Transcript

Slide 1 Chest Radiology Interpretation: Findings of Tuberculosis

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Slide 2 Case #1

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Slide 3

Reading the TB CXR

Be systematic!

Start centrally and work outwards

Normal or abnormal

Describe the finding(s)

Consider the significance of the finding(s)

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Slide 4 Mediastinum

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Slide 5 Hila

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Slide 6 Lungs

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Slide 7 Pleura & Diaphragms

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Slide 8 Pleura & Diaphragms

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Slide 9 Pleura & Diaphragms

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Slide 10 Soft tissue & bones

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Slide 11

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Slide 12 Mediastinum

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Slide 13

Lymphoma

AbnormalNormal

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Slide 14

Metastatic disease (unknown primary)

Normal Abnormal

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Slide 15

Lung Cancer

Normal Abnormal

AO

PA

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Slide 16 Heart

<55% thoracic diameter

Technique important

Larger in: AP film

Poor inspiration

Rotation

Children

True enlargement Chamber enlargement

Pericardial effusion

Mass

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Slide 17 Artifactual cardiomegaly

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Slide 18

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Slide 19 End stage rheumatic heart disease

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Slide 20 Pericarditis

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Slide 21 Hila

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Slide 22

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Slide 23 Q1. Pathology in this patient is most

likely to show?

A. Caseating granulomas

B. Non-caseating granulomas

C. Atypical cells with high nuclear/cytoplasmic ratio

D. Fibrosis

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Slide 24

Sarcoidosis

Normal Abnormal

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Slide 25

Pulmonary Hypertension

Normal Abnormal

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Slide 26 Lungs

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Slide 27 Pleura & Diaphragms

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Slide 28 Pleura & Diaphragms

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Slide 29

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Slide 30

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Slide 31

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Slide 32 Q2. Where is this lesion located?

A. Lung

B. Mediastinum

C. Pleura

D. Chest wall

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Slide 33

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Slide 34 Lung Pleura

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Slide 35 Lung Pleura

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Slide 36 Lung Pleura

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Slide 37 Lung Pleura

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Slide 38 TB Empyema

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Slide 39 Don’t forget about the bones

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Slide 40 Case #1

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Slide 41 Case #2

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Slide 42 Q3. What is the primary

abnormality?

A. Mediastinal widening

B. Diffuse lung opacities

C. Pleural effusion

D. Normal

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Slide 43 Inspiration: (≥10 posterior ribs)

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Slide 44

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Slide 45

1st rib

2nd rib3rd rib

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Slide 46 2nd3rd

4th

5th

6th

7th

8th

9th

10th

1st

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Slide 47 Poor inspiration

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Slide 48 Good inspiration

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Slide 49 Rotation

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Slide 50

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Slide 51

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Slide 52 PenetrationIntervertebralDisks

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Slide 53

Over-penetrated

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Slide 54 Case #3

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Slide 55 Q4. What is the most likely diagnosis?

A. Tuberculosis

B. Aspergillosis

C. Malignancy

D. Mycoplasma

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Slide 56 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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Slide 57 Nodule ≤ 3cm, Mass > 3 cm

2.7 cm3.4 cm

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Slide 58 Consolidation

Confluent opacity

Fluffy around the periphery

Air bronchograms

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Slide 59 ARDS

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Slide 60

Normal Nodular Reticular

Interstitial disease

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Slide 61 Miliary TB

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Slide 62 Idiopathic pulmonary fibrosis

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Slide 63

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Slide 64 Airways disease

Circular

Tubular

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Slide 65

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Slide 66 Tuberculosis

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Slide 67 Case 3

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Slide 68 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?

Is TB an unlikely diagnosis?

What are possible alternative diseases to produce the radiographic pattern?

(the answer is always yes!)

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Slide 69 Key points

You must know the classic TB patterns

TB patterns overlap with each other

TB patterns overlap with other diseases

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

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

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Slide 70 Case #3

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Slide 71 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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Slide 72 Chest Radiology Interpretation: Findings of Tuberculosis (Part 2)

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Slide 73 Is this likely TB?

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Slide 74 Q5. What lobe is involved?

A. Right upper lobe

B. Azygous lobe

C. Right middle lobe

D. Right lower lobe

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Slide 75 Lobar anatomy

Left Lung

LLL

LUL

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Slide 76

Right Lung

RLLRML

RUL

Lobar anatomy

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Slide 77

Right Lung

RLLRML

RUL

Lobar anatomy

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Slide 78 RUL Pneumonia

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Slide 79

Right Lung

RLLRML

RUL

Lobar anatomy

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Slide 80

Right Lung

RLLRML

RUL

Lobar anatomy

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Slide 81

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Slide 82 Silhouette sign

A B A B

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Slide 83 Silhouette sign

A B A B

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Slide 84

Right Lung

RLLRML

RUL

Lobar anatomy

Diaphragm

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Slide 85

RLL

ObscuredDiaphragm

ClearHeartBorder

RLL pneumonia

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Slide 86 ? Which lobe is involved

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Slide 87

Right Lung

RLLRML

RUL

Lobar anatomy

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Slide 88

RML

RML pneumonia

ClearDiaphragm

ObscuredHeartBorder

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Slide 89 ? pneumonia

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Slide 90 ? pneumonia

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Slide 91

Anterior Posterior

Superior

Inferior

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Slide 92 Lateral Viewof the Chest

Heart

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Slide 93 Lateral Viewof the Chest

Spine

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Slide 94 Lateral Viewof the Chest

Diaphragm

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Slide 95 Lateral Viewof the Chest

Diaphragm

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Slide 96 Normal LLL Pneumonia

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Slide 97 Normal Pleural effusion

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Slide 98 Normal Nodule

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Slide 99 Normal Pott’s disease

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Slide 100 Case #4

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Slide 101

Q6. What is the primary abnormality?1. Consolidation

2. Emphysema

3. Airway enlargement

4. Fibrosis

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Slide 102 Abnormal Normal

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Slide 103 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

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Slide 104

Prior TB

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Slide 105

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Slide 106

Warning signs

Consolidation outside areas of fibrosis

Consolidation with cavitation

Lower lobe abnormalities

Non-calcified nodules (ill-defined)

Change from prior CXR

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Slide 107

Reactivation TB

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Slide 108 Case #5

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Slide 109 Q7. What is the likelihood of malignancy?

A. <5%

B. 5-10%

C. 10-20%

D. >20%

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Slide 110

Solitary nodule/mass- the top 5

Granuloma

Hamartoma

Solitary metastasis

Bronchogenic carcinoma

Lots of others

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Slide 111

So you see a nodule on CXR…

1. Look for old films

2. Is diffuse calcification present?

3. Get a CT scan

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Slide 112

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Slide 113

When to get a CT scan?

Questionable CXR findings

Further characterization of CXR findings

Concern for cancer

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Slide 114 Role of CT scan for nodules

1. Attempt to prove they are definitively benignBenign pattern of calcification (diffuse, central,

ring-like, popcorn)

Fat

≥2 years of stability

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Slide 115 Features of benign nodules include:

PopcornRing-like

CentralDiffuse Initial CT

24 monthfollow-up

Benign patterns of calcification

Presenceof fat

Long term stability

Hamartoma

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Slide 116 Hamartoma

.

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Slide 117 Irregular calcification: adenocarcinoma

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Slide 118 Role of CT scan for nodules

1. 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 malignant Low likelihood -> CT follow-up

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

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Slide 119 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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Slide 120 Size and likelihood of cancer

Swensen. Radiology 2005; 235: 259

0% 1%

15%

81%

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Slide 121 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.

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Slide 122 Old tuberculosis

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Slide 123 Bronchogenic carcinoma

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Slide 124 Case #6

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Slide 125 Case #6Ghonfocus

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Slide 126 Case #6Rankecomplex

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Slide 127

Prior tuberculosis

Mid to lower lung predominance

Can be anywhere

Nodule: Ghon focus

Nodule + lymph node: Ranke complex

Calcification indicative of inactivity

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Slide 128 Case #7

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Slide 129 Q8. What is the most likely diagnosis?

A. Tuberculosis

B. Bacteria

C. Adenovirus

D. Mycoplasma

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Slide 130 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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Slide 131 Primary tuberculosis

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Slide 132 Primary tuberculosis

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Slide 133 Case #8

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Slide 134 Q9. What is the LEAST likely diagnosis?

A. Tuberculosis

B. Hypersensitivity pneumonitis

C. Fungal infection

D. Sarcoidosis

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Slide 135

Miliary pattern CXR

Miliary tuberculosis

Fungal infection (histo, cocci, blasto)

Metastases

Sarcoidosis

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Slide 136

Miliary tuberculosis

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Slide 137

Miliary TB

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Slide 138

Sarcoidosis

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Slide 139

Metastases

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Slide 140 Case #10

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Slide 141 Pleural + pericardial disease

Primary or secondary

May be only manifestation in 1° TB

Empyema more common in secondary

Adults >> kids

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Slide 142 Suspected pleural effusion

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Slide 143

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Slide 144 Case #11

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Slide 145 Q10. What is the primary

abnormality?

A. Lymphadenopathy

B. Pericardial effusion

C. Lytic bony lesion

D. Normal

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Slide 146 Case #11

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Slide 147

Lymphoma

Leukemia

Germ cell tumor

Bacterial mediastinitis

Fungal infection

Tuberculosis

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Slide 148 Lymphadenopathy with TB

Kids >> adults

Primary >> secondary

Asymmetric (right > left)

Most common locationsHilar

Right paratracheal

Necrosis very common

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Slide 149

TB lymphadenitis

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Slide 150 Case #12

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Slide 151

heart <65% thoracic diameter

thymus

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Slide 152 Conclusions

Be systematic when reading CXR

Typical TB patterns

Mimics of TB

Get a CT scan when appropriate

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Slide 153

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