Radiology of Tuberculosis

Collection of cases I saw during my residency.

1. Radiology of Tuberculosis
Mohit Goyal
Under the guidance of: Sr. Prof. Dr. V.K. Goyal
Department of Medicine, R.N.T. Medical College, Udaipur
13
th
February, 2014

2. Radiology of Tuberculosis
Common Roentgenograms
Summary of Roentgenographic manifestations of TB
An extremely rare case
Some CT and MRI findings in TB

3. XR01
Radiology of Tuberculosis

4. Presentation
Thispatient,a32-year-oldmalepresentedwithinsidiousonset,
progressive,productivecoughfor3months;feverishfeelingfora
monthandlooseningofclothesovertime.
Pasthistory:Nohistoryofanyotherillnesses.
Overthecountermedicationstakenonandoffoverthepastmonth
forcoughandfever.
Thepatienthaddifficultyproducingsputumfortheexamination.
ThesamplemainlycontainedsalivaandwasfoundnegativeforAFB.
ThepatientwasreferredtoDept.ofTBCD.BALsamplewastaken,
subjectedtomicrobiologicalexaminationandfoundpositiveforAFB.
XR01

5. Miliaryshadows/mottling
Milletseedsizedopacities~2mm
Miliarydensitiesareseenin:MiliaryTB,Anthracosis,Sarcoidosis,
Tropicaleosinophilia,Fibrosingalveolitis,Allergicalveolitis,
Histoplasmosis,Coccidioidomycosis,Blastomycosis,Cryptococcosis.
PulmonaryhaemosiderosisandSilicosisarealsoseenasmilliary
mottlingbuttheradiodensityismorethansofttissue.
Carcinomatosis,lymphomaandsarcoidosishavediscretebutslightly
largershadows(>2mm).
Somepneumonias,fatemboliandpulmonaryoedemacanpresentas
shadows>2mmthattendtocoalesce.

6. MetastasisfromPapillaryca MiliaryTuberculosis
XR01

7. XR02
Radiology of Tuberculosis

8. Presentation
Thispatient,a23-year-oldmalepresentedwithfever,productive
coughandweightlossforonemonth.
Pasthistory:Nohistoryofanyotherillnesses.
Overthecountermedicationstakenoverthepastmonthforfever.
Thepatient’ssputumwassentforexaminationandfoundtobe
positiveforacidfastbacilli.
XR02

9. Cavity
Agascontainingspaceinthelungssurroundedbyawallwhose
thicknessis>1mm.
Inbullae,thewallthicknessis<1mm.
Thinwalledcavitiesmaybeseenintuberculouscavity,infected
bullae,staphylococcus, Klebsiella,post-traumatic cysts,
Coccidioidomycosis,Mycobacteriumkansasiiinfection,metastatic
cavitatingsquamouscellcaofcervix.
Thickwalledcavitiesmaybeseeninlungabscess,metastatic
carcinoma,bronchogeniccarcinoma,Wegener’sgranulomatosis,
fungalcavity,necrotisingsquamouscellcarcinoma,Blastomycosis.
XR02

10. Cavity
Thecavitywallisirregularornodularincarcinoma,ruggedor
shaggyinacutelungabscessandsmoothinothercavitatinglesions.
Cavitywithwallthickness<5mmislikelytobebenign;5-15mmmay
bebenignormalignantand>15mmislikelytobemalignant.
Lungabscess-superiorsegmentofthelowerlobeandaxillarysub
segmentsofanteriorandposteriorsegmentoftheupperlobe.
Tubercular–superiorsegmentsofupperandlowerlobes.
Klebsiella,SCC–upperlobes.
Cysticbronchiectasis,hydatidcyst–lowerlobes
Note:whenacavityintheanteriorsegmentisencountered,strong
suspicionforlungcancershouldberaised.

11. XR03
Radiology of Tuberculosis

12. Presentation
Thispatient,a70-year-oldmalepresentedwithinsidiousonset,
progressiveshortnessofbreath.Nohistoryofcough,expectoration.
Pasthistory:TakenATT10yearsbackforpulmonaryTB.
Thepatient’ssputumwassentforexaminationandwasfoundtobe
negativeforacidfastbacilli.CTimagingofthoraxwasplannedbut
thepatientrefused.
XR03

13. XR04
Radiology of Tuberculosis

14. Presentation
Thispatient,a60-year-oldmalepresentedwithdifficultybreathing,
painontherightsideofchestanddrycoughonandoff.
Pasthistory:TakenATT8yearsbackforpulmonaryTBwithpossibly
pleuraleffusion.Documentsnotavailablebutthepatientdescribes
bothparenchymaldiseaseaswellaspleuraleffusion.
Thepatient’ssputumwassentforexaminationandwasfoundtobe
negativeforacidfastbacilli.CTimagingofthoraxrevealedpleural
thickeningandcalcification.Therewasnotevidenceofactivity.
XR04

15. XR05
Radiology of Tuberculosis

16. XR05
Radiology of Tuberculosis

17. Presentation
Thispatient,a20-year-oldmalepresentedwithinsidiousonset,
progressiveshortnessofbreathfor2months.
Pasthistory:Nohistoryofanychronicillnesses.
Pleuralfluidwassentforanalysis.Itwasfoundtohave800cells,
with90%lymphocytes.Proteinswere6g%andthefluidwaspositive
forADA.Patient’sESRwas63.
Thepatient’ssputumwassentforexaminationandwasfoundtobe
negativeforacidfastbacilli.
XR05

18. XR06
Radiology of Tuberculosis

19. Presentation
Thispatient,a57-year-oldmalepresentedwithacuteonset
shortnessofbreath.
Pasthistory:TwoyearsbackhetookATTfor6months.
Emergencymanagementwasdone.Thepatient’ssputumwassent
forexaminationandwasfoundtobenegativeforacidfastbacilli.
XR06

20. XR07
Radiology of Tuberculosis

21. Presentation
Thispatient,a40-year-oldmalepresentedwithinsidiousonset,
progressiveedemaandshortnessofbreath.
Pasthistory:Hewasdiagnosedtohavepericardialeffusionanyear
back,whichwasfoundtobetubercular,andhewasgivenATTforit.
Thepatient’ssputumwassentforexaminationandwasfoundtobe
negativeforacidfastbacilli.
ECHOrevealedpericardialcalcification,constrictivepericarditis.The
patientwastakenoverbytheDept.ofCardio-Thoracic-Vascular
surgeryforfurthermanagement.
XR07

22. XR08
Radiology of Tuberculosis

23. Radiology of Tuberculosis
Common Roentgenograms
Summary of Roentgenographic manifestations of TB
An extremely rare case
Some CT and MRI findings in TB

24. Consolidationinprimaryinfection
Thismayinvolveanypartofthelung,andtheappearanceisnon-
specificunlessthereiscoincidentallymphadenopathy.
Theareainvolvedmaybesmalloraffectanentirelobe,andanair
bronchogrammaybevisible.Occasionallyconsolidationappearsasa
well-definednoduleornodules.
Healingisoftencompletewithoutanysequelaeonthechest
radiographalthoughfibrosisandcalcificationmayoccur.
Tuberculousbronchopneumonia mayoccurinbothprimaryand
post-primaryinfection,causingpatchy,oftennodular,areasof
consolidation.

25. Consolidationinpost-primaryinfection
Thisusuallyappearsintheapexofanupperorlowerlobe,and
almostneverintheanteriorsegmentsoftheupperlobes.
Theconsolidationisoftenpatchyandnodularandmaybebilateral.
Aminimalapicallesioncaneasilybeoverlookedbecauseof
overlappingshadowsofribsandclavicle.Comparisonwiththe
oppositesideisthenhelpful,lookingforasymmetriesofdensity.The
apicalprojectionwasdesignedtoovercomethisdifficulty,butis
rarelyuseful.
Progressiveinfectionisindicatedbyextensionandcoalescenceofthe
areasofconsolidation,andthedevelopmentofcavities.

26. Consolidationinpost-primaryinfection
Simultaneouslytheremaybefibrosisandvolumelossindicating
healing.
Cavitiesmaybesingleormultiple,largeorsmallandthinorthick
walled.Fluidlevelsaresometimesvisiblewithincavities.
Withfibrosisthereisoftenobliterationofcavities;however,larger
cavitiesmaypersistandareasofbronchiectasisandemphysema
maydevelop.Healedlesionsoftencalcify.
Becausetheupperlobesarepredominantlyinvolved,theeffectsof
fibroticcontractionareseenasthetracheabeingpulledawayfrom
themidline,elevationofthehilaanddistortionofthelung
parenchyma.

27. XR02
Radiology of Tuberculosis

28. Miliarytuberculosis
Thisisduetohaematogenousspreadofinfectionandmaybeseenin
bothprimaryandpost-primarydisease.Intheformerthepatientis
oftenachild,andinthelattercasethepatientsareoftenelderly,
debilitatedorimmunocompromised .
Atfirstthechestradiographmaybenormal,butthensmall,discrete
nodules,1-2mmindiameter,becomeapparent,evenlydistributed
throughoutbothlungs.
Thesemayenlargeandcoalesce,butwithadequatetreatmentthey
slowlyresolve.Occasionally,somemaycalcify.

29. XR01
Radiology of Tuberculosis

30. Tuberculoma
Thisisalocalizedgranulomaduetoeitherprimaryorpost-primary
infection.Itusuallypresentsasasolitarywell-definednodule,upto
5cmindiameter.Calcificationiscommonbutcavitationisunusual.
Lymphadenopathy
Hilarandmediastinallymphadenopathyisacommonfeatureof
primaryinfectionandmaybeseeninthepresenceorabsenceof
peripheralconsolidation.Followinghealing,involvednodesmay
calcify.Lymphadenopathy isusuallyunilateralbutmaybebilateral
wherethedifferentialdiagnosesoflymphomaandsarcoidosiscome
in.Itisoftenmorepronouncedinchildren.

31. Pleuralchanges
Pleuraleffusioncomplicatingprimaryinfectionisusuallyunilateral
andduetosubpleuralinfection.Pulmonaryconsolidationand/or
lymphadenopathymayormaynotbeapparent.
Atpresentationtheeffusionmaybelargeandrelatively
asymptomatic.Theseeffusionsusuallyresolvewithoutcomplication.
Pleuraleffusioninpost-primaryinfection,however,oftenprogresses
toempyema.Healingisthencomplicatedbypleuralthickeningand
oftencalcification.Uncommon complicationsoftuberculous
empyema arebronchopleuralfistula,osteitisofarib,
pleurocutaneous fistulaandsecondaryinfection.Previous
thoracoplastymayalsocomplicatetheappearances.

32. XR05
Radiology of Tuberculosis

33. Pleuralchanges
Pleuralthickeningovertheapexofthelungoftenaccompaniesthe
fibrosisofhealingapicaltuberculosis.Pneumothoraxmaycomplicate
subpleuralcavitatorydisease.
AirwayInvolvement
Thismaybesecondarytolymphadenopathy orendobronchial
infectionandmaythereforecomplicatebothprimaryandpost-
primarydisease.Compressionofcentralairwaysbyenlargednodes
maycausepulmonarycollapseorairtrapping.Healingof
endobronchialinfectionwithfibrosismayresultinbronchostenosis.
Thelungdistaltobronchialnarrowingmaydevelopbronchiectasis.

34. XR04
Radiology of Tuberculosis

35. Radiology of Tuberculosis
Common Roentgenograms
Summary of Roentgenographic manifestations of TB
An extremely rare case
Some CT and MRI findings in TB

36. Rare Case
Radiology of Tuberculosis

37. Presentation
Thispatient,a48-year-oldmalepresentedwithinsidiousonset,
progressivedysphagiafor5months.
Pasthistory:ATTtaken1yearbackforpulmonaryTB.
EndoscopicbiopsyandCTthoraxandabdomenwereplanned.
Biopsyexaminationrevealedcasseatingepitheloidgranulomaand
positiveacidfaststaining.
TheoesophaguswasdilatedandthepatienthasbeenputonATT.
Rare Case

39. Rare Case
Radiology of Tuberculosis

40. Radiology of Tuberculosis
Common Roentgenograms
Summary of Roentgenographic manifestations of TB
An extremely rare case
Some CT and MRI findings in TB

41. XR08
Radiology of Tuberculosis

42. CT08

43. CT08

44. CT08

45. CT09

46. Presentation
Thispatientpresentedwithfeverforonemonth,alteredbehaviorfor
3daysandlossofconsciousnessfor6hours.
Pasthistory:Nohistoryofanychronicillnesses.
CSFexaminationrevealed100cells,mainlylymphocytes.Proteins
were6.4g%andthefluidwaspositiveforAdenosinedeaminase.
CT09

47. CT09

48. NeuroimagingfindingsinTB
Hydrocephalus–seenin50-80%cases
Enhancementofbasalmeninges–60%
Cerebralinfarctions–28%
Tuberculomas–10%
Masseffectsduetotuberculomasandabscess
Vasculitis
Thrombosis

49. MR10

50. MR10

51. MR10

52. MR10

53. THANK YOU
for the patience
Department of Medicine, R.N.T. Medical College, Udaipur
Acknowledgements:
Dept. of Radiodiagnosis, R.N.T. Medical College
Dr. Rambir Singh, MRI Centre, M.B. Govt. Hospital
Dr. Vinita Goyal, M.D. Radiodiagnosis
Sources:
Harrison’s Principles of Internal Medicine
Textbook of Radiology and Imaging, David Sutton
Tuberculosis, Surendra K. Sharma