tb_radiology_basic_presentation_slides.pptx

interprete the CxR of pulmonary tuberculosis

1. Basic Chest Radiology for the TB Clinician Adapted from the ISTC TB Training Modules 2009 PRESENTATION MATERIALS

2. Basic Radiology for the TB Clinician Objectives: At the end of this presentation, participants will be able to: Analyze the technical quality of chest X-rays (CXRs) using simple parameters Identify basic normal CXR anatomy on both frontal and lateral views Recognize radiographic patterns of disease and describe using appropriate terminology Describe both the typical and atypical patterns of radiographic presentation for pulmonary tuberculosis 2

3. Basic Radiology for the TB Clinician (2) Overview: Technical aspects of chest radiography Systematic approach to reading CXR Basic CXR anatomy Patterns of disease Radiographic manifestations of tuberculosis (TB) 3

4. Chest Radiography: Basic Principles Blackest air fat soft tissue calcium bone X-ray contrast metal Whitest Maximum X-Ray Transmission (least dense tissue) Maximum X-Ray Absorption (densest tissue) X-ray photon: Absorbed / scattered / transmitted X-ray absorption depends on: Beam energy (constant) Tissue density 4

5. Differential X-Ray Absorption Why we see what we see: Structures are visible on a radiograph because of the juxtaposition of two different densities  creating an interface Silhouette Sign Loss of an expected interface  No boundary can be seen between two structures because they now are similar in density Image credit: Curry International Tuberculosis Center, University of California, San Francisco 5

6. Silhouette Sign: RLL Pneumonia Silhouette Sign: RLL Pneumonia Image credit: Curry International Tuberculosis Center, University of California, San Francisco 6

7. Silhouette Sign: RLL Pneumonia Silhouette Sign: RLL Pneumonia Image credit: Curry International Tuberculosis Center, University of California, San Francisco 6

8. Assess CXR Technical Quality Inspiratory effort 9-10 posterior ribs Penetration thoracic intervertebral disc space just visible Positioning / rotation medial clavicle heads equidistant from spinous process 7

9. Image credit: Curry International Tuberculosis Center, University of California, San Francisco 8

10. 10 1 2 3 4 5 6 7 8 9 Image credit: Curry International Tuberculosis Center, University of California, San Francisco 8

11. 10 1 2 3 4 5 6 7 8 9 Image credit: Curry International Tuberculosis Center, University of California, San Francisco 8

12. 10 1 2 3 4 5 6 7 8 9 Image credit: Curry International Tuberculosis Center, University of California, San Francisco 8

13. Inspiratory Effort Low Lung Volumes Full Inspiration Image credit: Curry International Tuberculosis Center, University of California, San Francisco 9

14. Overexposure Proper Exposure Exposure Image credit: Curry International Tuberculosis Center, University of California, San Francisco 10

15. Overexposure Proper Exposure Image credit: Curry International Tuberculosis Center, University of California, San Francisco 11

16. Rotated (Oblique) Image credit: Curry International Tuberculosis Center, University of California, San Francisco 12

17. Basic Radiology for the TB Clinician A systematic approach to reading a CXR Image Credit: Lung Health Image Library/Gary Hampton 13

18. Approach to Reading a CXR Be Systematic Lungs Pleural surfaces Cardiomediastinal contours Bones and soft tissues Abdomen Image credit: Curry International Tuberculosis Center, University of California, San Francisco 14

19. Worth a Second Look Apices Retrocardiac areas (left and right) Hilar regions Below diaphragm 15

20. Apical TB Image credit: Curry International Tuberculosis Center, University of California, San Francisco 16

21. Image credit: Curry International Tuberculosis Center, University of California, San Francisco Apical TB (2) 17

22. Left Retrocardiac Opacity Image credit: Curry International Tuberculosis Center, University of California, San Francisco 18

23. Nodule Behind Diaphragm Image credit: Curry International Tuberculosis Center, University of California, San Francisco 19

24. Basic Radiology for the TB Clinician Basic CXR Anatomy Image credit: Curry International Tuberculosis Center, University of California, San Francisco 20

25. Basic CXR Anatomy Frontal and Lateral Views Heart Aorta Pulmonary arteries Airways Image Credit: Lung Health Image Library/Pierre Virot 21

26. Image credit: Curry International Tuberculosis Center, University of California, San Francisco 22

27. Aortic arch Right pulmonary artery Left pulmonary artery Trachea & bronchi Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23

28. Aortic arch Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23

29. Aortic arch Right pulmonary artery Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23

30. Aortic arch Right pulmonary artery Left pulmonary artery Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23

31. Aortic arch Right pulmonary artery Left pulmonary artery Trachea & bronchi Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23

32. Basic Radiology for the TB Clinician Patterns of disease 24

33. Chest Radiographic Patterns of Disease Consolidation / air-space opacity Interstitial opacity Nodules and masses Lymphadenopathy Cysts and cavities Pleural abnormalities 25

34. Consolidation / Air-Space Opacity Caused by filling of alveoli with fluid, pus, blood, cells (tumor), etc. May be diffuse, or isolated to segments or lobes of the lung May be associated with air bronchograms (air-filled bronchus surrounded by opacified lung) 26

35. Pneumonia Image credit: Curry International Tuberculosis Center, University of California, San Francisco 27

36. Interstitial Opacity Disease localized to pulmonary interstitium, i.e., the alveolar septae and connective tissues that support the alveoli Hallmarks: Lines and/or reticulation Small, well-defined nodules Miliary pattern DDX: Pulmonary edema, interstitial lung diseases (e.g., idiopathic pulmonary fibrosis), sarcoidosis, infection, tumor (lymphangitic spread), etc. 28

37. Interstitial Opacity: Lines Image credit: Curry International Tuberculosis Center, University of California, San Francisco 29

38. Interstitial Opacity: Lines Image credit: Curry International Tuberculosis Center, University of California, San Francisco 29

39. Interstitial Opacity: Lines & Reticulation Image credit: Curry International Tuberculosis Center, University of California, San Francisco 30

40. Nodules and Masses Nodule: discrete pulmonary lesion, sharply defined, nearly circular opacity 0.2 - 3 cm Mass: larger than 3 cm Describe with qualifiers: Single or multiple Size Border characteristics Presence or absence of calcification Location 31

41. Well-Defined Calcification Ill-Defined Mass Image credit: Curry International Tuberculosis Center, University of California, San Francisco 32

42. Lymphadenopathy (LAN) Non-specific terms: Mediastinal widening Hilar prominence Specific patterns: Particular station enlargement (location)  Important to know what “normal” should look like in order to recognize “abnormal ” 33

43. Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34

44. Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34

45. Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34

46. Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34

47. Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34

48. Infrahilar window (right hilar and/or subcarinal) Left hilar Subcarinal Lymphadenopathy Image credit: Curry International Tuberculosis Center, University of California, San Francisco 35

49. Infrahilar window (right hilar and/or subcarinal) Lymphadenopathy Image credit: Curry International Tuberculosis Center, University of California, San Francisco 35

50. Left hilar Lymphadenopathy Image credit: Curry International Tuberculosis Center, University of California, San Francisco 35

51. Subcarinal Lymphadenopathy Image credit: Curry International Tuberculosis Center, University of California, San Francisco 35

52. Right Paratracheal & Bilateral LAN Image credit: Curry International Tuberculosis Center, University of California, San Francisco 36

53. Right Hilar LAN Image credit: Curry International Tuberculosis Center, University of California, San Francisco 37

54. Right Hilar LAN Image credit: Curry International Tuberculosis Center, University of California, San Francisco 38

55. * Subcarinal LAN Image credit: Curry International Tuberculosis Center, University of California, San Francisco 39

56. AP Window LAN Image credit: Curry International Tuberculosis Center, University of California, San Francisco 40

57. Cysts & Cavities Abnormal pulmonary parenchymal spaces (“holes”), filled with air and/or fluid, with a definable wall (>1 mm) Cyst: congenital or acquired Cavity: caused by tissue necrosis, (inflammatory and/or neoplastic) Characterize: Wall thickness at thickest portion Inner lining Presence / absence of air / fluid level Number and location 41

58. TB or Not TB? Cysts and Cavities Are there radiographic features that suggest benign vs. malignant diagnoses? A “45 year old man from China with cough, weight loss” C D B Image credit: Curry International Tuberculosis Center, University of California, San Francisco 42

59. TB or Not TB? Cysts and Cavities (2) Are there radiographic features that suggest benign vs. malignant diagnoses? Benign cysts: uniform wall thickness, 1mm, smooth inner lining (e.g., PCP) Benign cavities: max. wall thickness  4 mm, minimally irregular inner lining (e.g., TB) Malignant cavities: max. wall thickness 16 mm, i rregular inner lining 43

60. Pleural Disease: Basic Patterns Effusion Angle blunting to massive Thickening Mass Air Calcification 44

61. Pleural Effusion 45

62. Post-TB Pleural Calcification 46

63. Plombage with Lucite balls 47

64. Basic Radiology for the TB Clinician Radiographic Manifestations of TB 48

65. Can this be TB? “ Typical Pattern”: Post-primary TB Distribution Apical / posterior segments of upper lobes Superior segments of lower lobes Isolated anterior segment involvement unusual for M.tb (think M. avium complex) 49

66. “Typical pattern”: Post-Primary TB Patterns of disease Air-space consolidation Cavitation, cavitary nodule Endobronchial spread Miliary Bronchostenosis Tuberculoma Pleural effusions (empyema most likely in post-primary disease) 50

67. Can this be TB? “Atypical pattern”: Primary TB Distribution : any lobe involved (slight lower lobe predominance) Air-space consolidation Cavitation is uncommon (<10%) Adenopathy is common (esp. children and HIV), predilection for right side Miliary pattern Pleural effusions 51

68. Can this be TB? Miliary TB 52

69. Radiographic Patterns: Pulmonary TB TB Pattern “Typical” (Post-Primary) “Atypical” (Primary) Infiltrate 85% upper Upper : Lower 60 : 40 Usually upper in children Cavitation Common Uncommon Adenopathy Uncommon Children common Adults ~30% Unilateral > bilateral Effusion May be present May be present 53

70. CXR Pattern: Early vs. Advanced HIV Early HIV (CD4>200) Advanced HIV (CD4<200) Pattern “Typical” (Post-primary) “Atypical” (Primary) Infiltrate Upper lobes Lower lobes, multiple sites, or miliary Cavitation Common Uncommon Adenopathy Uncommon Common Effusion Uncommon More common 54

71. Can this be TB? “Old / Healed” TB Ca ++ granuloma–Ghon lesion Ca ++ granuloma and hilar node calcification–Ranke complex Apical pleural thickening Fibrosis and volume loss 55

72. Basic Radiology for the TB Clinician Summary: Remember: Technical quality can significantly impact your CXR interpretation Develop a systematic approach (and use it every time!) Practice identifying normal CXR anatomy Important to characterize and describe lesions—this can help with your differential diagnosis Whether typical or atypical  TB can always fool you! 56