RADIOLOGIC EVALUATION OF PULMONARY NTM INFECTION

Tilman Koelsch, MDNational Jewish Health - Department of Radiology

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

Disclosures

NoneProp

erty o

f Pres

enter

Not for

Rep

roduc

tion

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

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

Overview

I. CT technique

II. NTM imaging signs

III. Radiological/Clinical Phenotypes

IV. NTM & Underlying Lung Disease

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

CT Technique

• Spiral &

Volumetric CT

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

“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

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

• 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.

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

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

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

• 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

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

• 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

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

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.

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

NTM Imaging Signs

• Tree-In-Bud and Centilobular Nodules

• Bronchiectasis

• Cavities

• Ground-Glass and Consolidation

• Atelectasis

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

NTM Imaging SignsWhere we are going

65 F with several + NTM cultures

& imaging features suggesting NTM

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

NTM Imaging Signs• Centrilobular Nodules and Tree-In-Bud

• Typically from Airways

• (i.e. infection, HP, smoking)

• Infection, Infection, Aspiration/Mucus Plugs…

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

NTM Imaging Signs• Bronchiectasis – Chest X-ray “Tram-Track” lines and

Rings

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

NTM Imaging Signs• Bronchiectasis

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

NTM Imaging Signs

• Bronchiectasis

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

NTM Imaging Signs• Bronchiectasis

figures from chestmedicine.org

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

Slice Thickens

Bronchiectasis?

5 mm 1 mm

Yes! Bronchi bigger than arteries

Maybe?

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

NTM Imaging Signs• Cavities - and “feeding bronchus” sign

• Kim et al AJR 2005; 184:1247-

1252

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

NTM Imaging Signs• Cavities - and “feeding bronchus” sign

• Kim et al AJR 2005; 184:1247-

1252

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

NTM Imaging Signs• Cavities - and “feeding bronchus” sign

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

NTM Imaging Signs• Cavities

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

NTM Imaging Signs• Cavities

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

NTM Imaging Signs• Consolidation and Ground-Glass

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

NTM Imaging Signs• Consolidation and Ground-Glass

Ground-GlassConsolidation

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

NTM Imaging Signs• Atelectasis

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

NTM Imaging Signs• Atelectasis

RML

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

NTM Imaging Signs• Atelectasis

RML

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

Pt. had surgery to remove RML and Lingula

Before

After

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

Aside: NTM with Normal CXR

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

Overview

I. CT technique

II. NTM imaging signs

III. Radiological/Clinical Phenotypes

IV. NTM & Underlying Lung Disease

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

Radiological/Clinical Phenotypes of NTM

I. Bronchiectasis/Tree-in-bud

- Right middle lobe/lingular bronchiectasis

II. Upper Lobe Cavities

III. Solitary Pulmonary Nodule – rare

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

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

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

I. Bronchiectasis & Tree-in-Bud - CASE 2

Radiological/Clinical Phenotypes of NTM

CASE 2 – More SeverePropert

y of P

resen

ter

Not for

Rep

roduc

tion

Progressionfrom

2011-2014

2014

CASE 2 –

More

Severe

2011

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

I. Bronchiectasis & Tree-in-Bud - CASE 2

Radiological/Clinical Phenotypes of NTM

CASE 2• More severe, progressive• Cavity formation

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

II. Upper Lobe Cavities- CASE 3

Radiological/Clinical Phenotypes of NTM

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

II. Upper Lobe Cavities- CASE 3

Radiological/Clinical Phenotypes of NTM

CASE 3 - Severe upper lobe cavitary dz.

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

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

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

Radiological/Clinical Phenotypes of NTM

CASE 4

• Developed broncho-cutaneous fistula. Rare with NTM. Here after surgery.

II. Upper Lobe Cavities- CASE 4

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

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)

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

III. Solitary Pulmonary Nodule – CASE 6

Radiological/Clinical Phenotypes of NTM

CASE 6• Solitary “Cavity”

• Not squamous

neoplasm?

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

Overview

I. CT technique

II. NTM imaging signs

III. Radiological/Clinical Phenotypes

IV. NTM & Underlying Lung Disease

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

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

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

CASE 7

NTM in COPD/Emphysema

• Cavities can form: • with bronchiectasis • OR in preexisting disease

• Can “spill” contents

NTM & underlying lung disease

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

CASE 7

NTM & Underlying Lung Disease

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

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

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

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

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

CASE

9NTM in Adult CF

• more “classic” upper lung adult CF

NTM & Underlying Lung Disease

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

CASE

10

NTM in Adult CF - often NOT specific findings

NTM & Underlying Lung Disease

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

CASE 11

NTM in

Silicosis

NTM & Underlying Lung Disease

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

CASE

12

NTM in IPF

NTM & Underlying Lung Disease

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

CASE 13

Hot Tub Lung

“Hot Tub Lung”

• Ground-Glass• Centrilobular nodules

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

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

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

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.

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

PET/CT and NTM• Lung Cancer with NTM

6/13

1/14

6/15

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

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

erty o

f Pres

enter

Not for

Rep

roduc

tion

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

Propert

y of P

resen

ter

Not for

Rep

roduc

tion

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.

Propert

y of P

resen

ter

Not for

Rep

roduc

tion