chest radiology interpretation: findings of tuberculosis

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Chest Radiology Interpretation: Findings of Tuberculosis

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Case #1

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Plombage

Pneumonia

Cancer

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Reading the TB CXR

Be systematic!

Start centrally and work outwards

Normal or abnormal

If abnormal, consider technique as cause

Describe the finding(s)

Consider the significance of the finding(s)

Mediastinum

Hila

Lungs

Pleura

Bones

Mediastinum

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Lymphoma

AbnormalNormal

Metastatic disease (unknown primary)

Normal Abnormal

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Lung Cancer

Normal Abnormal

AO

PA

Heart

<55% thoracic diameter

Technique important

Larger in: AP film

Poor inspiration

Rotation

Children

True enlargement Chamber enlargement

Pericardial effusion

Mass

Artifactual cardiomegaly

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End stage rheumatic heart disease

Pericarditis

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Hila

Sarcoidosis

Normal Abnormal

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Pulmonary Hypertension

Normal Abnormal

Lungs

Pleura & Diaphragms

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Pleura & Diaphragms

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Lung Pleura

Lung Pleura

Lung Pleura

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Lung Pleura

TB Empyema

Don’t forget about the bones

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Case #1

Case #2

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Inspiration: (≥10 posterior ribs)

1st rib

2nd rib3rd rib

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2nd3rd

4th

5th

6th

7th

8th

9th

10th

1st

Poor inspiration

Good inspiration

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Rotation

Rotation

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PenetrationIntervertebralDisks

Over-penetrated

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Case #3

Categories of lung opacities

1. Nodule(s) or mass(es)

2. Alveolar, airspace, consolidation

3. Interstitial (diffuse lines or nodules)

4. Airways (circular or tubular)

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Nodule ≤ 3cm, Mass > 3 cm

2.7 cm3.4 cm

Consolidation

Confluent opacity

Fluffy around the periphery

Air bronchograms

ARDS

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Normal Nodular Reticular

Interstitial disease

Miliary TB

Idiopathic pulmonary fibrosis

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Airways disease

Circular

Tubular

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Tuberculosis

Case 3

Questions

Could this be TB?

Is TB the most likely diagnosis?

If so, what form of TB does the radiology suggest?

Is active disease likely or unlikely?

What are possible alternative diseases to produce the radiographic pattern?

(the answer is always yes!)

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Key points

TB patterns overlap with each other

TB patterns overlap with other diseases

If there is an abnormality, it could be due to TB

You must know the classic TB patterns

But, if it doesn’t fit into a typical TB pattern, it is unlikely to be TB

It’s all about likelihood!

Clinical-radiographic correlation

Case #3

Reactivaton TB- radiology

LocationApical/posterior segments upper lobes

Superior segment lower lobes

Isolated anterior disease very unusual

Presence of cavities

Pleural disease

Volume loss/scarring early in disease

Diff dx: fungal, bacterial infections

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Chest Radiology Interpretation: Findings of Tuberculosis (Part 2)

Is this likely TB?

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Lobar anatomy

Left Lung

LLL

LUL

Right Lung

RLLRML

RUL

Lobar anatomy

Right Lung

RLLRML

RUL

Lobar anatomy

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RUL Pneumonia

Right Lung

RLLRML

RUL

Lobar anatomy

Right Lung

RLLRML

RUL

Lobar anatomy

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Silhouette sign

A B A B

Silhouette sign

A B A B

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Right Lung

RLLRML

RUL

Lobar anatomy

Diaphragm

RLL

ObscuredDiaphragm

ClearHeartBorder

RLL pneumonia

? Which lobe is involved

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Right Lung

RLLRML

RUL

Lobar anatomy

RML

RML pneumonia

ClearDiaphragm

ObscuredHeartBorder

? pneumonia

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? pneumonia

Anterior Posterior

Superior

Inferior

Lateral Viewof the Chest

Heart

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Spine


Diaphragm


Diaphragm

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Normal LLL Pneumonia

Normal Pleural effusion

Normal Nodule

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Normal Pott’s disease

Case #4

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Abnormal Normal

Prior reactivation tuberculosis

Upper lobe scarringVolume loss

Retraction of hila superiorly

Band-like (linear) opacities

Architectural distortion

Asymmetric > symmetric

Bronchiectasis

Cystic changes

Diff dx: fungal, sarcoid, pneumoconioses

Prior TB

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Warning signs

Consolidation outside areas of fibrosis

Consolidation with cavitation

Lower lobe abnormalities

Non-calcified nodules (ill-defined)

Change from prior CXR

Reactivation TB

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Case #5

Solitary nodule/mass- the top 5

Granuloma

Hamartoma

Solitary metastasis

Bronchogenic carcinoma

Lots of others

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So you see a nodule on CXR…

1. Look for old films

2. Is diffuse calcification present?

3. Get a CT scan

When to get a CT scan?

Questionable CXR findings

Further characterization of CXR findings

Concern for cancer

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Role of CT scan for nodules1. Attempt to prove they are definitively

benignBenign pattern of calcification (diffuse, central,

ring-like, popcorn)

Fat

≥2 years of stability

Features of benign nodules include:

PopcornRing-like

CentralDiffuse Initial CT

24 monthfollow-up

Benign patterns of calcification

Presenceof fat

Long term stability

Hamartoma

Hamartoma

.

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Irregular calcification: adenocarcinoma

Role of CT scan for nodules1. Attempt to prove they are definitively

benignBenign pattern of calcification (diffuse, central,

ring-like, popcorn)

Fat

≥2 years of stability

2. Determine likelihood of nodule being benign or malignantLow likelihood -> CT follow-up

High likelihood -> immediate action (e.g. biopsy)

Suspicious features of nodules include:

Initial CT

Follow-up

Large size Spiculatedborders

Growth

The size threshold above which malignancy is likely demonstrates geographic variability, depending upon the prevalence of endemic granulomatous infection.

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Size and likelihood of cancer

Swensen. Radiology 2005; 235: 259

0% 1%

15%

81%

Follow-up recommendationsNodule size Low-risk patient High-risk patients

≤4 mm No follow-up 12 months

>4-6 mm 12 months 6-12 months

18-24 months

6-8 mm 6-12 months

18-24 months

3-6 months

9-12 months

24 months

>8 mm 3 months

9 months

24 months

3 months

9 months

24 months

Fleischner Guidelines. Radiology 2005; 237: 395.

Old tuberculosis

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Bronchogenic carcinoma

Case #6

Case #6Ghonfocus

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Case #6Rankecomplex

Case #7

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Primary tuberculosis

Difficult radiologic diagnosis

Mimics other diseases

FindingsNonspecific consolidation

Nodule

Lymphadenopathy

Cavitation unusual

LAD more common than with 2° TB (particularly kids + HIV)



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Case #8

Miliary pattern CXR

Miliary tuberculosis

Fungal infection (histo, cocci, blasto)

Metastases

Sarcoidosis

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Miliary tuberculosis

Miliary TB

Sarcoidosis

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Metastases

Case #10

Pleural + pericardial disease

Primary or secondary

May be only manifestation in 1° TB

Empyema more common in secondary

Adults >> kids

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Suspected pleural effusion

Case #11

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Case #11

Lymphoma

Leukemia

Germ cell tumor

Bacterial mediastinitis

Fungal infection

Tuberculosis

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Lymphadenopathy with TB

Kids >> adults

Primary >> secondary

Asymmetric (right > left)

Most common locationsHilar

Right paratracheal

Necrosis very common

TB lymphadenitis

Case #12

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heart <65% thoracic diameter

thymus

Conclusions

Be systematic when reading CXR

Typical TB patterns

Mimics of TB

Get a CT scan when appropriate

chest radiology interpretation: findings of tuberculosis

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