from the epididymis , retrograde seeding from the epididymis and rarely by hematogenous spread Involvement of scrotal wall suggests local extratesticular extension of disease process Male genital tuberculosis usually is associated with renal TB in 60 to 65% cases or with pulmonary TB in around 34% cases.

80. TB Female genital tract In females the genital organs commonly affected are as follows: fallopian tube (95-100%) endometrium (50-60%) ovaries (20-30%) cervix (5-15%) myometrium (2.5%) vulva/vagina (1%) The bacilli reach the genital tract by three principal routes: 1. The hematogenous route (90%) 2. descending direct spread or 3. lymphatic spread

81. TB Female genital tract Fallopian tube In early phases, tube diameter is normal and changes are noted mainly in advanced disease, in the form of nodular transformation. Adhesion may occur between ovaries and other pelvic organs with loss of fimbrial structures Patent ostia along with grossly diseased fallopian tube are often an indicator of tubercular salpingitis Ovary: Affected in 10% cases Adhesion with the fimbria or formation of unilateral or bilateral Adnexal mass can be seen Gross caseous necrosis in ovaries is uncommon

82. TB Female genital tract Endometrium: Diagnosis is often missed in biopsies, as the involvement can be focal In widespread endometrial TB ulceration, caseous necrosis and hemorrhage can be seen Cervicitis: Grossly, the cervix can be normal, ulcerated or may present with a Mass mimicking malignancy External genitalia: Rarely can involve the vulva in the form of nonhealing ulcers

83. Conclusion In conclusion, clinicians need to be aware of the myriad manifestations of TB and resist the temptation of premature diagnostic closure. The diagnosis of a tuberculous infection remains challenging and requires a high index of suspicion, especially when it complicates the clinical presentation of cancer patients. Also, further research is warranted to determine if a tuberculous infection, similar to other chronic infections and inflammatory conditions, may facilitate carcinogenesis.

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