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Dr. Wong Soon Li MBBS (India), M.Med Radiology(UKM) A.M. (Malaysia) Columbia Asia Hospital – Bukit Rimau (Shah Alam)

Pulmonary Tuberculosis - 1

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Cases presentation of pulmonary tuberculosis

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  • 1. MBBS (India), M.Med Radiology(UKM) A.M. (Malaysia)Columbia Asia Hospital Bukit Rimau (Shah Alam)

2. PulmonaryTuberculosis 3. Pulmonary tuberculosis Discovery of the specific infectious agent, the tuberclebacillus (Mycobacterium tuberculosis) by Robert Koch in 1882. Descriptions of airborne transmission of infection and of reactivation of dormant infection in the 1960s by Riley et al and Stead and colleagues, respectively, furthered our understanding of the spread and pathogenesis of this disease. In 1993, the World Health Organization declared TB to be a global emergency. 4. Case 1 A man presented with chronic cough. Occasionalhaemoptysis. No previous illness before. Mantoux test - indurated area of 24mm. 5. Chest radiograph Small cavitations in theleft upper lobe with fibrosis and nodular opacities. 6. HRCT Thorax 7. Reconstructed 3D images Lung fibrosis. Small granulomas. Small lung cavitations. Patchy consolidation. 8. Case 2 A 47 year-old man with chronic cough. Poorly controlled DM status. 9. Chest radiograph Cavitating pneumonia ofleft upper lobe. Sputum AFB direct smear is positive. 10. Case 3 A 29 year-old lady with persistent cough for 1month. Delivered a baby 3 month ago. History of contact with pulmonary TB. 11. Chest radiograph Reticulo-nodularopacities in both upper lobes (right > left). Minimal fibrosis in right lung apex. Sputum AFB: positive. 12. Case 4 A 52 years-old gentleman with underlying DM. Presented with cough and fever for 2months duration. Admitted to hospital for haemoptysis. 13. Chest radiograph: A cavitating lung lesion in the superior segment of left lower lobe. 14. CT Thorax In the superior segmentof left lower lobe a lung cavitation. 4.6cm x 2.7cm in size. This lesion is representing lung tuberculoma. 15. CT Thorax lung reconstruction tree-in-buds appearanceadjacent to the cavitating lung lesion. 16. Case 5 A 60 years old man of poorly controlled diabetismellitus presented with cough. No fever. No loss of appetite or loss of weight. 17. Chest radiograph Multiple lung nodules ofvarying sizes predominantly in lower and mid lung fields bilaterally. Patchy consolidation in the right upper lobe. 18. CT Thorax images in lung setting Lung consolidation in right upper lobe.Cavitating lung lesion in left upper lobe. Nodular opacities in both lower lobes. 19. CT Thorax - images in lung setting Tree-in-buds in superiorsegment of left lower lobe 20. CT Thorax - images in lung settingSpiculated multiple lung nodules in both lower lobes. Some appearing as flame-shaped lung lesions. 21. Differentials Pulmonary TB Metastases Thoracic Kaposi sarcoma. SPUTUM: AFB 3+. 22. Thoracic Kaposi Sarcoma 23. Case 6 FOMEMA Screening 24. Discussion Types of TB infection. 25. Primary TB lungs are the primary organ of spread- accounting forabout 70% of cases. extrapulmonary infection generally occurs as a result of hematogenous dissemination from a clinically occult pulmonary focus. typically a self-limited infection. about 5% of adults and up to 60% of infected children are asymptomatic. 26. Primary TB in a less competent host, the infection is walled off,but the bacillus remains viable, but dormant for many years. typically presents as a segmental or lobar consolidation usually involving the lower lobes (although any lobe may be involved) and the appearance is often indistinguishable from bacterial pneumonia. multifocal involvement is seen in 12-24% of cases. 27. Primary TB prevalence of lymphadenopathy is greatest in thepediatric age group (about 90-96% of affected children (4,6,7) and is seen in about 43% of adults. Pleural effusion is found in up to 40% of adults, but only 5-10% of children with primary infection (7). Pleural fluid cultures are positive in only 20-40% of cases (pleural biopsy cultures are positive in 65-75% of cases). 28. Primary TB Pleural effusion can be the only radiographic findingindicative of primary TB infection in about 5% of cases. Regression of radiographic findings is a slow processrequiring from 6 months to 2 years for resolution. 29. Primary TB Radiographic differentiation between active andinactive disease can only be made reliably on the basis of temporal evolution. The American Tuberculosis Association requires that a radiograph remain unchanged for a period of 6 months to indicate stable/inactive disease. 30. Primary TB Computed tomography can detect the presence ofadenopathy, parenchymal consolidations, or evidence of endobronchial spread not seen on plain film radiographs. A normal chest radiograph has a high negative predictive value for the presence of active TB. 31. Primary TB Common findings of infection in infants includemediastinal and hilar adenopathy (seen in 90-95% of cases. The adenopathy is usually unilateral and located in the hilum or paratracheal region. On CT the nodes demonstrate central necrosis with rim enhancement. Pulmonary tuberculosis can manifest as pulmonary nodules mimicking lung metastasis. 32. Miliary (disseminated) TB Typical miliary lesions may not be visible for 3 to 6weeks after hematogenous dissemination. CXR reveals micronodular densities (1-2mm) diffusely throughout both lungs. HRCT demonstrates a combination of sharp and poorly defined 1 to 3 mm nodules distributed throughout the lungs and have no relationship to the airways in their distribution. The nodules usually resolve within 2-6 months with treatment. 33. Miliary (disseminated) TB 34. Reactivation or post-primary TB. Reactivation infection usually develops in theapical/posterior segments of the upper lobes (83-85% of cases) or superior segment of the lower lobes (1114% of cases). Patchy alveolar infiltrate. The cavities typically have thick, irregular walls which become smooth and thin with successful treatment. 35. Reactivation or post-primary TB Hilar or mediastinal adenopathy is unusual inreactivation TB. An effusion may be the sole manifestation of reactivation TB. 36. Tuberculous airway disease CT of the chest during active infection willreveal irregular tracheobronchial narrowing and wall enhancement with I.V. contrast. The mediastinal fat around the trachea often demonstrates increased density consistent with inflammation. 37. Chronic tuberculous empyema On CXR there is usually a moderate to large loculatedpleural fluid collection with pleural calcification and enlargement of the overlying ribs. CT demonstrates the loculated pleural fluid surrounded by a thick, calcified pleural rind. 38. Chronic tuberculous empyema loculated pleural fluidcollection in right lower lateral hemithorax. Surrounding pleural thickening and calcifications. 39. Tuberculoma Well defined or have irregular margins and mimic alung neoplasm. Most lesions are less than 3 cm in size and calcification can be seen in 20-30% of cases (usually nodular or diffuse). Small satellite nodules about the larger lesion can be found in up to 80% of cases. 40. Tuberculoma Tuberculoma seems to be round or polygonal shapeand primary lung cancer is more likely to be lobulated shape. The smooth border nodule is found only in tuberculoma (27%) whereas 93% of primary lung cancer had spiculated border compared to 73% among tuberculoma (p < 0.05). 41. Tree-in-bud sign on HRCT 42. Tree-in-bud sign on HRCT a finding seen on thin-section computed tomographic(CT) images of the lung. Peripheral (within approximately 35 mm of the pleural surface). small (24 mm in diameter), centrilobular, and welldefined nodules of soft-tissue attenuation are connected to linear, branching opacities that have more than one contiguous branching site. Resembling a tree in bud. 43. Tree-in-bud sign on HRCT represents bronchiolar luminal impaction with mucus,pus, or fluid. dilated and thickened walls of the peripheral airways and peribronchiolar inflammation. descriptive term for various diseases. the appearance of the tree-in-bud sign is closely linked to the anatomy of the secondary pulmonary lobule. 44. Tree-in-bud sign on HRCT has primarily been used as a descriptive term forabnormalities found on CT scans of the lung in patients with endobronchial spread of Mycobacterium tuberculosis . Pulmonary infectious disorders involving the small airways are the most common causes of the tree-inbud sign. Any infectious organism, including bacterial, mycobacterial, viral, parasitic, and fungal agents. 45. Tree-in-bud sign on HRCT Also with immunologic disorders, cysticfibrosis, neoplasms, aspiration of irritant substances, and disease entities with idiopathic causes. almost invariably points to inflammatory disease of the small airways. 46. Lung nodules Benign if they: * Show little or no growth for 2 years * Calcification Central, laminated or diffuse pattern indicates a granuloma Eccentric calcification can be seen in a carcinoma or in a cancer that has engulfed a granuloma. 47. Lung nodules Granulomas and lung cancer are by far the two mostcommon causes for a pulmonary nodule. Incidental small pulmonary nodules, especially less than 5 mm, are an extremely common finding on chest CT in the population over age 50. 48. Lung nodules The current recommended follow-up of incidental pulmonary nodules per the Fleischner Society 2005 is given below. Low Risk Patient: 4mm: No follow-up needed. 4-6mm: 12 mo; if no change stop. 6-8mm: 6-12 mo; no change - follow-up at 18-24 mo. > 8mm: CT follow-up at 3, 9, 24mo or PET/CT, or biopsy. 49. Lung nodules High Risk Patient (eg. smoking history or history of malignancy). 4mm: 12 mo; if no change stop. 4-6mm: 6-12mo; no change - follow-up at 18-24 mo. 6-8mm: 3-6mo; no change - follow-up at 18-24 mo. > 8mm: CT follow-up at 3, 9, 24mo or PET/CT, or biopsy 50. Background radiation June 2006 51. Typically, CT of the chest CT gives a radiation dose equivalent to 400 chestradiographs. Chest tomography 8 mSv. Chest radiography=0.02 mSv. 52. References 1. AJR 2010; Tan CH, et al. Tuberculosis: a benign impostor. 194: 555-561 2. Radiology 1999; Leung AN. Pulmonary tuberculosis: The essentials. 210: 307-322. 3. AJR 2008; Jeong YJ, Lee KS. Pulmonary tuberculosis: up-to-date imaging and management. 191: 834-844 4. Radiographics 2007; Burrill J, et al. Tuberculosis: a radiologic review. 27: 1255-1273 5. Radiology 1999; Leung AN. Pulmonary tuberculosis: The essentials. 210: 307-322 6. Society of Thoracic Radiology Annual Meeting 2000 Course Syllabus; Leung AN. Pulmonary tuberculosis. 83-84. 7. Radiol Clin N Am 2005; Tarver RD, et al. Radiology of community-acquired pneumonia. 43: 497-512. 8. AJR 1997; 168-1005-1009. 9. Society of Thoracic Radiology Annual Meeting 2000 Course Syllabus; Leung AN. Pulmonary tuberculosis. 83-84 10. Radiographics 2001; Kim Hy, et al. Thoracic sequelae and complications of tuberculosis. 21: 839-860