Radiological_diagnosis_of_TB_ECHO_MOH[1].pptx

Radiology Diagnosis of TB

1. MOH HIV/TB ECHO Radiological Diagnosis of TB 04.09.2023 Dr Nteeni M.S. MMED Diag. Rad (UON) IR Merck fellow (TMH, India) (No Disclosures or Conflict of Interest

2. Learning Objectives To outline steps to reading a chest radiograph To describe common radiological features of TB on chest X-ray To distinguish TB from other respiratory diseases on chest X-ray The speaker has no significant financial conflicts of interest to disclose.

3. OUTLINE TWO PART PRESENTATION Assessing quality of chest x-ray Chest anatomy Chest interpretation Tuberculosis and chest x-ray Cases and practical exercises  

4. Projections

5. Postero -anterior view: essential image characteristics. Full lung fields are seen. Scapulae projected away from the lung fields. Medial ends of the clavicles symmetrical and equidistant from the spinous processes. -Sufficient inspiration: visualizing 6th anterior ribs/10 ribs posteriorly. Sharply defined costophrenic angles, diaphragm, mediastinum, lung markings and heart.

6. Anteroposterior (AP) view Used when patient unable to cooperate for the routine PA procedure ( very sick patient, infants) May be done with the patient seated or lying flat on a bed, with the cassette/detector behind the patient. The heart is at a greater distance from the film hence appear more magnified than PA view. Scapulae are usually visible in the lung fields.

7. Lateral chest radiograph Typically used in conjunction with the posteroanterior view. Allows the viewer to see behind the heart and diaphragmatic dome and the hilar . The side of the patient under investigation is brought in contact with the image receptor.

8. Technical considerations in every case Courtesy of professor pitcher

9. Technical Quality of a CXR Evaluate the following before CXR interpretation Patient details At least two identifiers Name Date Facility where X ray done View Supine, PA, AP, lateral The main qualities determining quality of a CXR Rotation Inspiration Penetration RIP

10. Assessing Quality of CXR Clavicular heads Spinous processes Vertebra bodies Ribs Anterior ribs Posterior ribs

11. View PA AP Scapula Periphery of the lungs Over the lung fields Clavicles Project over lung fields Above the lung apices Ribs Posterior ribs well visualized Anterior ribs well visualised Gastric Bubble Well visualized Not well visualized

12. Rotation Observe the clavicular heads (medial ends) and spinous Clavicular heads should be equidistant from the spinous processes of the thoracic vertebrae The spinous process should be between the clavicular heads Rotation is important in determining Tracheal deviation Heart size Normal rotation

13. Is there adequate inspiration? Courtesy of professor pitcher

14. Inspiration Inspiration Expiration Inspiration Courtesy of professor pitcher

15. Hyper-Expansion Flattened hemidiaphragms

16. Penetration Penetration is the degree to which the X-rays pass through the body In normal penetration 4 Lower thoracic vertebra should be visible through the heart Left hemidiaphragm should be visible at the of the spine The bronchovascular structures behind the heart should be seen Image Courtesy of drbeen https://www.drbeen.com/blog/the-basics-of-chest-x-ray-interpretation/ ) Hemidiaphragm Spine

17. Under exposure Makes structures radio-opaque (whiter) May cause “overcalling” some findings Features <4 lower vertebrae seen behind the heart Lung tissue behind the heart cannot be assessed Left hemidiaphragm not seen to the spine ? Hemidiaphragm Spine

18. Over Exposure Theres an excess of black on the film Reduced or no lung markings

19. Anatomy Basic CXR Anatomy

20. 22 Heart and outline on CXR

21. CARDIAC SIZE MEASUREMENT CTR=A/B...........<50-55% Adults & up to 60% children

22. aorta Left heart border Rt heart border

23. trachea Right bronchus Left bronchus

24. Left hilar Right hilar

25. Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34 RIGHT PARATRACHEAL REGION AORTO-PULMONARY WINDOW SUB-CARINAL PARAVERTEBRAL SPACE

26. Lobes as seen on a CXR RUL RML LUL LLL RLL COSTOPHRENIC ANGLES

27. Lungs and pleura

28. Lungs and pleura

29. Chest Interpretation

30. ABCDE approach

31. A irway Trachea Is the trachea significantly deviated? PULL or PUSH Paratracheal masses/lymphadenopathy Pushing of trachea –  e.g. large pleural effusion / tension pneumothorax Pulling of trachea –  e.g. consolidation with lobar collapse

32. A irway The carina On a good quality CXR this division should be visible The right main bronchus is generally wider, shorter and more vertical than the left main bronchus.

33. A irway Hilar structures Main pulmonary vasculature and the major bronchi. Collection of lymph nodes which aren’t usually visible in healthy individuals. The left hilum often positioned slightly higher than the right, but there is a wide degree of variability between individuals. The hilar are usually the same size, so asymmetry should raise suspicion of pathology.

34. B REATHING-Lung Divide each of the lungs into 3 zones, each occupying 1/3 of the height of the lung. Inspect each of the zones of the lung first ensuring that lung markings Compare each zone between lungs- any asymmetry

35. B REATHING-Pleura Inspect the pleura: Not normally visible in healthy individuals Inspect the borders of each of the lungs to ensure lung markings extend all the way to the edges of the lung Fluid-Pleural effusion

36. C ardiac Assess heart size In a healthy individual the heart should occupy no more than 50% of the thoracic width (e.g. a cardiothoracic ratio of <0.5). This rule only applies to PA chest x-rays More than 50% of the thoracic width ( on a PA CXR ) then this suggests cardiomegaly  

37. C ardiac Inspect the borders of the heart which should be well defined in healthy individuals: The heart borders may become difficult to distinguish from the lung fields as a result of various pathological processes (e.g. consolidation) which cause increased opacity of the lung tissue.

38. C ardiac

39. D iaphragm The right hemi-diaphragm is in most cases higher than the left in healthy individuals ( as a result of the underlying liver) .   The stomach underlies the left hemi-diaphragm and is best identified by the gastric bubble located within it. The diaphragm should be indistinguishable from the underlying liver in healthy individuals on an erect CXR

40. D iaphragm NORMAL !!!!!ABNORMAL!!!!! PNEUMOPERITONEUM ( FREE AIR IN THE ABDOMEN )

41. D iaphragm Costophrenic angles The costophrenic angles are formed from the dome of each hemi-diaphragm and the lateral chest wall. In a healthy individual the costo -phrenic angles should be clearly visible on a normal CXR as a well defined acute angle. Loss of this acute angle ( sometimes referred to as costophrenic blunting ) can suggest the presence of fluid or consolidation in the area

42. D iaphragm

43. E verything else Mediastinal contours The mediastinum contains the heart, great vessels, lymphoid tissue and a number of potential spaces where pathology can occur.    Aortic knuckle: Left lateral edge of the aorta as it arches back over the left main bronchus. Loss of definition of the aortic knuckles contours can be caused by an aneurysm. Aorto-pulmonary window: The aorto-pulmonary window is a space located between the arch of the aorta and the pulmonary arteries. This space can be lost as a result of mediastinal lymphadenopathy (e.g. malignancy).

44. E verything else Aortic knuckle and aorto pulmonary window

45. E verything else Bones Inspect the visible skeletal structures looking for any abnormalities (e.g. fractures / lytic lesions). Soft tissues Inspect the soft tissues for any obvious abnormalities (e.g. large haematoma ).

46. E verything else Tubes –  NGT are something you’ll often be asked to assess on a chest x-ray to confirm it is safe for feeding Lines (e.g. central line / ECG cables). Artificial valves (e.g. aortic valve replacement). Pacemaker ( often located below the left clavicle).

47. REVIEW AREAS Those parts of the CXR in which an abnormality can easily be overlooked and therefore require particular attention Lung apices Retrocardiac Behind the diaphragm Peripheral lungs Hilar

48. Pattern of lung disease Increased density White Reduced density black

49. Pattern of lung disease Lung abnormalities with an increased density - also called opacities - are the most common. A practical approach is to divide these into four patterns: Consolidation Interstitial Nodules or masses Atelectasis

50. Consolidation Any pathologic process that fills the alveoli with fluid, pus, blood, cells (including tumor cells) or other substances resulting in lobar, diffuse or multifocal ill-defined opacities.

51. Consolidation Pneumonia is by far the most common cause of consolidation. Usually starts within the alveoli and spreads from one alveolus to another. When it reaches a fissure the spread stops there.

52. Consolidation The key-findings on the X-ray are: ill-defined homogeneous opacity obscuring vessels Silhouette sign: loss of lung/soft tissue interface Air- bronchogram Extention to the pleura or fissure, but not crossing it No volume loss

53. Consolidation

54. Lobar pneumonia ill-defined area of increased density in the right upper lobe without volume loss.

55. Consolidation Lobar pneumonia - in a patient with cough and fever. Pulmonary hemorrhage - in a patient with hemoptisis . Organizing pneumonia (OP) - multiple chronic consolidations. Infarction - peripheral consolidation in a patient with acute shortness of breath with low oxygen level and high D-dimer. Pumonary cardiogenic edema - filling of the alveoli with transudate in a patient with congestive heart failure. Sarcoidosis - at first glanse this looks like consolidation, but in fact this is nodular interstitial lung disease, that is so wide-spread that it looks like consolidation.

56. Interstitial involvement of the supporting tissue of the lung parenchyma resulting in fine or coarse reticular opacities or small nodules.

57. Interstitial Reticular interstitial opacities Fine Nodular interstitial opacities

58. Interstitial

59. Interstitial Cystic versus Reticular ? reticular pattern or a cystic pattern. HRCT will give you more information. UIP - honeycombing. This creates a reticular pattern on the chest x-ray, because the cysts in honeycombing have thick walls.

60. Nodule or mass Any space occupying lesion either solitary or multiple.

61. Nodule or mass Solitary Pulmonary Nodule Multiple Masses SIZE Miliary nodules: <2 mm Pulmonary micronodule: 2-7 mm Pulmonary nodule: 7-30 mm pulmonary mass: >30 mm

62. Atelectasis Collapse of a part of the lung due to a decrease in the amount of air in the alveoli resulting in volume loss and increased density.

63. Atelectasis Atelectasis or lung-collapse is the result of loss of air in a lung or part of the lung with subsequent volume loss due to airway obstruction or compression of the lung by pleural fluid or a pneumothorax. In many cases atelectasis is the first sign of a lung cancer. Evidently it is very important to recognize the various presentations of atelectasis, since some of them can be easily misinterpretated . The key-findings on the X-ray are: Sharply-defined opacity obscuring vessels without air- bronchogram Volume loss resulting in displacement of diafragm , fissures, hili or mediastinum

64. Right upper lobe atelectasis Triangular density Elevated right hilus Obliteration of the retrosternal clear space (arrow)

65. Right upper lobe atelectasis A common finding in atelectasis of the right upper lobe is 'tenting' of the diaphragm (blue arrow). This patient had a centrally located lung carcinoma with metastases in both lungs (red arrows).

66. Right middle lobe atelectasis Blurring of the right heart border (silhouette sign) Triangular density on the lateral view as a result of collapse of the middle lobe Usually right middle lobe atelectasis does not result in noticable elevation of the right diaphragm. A pectus excavatum can mimick a middle lobe atelectasis on a frontal view, but the lateral view should solve this problem.

67. Right lower lobe atelectasis There is a right lower lobe atelectasis. Notice the abnormal right border of the heart. The right interlobar artery is not visible, because it is not surrounded by aerated lung but by the collapsed lower lobe, which is adjacent to the right atrium. On a follow-up chest film the atelectasis has resolved.. Notice the reappearance of the right interlobar artery (red arrow) and the normal right heart border (blue arrow).

68. Remember?

69. Left upper lobe atelectasis Minimal volume loss with elevation of the left diaphragm Band of increased density in the retrosternal space, which is the collapsed left upper lobe Abnormal left hilus , i.e. possible obstructing mass

70. Left upper lobe atelectasis There is an atelectasis of the left upper lobe. You would not expect the apical region to be this dark, but in fact this is caused by overinflation of the lower lobe, which causes the superior segment to creep all the way up to the apical region. This is called the luftsichel sign

71. Left lower lobe atelectasis The retrocardiac part of the left lung is increased in density Outline of the descending aorta is lost. Loss of the medial part of the left hemidiaphragm. A double contour to the left edge of the heart is visible. 

72. Total atelectasis The chest x-ray shows total atelectasis of the right lung due to mucus plugging. Notice the displacement of the mediastinum to the right. Re-aeration on follow-up chest film after treatment with a suction catheter. The mediastinum has regained its normal position. A common cause of total atelectasis of a lung is a ventilation tube that is positioned too deep and thus obstructing one of the main bronchi.

73. Pattern of lung disease Not always possible Work-up of both the differential diagnosis of masses and consolidation. Clinical data, old films or follow-up films and CT-scan Some cases only biopsy will provide a diagnosis.

74. Radiolucent disease Cyst, cavity, pneumatocele , emphysema, bulla, honeycombing, bleb etc. Many of these terms are based on the pathogenesis of the abnormality. A more practical approach is to describe areas of decreased density in the lung as: Cavity - lucency with a thick wall Cyst - lucency with a thin wall Emphysema - lucency without a visible wall

75. Radiolucent disease Cavities frequently arise within a mass or an area of consolidation as a result of necrosis. Cavities can heal and end up as lung cysts and lung cysts can become infected and turn into thick walled cavities.

76. Cavitation A cavity can be seen on the chest film. These patients are usually very ill in pyogenic pneumonia In granulomatous infection like TB, cavities may form, but these patients are usually not that ill. Cavitation is not seen in viral pneumonia, mycoplasma and rarely in streptococcus pneumoniae.

77. Cavitation

78. Summary of Key Points Key Point 1 – Technical Quality of an X-RAY is everything Key Point 2 – Be systematic when reading an X-ray - develop your own system Key Point 3 – Identify the overwhelming pattern of disease – radiopaque or radiolucent.

79. CAVITIES SCC

80. Pneumonia vs TB

81. RT upper zone consolidation with prominent RT hilum. CXR in a different patient shows multiple coalescent air-space nodules in RT upper zone

82. References https://www.currytbcenter.ucsf.edu/trainings/tbradiology-resource Daley, C. L., Gotway , M. B., & Jasmer , R. M. ( n.d. ). A PRIMER FOR CLINICIANS Radiographic Manifestations of Tuberculosis SECOND EDITION 2006 . McAdams HP, Erasmus J, Winter JA. Radiological manifestations of pulmonary tuberculosis. Radiol Clin North Am 1995;33(4):655– 678. Woodring JH, Vandiviere HM, Fried AM, Dillon ML, Williams TD, Melvin IG. Update: the radiographic features of pulmonary tuberculosis. AJR Am J Roentgenol 1986;146(3):497–506. Burrill J, Williams CJ, Bain G et-al. Tuberculosis: a radiologic review. Radiographics . 27 (5): 1255-73. doi:10.1148/rg.275065176 - Pubmed citation https://www.currytbcenter.ucsf.edu/products/view/radiographic-manifestations- Andreu, J. Cáceres , J., Pallisa , E. & Martinez-Rodriguez, M. (2004). Radiological manifestations of pulmonary tuberculosis. European Journal of Radiology , 51 (2), 139–149. https://doi.org/10.1016/j.ejrad.2004.03.009 Khan, R., Malik, N. I., & Razaque , A. (2020). Imaging of pulmonary post-tuberculosis sequelae. Pakistan Journal of Medical Sciences , 36 , S75–S82. https://doi.org/10.12669/pjms.36.ICON-Suppl.1722 https://www.youtube.com/watch?v=agCtsIE4kn4