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RADIOLOGIC EVALUATION OF PULMONARY NTM INFECTION
Tilman Koelsch, MDNational Jewish Health - Department of Radiology
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NoneProp
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Goals
• Identify the imaging features of pulmonary NTM infection on CT and X-ray
• Understand radiological phenotypes ofpulmonary NTM infection
• Understand the role of other imaging modalities
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Overview
I. CT technique
II. NTM imaging signs
III. Radiological/Clinical Phenotypes
IV. NTM & Underlying Lung Disease
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CT Technique
• Spiral &
Volumetric CT
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“Regular” CT - Spiral & Volumetric
CT Technique
• Nearly All CTs in US.• Quick - One breath hold (10-30 sec)• Reconstruct in: Any plane, Any thickness, 3D
Spiral/Volumetric Recon
NON-Spiral/Volumetric Recon
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• HRCT (1 mm)
Additional Images Also: • 1) End Expiration (for Air Trapping)
• 2) Prone (Mild Pulm. Fibrosis)
CT Technique
• When to order? (examples)• Possible HP or Hot Tub Lung! • Mild interstitial disease / fibrosis• “Subtle” bronchiectasis.
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HRCT
52 y/o F One + NTM culture and Indoor Hot Tub
Inspiratory Thin Cut Images
Expiratory – AIR TRAPPING (areas that stay dark)
Hot Tub Lung
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• Low Dose
At NJH we “automatically” use low dose for:
• NTM Follow-Up• Pulm. Nodule Follow-Up• Lung Cancer Screening
CT Technique
Regular Dose – Initial CT
Low Dose – Follow-Up
• ~ 1/3 to 1/5 Dose (smaller patients need less dose)• “Noisy” – but often Still Diagnostic Quality
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• Contrast?
• Usually not needed for LUNG
• Use for “Soft
Tissue”
• Mediastinum/Hila?
• Pleura/Chest Wall?
CT Technique
TB – Note Necrotic “Non-enhancing” LN
Empyema – Enhancing Plural Rind
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Question 1• For which of the following would a low-dose
CT NOT be preferred?
1. + NTM culture – question of underlying ILD
2. + NTM culture – question “Hot Tub Lung”
3. - NTM culture – uncertain diagnosis
4. Disseminated “hematogenous” NTM. For first chest CT.
5. None of above.
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NTM Imaging Signs
• Tree-In-Bud and Centilobular Nodules
• Bronchiectasis
• Cavities
• Ground-Glass and Consolidation
• Atelectasis
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NTM Imaging SignsWhere we are going
65 F with several + NTM cultures
& imaging features suggesting NTM
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NTM Imaging Signs• Centrilobular Nodules and Tree-In-Bud
• Typically from Airways
• (i.e. infection, HP, smoking)
• Infection, Infection, Aspiration/Mucus Plugs…
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NTM Imaging Signs• Bronchiectasis – Chest X-ray “Tram-Track” lines and
Rings
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NTM Imaging Signs• Bronchiectasis
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NTM Imaging Signs
• Bronchiectasis
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NTM Imaging Signs• Bronchiectasis
figures from chestmedicine.org
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Slice Thickens
Bronchiectasis?
5 mm 1 mm
Yes! Bronchi bigger than arteries
Maybe?
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NTM Imaging Signs• Cavities - and “feeding bronchus” sign
• Kim et al AJR 2005; 184:1247-
1252
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NTM Imaging Signs• Cavities - and “feeding bronchus” sign
• Kim et al AJR 2005; 184:1247-
1252
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NTM Imaging Signs• Cavities - and “feeding bronchus” sign
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NTM Imaging Signs• Cavities
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NTM Imaging Signs• Cavities
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NTM Imaging Signs• Consolidation and Ground-Glass
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NTM Imaging Signs• Consolidation and Ground-Glass
Ground-GlassConsolidation
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NTM Imaging Signs• Atelectasis
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NTM Imaging Signs• Atelectasis
RML
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NTM Imaging Signs• Atelectasis
RML
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Pt. had surgery to remove RML and Lingula
Before
After
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Aside: NTM with Normal CXR
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Overview
I. CT technique
II. NTM imaging signs
III. Radiological/Clinical Phenotypes
IV. NTM & Underlying Lung Disease
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Radiological/Clinical Phenotypes of NTM
I. Bronchiectasis/Tree-in-bud
- Right middle lobe/lingular bronchiectasis
II. Upper Lobe Cavities
III. Solitary Pulmonary Nodule – rare
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I. Bronchiectasis & Tree-in-Bud
Radiological/Clinical Phenotypes of NTM
• Look for active disease• Tree-in-bud, consolidation
• possible• look for stability, (& clinical)
• GGO • typically active inflammation
CASE 1 – Mild
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I. Bronchiectasis & Tree-in-Bud - CASE 2
Radiological/Clinical Phenotypes of NTM
CASE 2 – More SeverePropert
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Progressionfrom
2011-2014
2014
CASE 2 –
More
Severe
2011
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I. Bronchiectasis & Tree-in-Bud - CASE 2
Radiological/Clinical Phenotypes of NTM
CASE 2• More severe, progressive• Cavity formation
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II. Upper Lobe Cavities- CASE 3
Radiological/Clinical Phenotypes of NTM
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II. Upper Lobe Cavities- CASE 3
Radiological/Clinical Phenotypes of NTM
CASE 3 - Severe upper lobe cavitary dz.
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II. Upper Lobe Cavities- CASE 4
Radiological/Clinical Phenotypes of NTM
2007 2013 2014
CASE 4 -“Upper” lobe cavitary dz. Mixed Change. Overall worsening
Surgical Biopsy
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Radiological/Clinical Phenotypes of NTM
CASE 4
• Developed broncho-cutaneous fistula. Rare with NTM. Here after surgery.
II. Upper Lobe Cavities- CASE 4
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III. Solitary Pulmonary Nodule - CASE 5
Radiological/Clinical Phenotypes of NTM
CASE 5• Solitary nodule.
• Uncommon.
• Must still rule out other causes of nodule (i.e
neoplasm)
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III. Solitary Pulmonary Nodule – CASE 6
Radiological/Clinical Phenotypes of NTM
CASE 6• Solitary “Cavity”
• Not squamous
neoplasm?
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Overview
I. CT technique
II. NTM imaging signs
III. Radiological/Clinical Phenotypes
IV. NTM & Underlying Lung Disease
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NTM & Underlying Lung Disease
Risk factors for pulmonary NTM
• Honda et al Clin Chest Med 2015; 36:1-
11
• Often underlying
lung disease
• Structural• Non-structural
• Radiology also has role also in underlying disease
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CASE 7
NTM in COPD/Emphysema
• Cavities can form: • with bronchiectasis • OR in preexisting disease
• Can “spill” contents
NTM & underlying lung disease
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CASE 7
NTM & Underlying Lung Disease
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CASE 8
NTM in Chronic Aspiration
• Nothing Specific with known NTM
• Migratory Ground-Glass/Consolidation most suggestive
• Location? Anywhere, but:• lower-posterior - most common.• unilateral - sided sleeper?• upper - gardening, yoga, cough?
Few months later
NTM & Underlying Lung Disease
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Aspiration Work-up
1. Esophogram• Also evaluates
dysmotility• Only 2 min intermittent
for GERD
2. Tailored Barium Swallow with Speech Pathology
• Oral motility issues
3. Esophageal pH testing
CASE 8
NTM & Underlying Lung Disease
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CASE
9NTM in Adult CF
• more “classic” upper lung adult CF
NTM & Underlying Lung Disease
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CASE
10
NTM in Adult CF - often NOT specific findings
NTM & Underlying Lung Disease
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CASE 11
NTM in
Silicosis
NTM & Underlying Lung Disease
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CASE
12
NTM in IPF
NTM & Underlying Lung Disease
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CASE 13
Hot Tub Lung
“Hot Tub Lung”
• Ground-Glass• Centrilobular nodules
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CASE 13
Inspiratory Expiratory
“Hot Tub Lung”• Air-trapping is very often present (HRCT may be helpful!)• Could be only finding by CT• Normal CXR in 20+%
• Hartman et al. AJR. 2007 Apr;188(4):1050-3
Hot Tub Lung
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PET/CT and NTM• NTM will cause increased uptake (like most infections)
• SUV typically about 8.5 (4.4-9.7)
• So caution in evaluating for cancer with NTM
• May be useful for disease activity/response (but
higher radiation)• Hahm et al. Lung. 2010 Jan-Feb;188(1):25-31
• Treglia et al. J Comput Assist Tomogr.
2011;35(3):387-93.
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PET/CT and NTM• Lung Cancer with NTM
6/13
1/14
6/15
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Question 2• Which of the following Non-Cancer
diseases can have high uptake on PET?
1. Aspiration Pneumonia
2. Coccidiomycosis Infection
3. NTM Infection
4. Sarcoidosis
5. All of aboveProp
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MRI and NTM• Cavities - Excellent• Good but not perfect for other findings. (may miss small/mild findings and change)
• NO Radiation
• Chung et al. Ann Am Thorac Soc. 2016 Jan;13(1):49-57
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ReferencesKetai L, Currie B, Holt M, Chan E. Radiology of Chronic Cavitary Infections. JTI.
2018; 33(5):334-343.
Martinez S, McAdams HP, Batchu CS. The many faces of pulmonary nontuberculous mycobacterial infection. AJR Am J Roentgenol. 2007;189(1):177-186.
Ellis SM. The spectrum of tuberculosis and non-tuberculous mycobacterial infection. Eur Radiol. 2004;14 Suppl 3(3):E34-E42.
Ellis SM, Hansell DM. Imaging of Non-tuberculous (Atypical) Mycobacterial Pulmonary Infection. Clin Radiol. 2002;57(8):661-669.
Jeong YJ, Lee KS, Koh W-J, Han J, Kim TS, Kwon OJ. Nontuberculous mycobacterial pulmonary infection in immunocompetent patients: comparison of thin-section CT and histopathologic findings. Radiology. 2004;231(3):880-886.
Wittram C, Weisbrod GL. Mycobacterium avium complex lung disease in immunocompetent patients: radiography-CT correlation. BJR. 2002;75(892):340-344.
Erasmus JJ, McAdams HP, Farrell MA, Patz EF. Pulmonary nontuberculous mycobacterial infection: radiologic manifestations. RadioGraphics. 1999;19(6):1487-1505.
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