Chest radiograph interpretation in tuberculosis
Tilman L. Koelsch, MD
Associate Professor
National Jewish Health
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GoalsUnderstand importance of adequate radiographic technique
Basics of CXR interpretation
Identify features of tuberculosisAdults
Children
HIV
Healed/inactive
Role of CT
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Technical adequacy of chest radiograph Exposure
Positioning
Inclusion
Inspiration
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Approach to chest radiograph
TechnicalExposure
Inclusion
Rotation
Inspiration
Initial “Gestalt”
Systematic survey
Soft tissues/abdomen
Lungs/ribs- symmetry
Mediastinum/heart
Miss/”Hidden” areas
Apices
Hila/suprahilar
Trachea/bronchi
Retrocardiac
Retrodiaphragmatic
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Approach to chest radiograph
Describe findingsAppropriate descriptors
Make inferences
Hansell DM, et al.
Fleischner Society: Glossary of terms for thoracic imaging.
Radiology. 2008;246:697-722.
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Common radiographic findings in tuberculosis Opacity
Nodule
Nodular pattern
Consolidation
Atelectasis
Pleural effusion
Lucency
Cavity
Bronchiectasis
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Nodule
Rounded
opacity, well or
poorly defined,
measuring up to
3 cm in
diameter.
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Nodular pattern
Innumerable
small rounded
opacities that
are discrete
and range in
diameter from
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Miliary pattern profuse, discrete, rounded pulmonary opacities
2-3 mm in diameter
generally uniform in size
diffusely distributed throughout the lungs- sometimes lower
lung predominant
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Consolidation Homogenous increase
in lung opacity
Often poorly defined
and confluent
Signs helpful
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Atelectasis Reduced volume of a lobe or
lung, with increased opacity
Displacement of
mediastinum, hila, bronchi,
or fissures
Not talking about mild
atelectasis
Signs helpful
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Case courtesy of Dr. Dipti NevrekarFlat Waist Sign
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Flat Waist Sign Left lower lobe collapse
Flattening of contours of left mediastinum
Aortic arch
Pulmonary artery
Leftward deviation and rotation of heart
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Pleural effusion
Fluid in the pleural
space
On erect chest
radiograph,
characterized by
blunting of
costophrenic angle
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Pleural thickening vs effusion
Blunted CP angle is
not curved
Thickening usually
extends up the chest
wall
Often associated
with rounded
atelectasis or linear
scarring
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Cavity
Gas-filled space
within consolidation,
mass, or nodule
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Bronchiectasis
Ring shadows
Train tracks
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Adenopathy
Challenging to see on radiography unless bulky
Luckily TB adenitis tends to be quite conspicuous
Hilar>mediastinal LANProp
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Hilar Adenopathy
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Hilar Adenopathy
Normal Lateral Hilum vs. Adenopathy
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Mediastinal Adenopathy
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Normal AP Stripe
•Formed by 2 layers of pleura
reflecting over left
anterolateral mediastinal fat
•Usually straight or minimally
convex
•Abnormal convexity:
•Prevascular/Anterior
Mediastinal lymph
nodes/mass.
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Normal AP Stripe
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Abnormal AP Stripe vs. Normal
Abnormal AP Stripe
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Normal Right Paratracheal Stripe
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Right Paratracheal Adenopathy
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AP Window•Left lung between aortic
arch and the left PA
•Seen almost always
•Usually concave or straight
•Abnormal convexity
•Lymph nodes
•Mediastinal mass
•Vascular abnormality
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Abnormal AP Window vs. Normal AP Window
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Hilar Adenopathy
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Hilar Adenopathy
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Hilar/mediastinal Adenopathy
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Primary vs Post-primary Tuberculosis
In adults, there is no significant difference in
radiographic features between recently and
remotely acquired TB, confirmed by RFLP
Therefore, “primary” and “post-primary” terms
inaccurate
Better to use terms “atypical” and “typical”
Geng E et al. JAMA. 2005 Jun 8;293(22):2740-5.
Jones BE, et al. AJRCCM 1997 Oct;156(4 Pt 1):1270-3.
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Typical tuberculosis
Upper lobe “infiltrate”
Upper lobe cavities
Geng E et al. JAMA. 2005 Jun 8;293(22):2740-5.
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Typical TuberculosisApical/Posterior Segment Involvement
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Typical TuberculosisConsolidation with Cavitation
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Typical Tuberculosis
Endobronchial spread
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Typical Tuberculosis
Endobronchial spread
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Atypical radiographs in tuberculosis
Lymphadenopathy
Lower or mid-lung opacity
Effusions without cavity or upper lung opacity
More common in children
Geng E et al. JAMA. 2005 Jun 8;293(22):2740-5.
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Atypical tuberculosis: RLL cavity/hilar adenopathy
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Atypical Tuberculosis
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Atypical TuberculosisHilar/Mediastinal Lymphadenopathy
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Atypical TuberculosisMiliary Pattern
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Finding
Any adenopathy 175 92%
Right hilar 83 43%
With mediastinal
nodes 43 23%
Left hilar 37 19%
With mediastinal
nodes 16 8%
Bilateral hilar 49 26%
With mediastinal
nodes 44 23%
Mediastinal only 6 3%
Lymphadenopathy in childhood tuberculosis (n=191)
Leung AN.
Radiology.
1992
Jan;182(1)
:87-91.
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Parenchymal abnormality in childhood tuberculosis
Finding
Parenchymal abnormality
with adenopathy 130 68%Parenchymal abnormality
without adenopathy 2 1%
Right lung consolidation 78 41%
Left lung consolidation 21 11%
Bilateral consolidation 33 17%
Lobar atelectasis 16 8%
Effusion 11 6%
Normal CXR 14 7%
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“Primary” tuberculosis in childhood: Pearls
Parenchymal abnormality is more common in >
3 years old
Lymphadenopathy more common in Native
American and Asian than in whites
Adolescents with recent infection usually have
typical features of tuberculosis with upper lobe
nodules or cavity
Leung AN, et al. Radiology. 1992 Jan;182(1):87-91.
Koh WJ, et al. Korean J Radiol. 2010 Nov-Dec;11(6):612-7.
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Childhood TuberculosisMid/lower lung Consolidation
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Childhood TuberculosisHilar/Mediastinal Lymphadenopathy
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Chest RadiographTB and HIV Chest radiograph often looks like “atypical” (“primary”)
disease
Adenopathy is common and highly predictive of tuberculosis
Radiograph may be normal in up to 10% of cases
Geng E et al. JAMA. 2005 Jun 8;293(22):2740-5.
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Chest radiograph: TB in HIV
With decreasing CD4 count
Lower likelihood of
Cavitary disease
Fibrosis
Upper lobe disease
Higher likelihood of
Normal CXR
Miliary abnormality
Adenopathy
Pleural effusion
Chamie G, et al. Int J
Tuberc Lung Dis. 2010
Oct;14(10):1295-302.
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Chest RadiographTB and HIV
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Chest RadiographTB and HIV
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Chest RadiographTB and HIV
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Pleural Tuberculosis Effusions common in adults (6-15%)
Less common in children
Very uncommon finding in infants
May be sole finding
Air fluid level may indicate bronchopleural or alveopleural
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Pleural Effusion
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Post-Primary TuberculosisEmpyema
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Tuberculosis and Airways
Atelectasis due to
1) Nodal enlargement - compressing airway
2) Endobronchial abnormality - obstructing airway
Medial segment of middle lobe
Anterior segment of upper lobe
Right side more common
Can mimic lung cancer
May never resolve
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Airway narrowing due to nodal enlargement
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Bronchostenosis
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The Chest RadiographBronchostenosis
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The Chest RadiographHealed Tuberculosis
Calcified granuloma - Ghon lesion
Calcified granuloma & hilar calcification - Ranke complex
Apical pleural thickening
Fibrosis and volume loss
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The Chest RadiographGhon Lesion
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The Chest RadiographRanke Complex
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The Chest RadiographApical Fibrosis
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Tuberculoma
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“Activity” of tuberculosis
Activity cannot be determined from single chest radiograph
Progressive disease indicates activity
Cavitation and bronchogenic spread suggest activity
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Stable tuberculosis
20062004
Old X-rays often helpful
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Role of CT in tuberculosis Not indicated in most cases
Occult miliary disease and cavities
Necrotizing adenopathy
Undiagnosed effusion
Roadmap for bronchoscopist
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Adenitis
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Spinal involvement
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Summary Chest radiograph requires systematic approach
Typical (Post-primary) TB: Upper lung fibrocavitary disease, “endobronchial spread” nodules
Atypical (Primary) TB: Usually children, HIV, consolidation with adenopathy
Serial radiographic evaluation important to determine activity
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Acknowledgements David Lynch, MBBS
Jonathan Chung, MD
Charles Daley, MD
Gwen Huitt, MD
Shannon Kasperbauer, MD
Wendy Drummond, MDProp
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