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Pulmonary TB:
HRCT findings
Jung-Gi Im, MD
Department of Radiology Seoul National
University Hospital
Tuberculosis: History
BC 5000: Evidence of
TB in neolithic man
BC 2900: Pyramid
builders
BC 1000 : Pott’s dis.
in mummies
Frederic Chopin (1810-1849)
Victims of tuberculosis
Fyodor Mikhailovich Dostoevsky
(1821-1881)
Writer : Goethe, Schiller, Dostoevsky,
Chekhov, Laurence, Poe,
Kafka, Rousseau
Philosopher : Spinoza, S.Johnson
Artist : Modigliani, Gauguin
Musician : Chopin, Paganini
Physician : Laennec
Victims of tuberculosis
M. tuberculosis: Genome Sequence
Determination of genome sequence
: help new prophylatic & therapeutic intervention
M. tuberculosis, H37RV
4,411,529 base pairs: 4,000 genes
Cole ST Nature 1998;393:537
Estimates of the global burden caused by TB in 2010
12 million prevalent cases
8.8 million new TB cases (128 cases/100,000 population)
1.7 million death from TB (4700 deaths/day)
Most cases were in the Asia (59%), African (26%) and smaller cases were in Europe (5%).
Towards universal access to diagnosis and treatment of multidrug-resistant
and extensively drug-resistant tuberculosis by 2015
WHO PROGRESS REPORT 2011
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Estimated TB incidence rates, 2010
WHO REPORT 2010 GLOBAL TUBERCULOSIS CONTROL
Diagnosis of tuberculosis
Prompt Dx of TB
–Public health infection control
–Ensure appropriate Tx of TB patient
• Conversion to noninfectious condition
• Cure
–Limited sensitivity of culture test
Imaging Dx would provide opportunity of
prompt Dx. & appropriate Tx.
Tuberculosis Primary vs Reactivation
Primary TB
Disease developing after initial exposure
atypical radiologic presentation
Reactivation TB
Disease developing as a result of reactivation of a previous focus typical radiologic presentation
TuberculosisMolecular epidemiology concept
Based on DNA fingerprinting
–Restriction fragment length polymorphism (RFLP) analysis of M. TB isolates
TB isolates in terms of space & time
Identification of primary & reactivation TB
–Clustered isolates (primary)
–Unique isolates (reactivation)
Alland D, et al. N Engl J Med 1994
Radiographic manifestation of TB New concept
• No difference in radiographic features bet. primary & reactivation TB
• Significant predictors of radiographic appearance of TB
• Patients’ Immune status
– Immunocompromised patients: tendency toward primary TB form
– Immunocompetent patients tend to have the reactivation TB form
Geng E, et al. JAMA 2005
M/20, private soldier
No respiratory symptom
Share a room with soldier diagnosed with active TB
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Radiologic features of
Tuberculosis:
Atypical vs Typical
Atypical radiologic features:Primary pattern
Lymphadenopathy
Pleural effusion
Miliary nodules
Lower lobe disease
Primary Tuberculosis in Children
Unsensitized host
Airborne droplets (2 - 10μ)
Necrotizing pneumonitis
Spread by lymphatics
Spontaneous resolution : over
90%
13 mo/m. Prim. TB : consolidation & LN
Pulmonary TB in Children : CT
41 patients (mean age, 6 yrs)
CT findings :
Mediast. & hilar lymphad. : 83%
Seg. or lobar consolidation : 49%
Bronchogenic spread : 29%
Miliary nodule : 17%
CT is useful in Dx. and detection of Cx.
Kim WS et al. AJR 1997;168:1005
24/F
Fever, weakness
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Miliary Tuberculosis : HRCT
25 patients
Millary nodules : 88%
Ground-glass opacity : 92%
large GGO : dyspnea, impending ARDS
Intralobul. reticulation, septal line: 40%
Hong SW et al JCAT 1998;22:220
Miliary TB
Random
Uniform
Abut pleura
Miliary TB with DIC & ARDSMiliary TB with DIC & ARDS
Typical radiologic features:Reactivation pattern
Caseating granuloma
Bronchogenic spread
Cavitation
Upper lobe disease
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Postprimary or Reactivation Tuberculosis
Sensitized host
Tendency to be localized
Rare lymphatic spread
: mainly bronchogenic
Apex, Sup. segment of lower lobe
Typical radiologic features
Caseating granuloma
Bronchogenic spread
Cavitation
Upper lobe disease
50/F
Incidentally-detected mass Typical radiologic features
Caseating granuloma
Bronchogenic spread
Cavitation
Upper lobe disease
Tuberculosis
Chronic debilitating granulomatous disease
Early lesions?
Advanced lesions?
N.T 1976.2.13
Pulmonary TB
Courtesy
of Dr. Itoh
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R
Highly contrasted lesionsN.T
Tuberculosis
Highly contrasted centrilobular lesions
N.T
Tuberculosis
TB: Highly contrasted lesions
Why?
Bronchiole
AD
PA
Pulmonary TB
: fill the bronchiole and alveolar ducts
55
Caseous materials
Bronchogenic
Spread:
“Tree-in-bud”
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Bronchogenic spread TB
Centrilobular: tree-in-bud
K.A
1976.7.1
Bronchopneumonia
Multiple nodulesCourtesy of Dr. Itoh
K.A
R
Centrilobular inflammatory nodulesK.A
5 mm
ILS
PV
ILS
Bronchiole
Centrilobular inflammatory nodule
K.A
1 mm
Bronchiole
Paraseptal parenchyma
Pulmonary vein
43
Hypersensitivity pneumonitis
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19/F
Productive cough
Diffuse PanbronchiolitisTB Sarcoid
Bronchogenic spread TB DPB
Tuberculosis: HRCT of Early Bronchogenic Spread Lesions
Tree-in-bud appearance
High contrasted lesions
Caseation Necrosis: Good & Bad
Tissue damage
Delayed type
hypersensitivity
Activated mono/macroph,
cytokines, chemotactic factor
Homo sapiens M. TB
Unable to multiplywithin solid caseum
Tsuyuguchi I. Dialogue between M tb & H sapiens. Tuberculosis 2001
Recent Bronchogenic Spread of Tuberculosis : HRCT
Centrilobular lesion (97%)
Tree-in-bud
Bronchial wall thickening (79%)
Poorly-defined nodule (76%)
(5-8mm)
Cavitary nodules (66%)
Lobular consolidation (52%)
Im G-J, et al. Radiology 1993. Cited 159 x
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Miliary Tuberculosis : HRCT
25 patients
Millary nodules : 88%
Ground-glass opacity : 92%
large GGO : dyspnea, impending ARDS
Intralobular reticulation, septal line : 40%
Hong SW et al JCAT 1998;22:220
Random
Uniform
Abut pleura
Coal worker’s pneumoconiosis with
PMF
Centrilobular nodule
Miliary TB with DIC & ARDSMiliary TB with DIC & ARDS
Immunologic Balance btw
H.sapiens & M.TB
Homo sapiens
Cell mediated
immunity
Delayed type
hypersensitivity
Anti-TB drug
M. TB
Armour-plated with
lipid cover
Genetic mutation
Tsuyuguchi I. Tuberculosis 2001 39/M . Multi-Drug Resistant TB
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31/M. MDR TB 1°
peumonectomy, menigitis
Typical radiologic features
Caseating granuloma
Bronchogenic spread
Cavitation
Upper lobe disease
Courtesy of Dr. Itoh Courtesy of Dr. Itoh
TB cavity
Centrilobular cavity evolution
5 mo
Anti-TB Rx
9 mo
Anti-TB Rx
Cavities in MDR-TB
M/19
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Healing process of tuberculosis
Healing of tuberculous lesion
Resolution
Fibrosis
Calcificationbu
BE
Anti-TB 2 wks Anti-TB 7 months
brochiolar stricture
Tuberculosis in subsets of patients
Tuberculosis in Altered Immunity
● Acquired Immune Deficiency Syndrome
● Diabetes Mellitus
● SLE
● Myelodysplastic synrome
● Alcoholics
Impaired granuloma formation atypical findings
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Pulmonary tuberculosisAIDS
Risk : 50 - 200 times
Radiology : depends on CD4 count
200 : post-primary
200 : primary
Pathology : Extensive necrosis but few cavity
Poorly organized or no granuloma
Numerous bacilli
TB in AIDS CD4 : 47/mm³
Pulmonary tuberculosis Diabetes Mellitus
Pathophysiology :
Phagocytosis & intracellular killing Suppress granuloma formation
Radiology:
Large airspace consolidation
Multiple small cavities
Extensive local & bronchog. spread
59/F, DM
Dyspnea
62/M DM
Incidental mass
Pulmonary tuberculosisSLE
22 pt. with active TB (8.8%) /256 consecutive SLE pts., all on steroid
HRCT findings: Miliary TB : 54%
CLN in upper lobe: 36%
Consolidation in LL: 18%
Lymphadenitis: 18%
Cavity: 0%
Immunity: Steroid (lymphokine, chemotaxis ↓) Inherent cell-mediated immunity↓
•Kim HY, et al. AJR 1999
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Pulmonary tuberculosis Myelodysplastic Syndrome
Acquired blood disorders
- May progress to acute leukemia
- Pancytopenia in spite of having a cellular marrow
12 TB/ 195 MDS
Common extrapulmonary involvement
–50%
Primary pattern (50%)
•Kim HC, et al. Clin Radiol 2001
21/F, Myelodysplastic syndrome
Fever, weight lossChronic Alcohol Abuse vs
Immunity
Humoral immunity ↓
Neutropenia
Marrow suppression
Chemotaxis
Cell-mediated immunity ↓
Lymphopenia
T-cell, natural killer cells
Delayed hypersensitivity
sensitization
•MacGregor RR. JAMA 1986;256:1474
Reversible Cystic Pulmonary TB
3 women with TB and respiratory failure
no underlying disease
HRCT: Multiple thin-walled cysts
at area of consolidation
Disappeared 6-8 mo. of chemo.
Mechanism: Bronchiolar narrowing with
cystic dilatation
•Ko KS, et al. Radiology 1997;204:165-169
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24/F previous healthy. AFB(+)
Dyspnea, fever
„01.04.03 „01.04.13
’01-04-14
2001-04-14 2001-07-30
2003-07-04 2003-12-19
TB Pleural Effusion: Paradoxical Response
•Choi YW, et al. Radiology 2002;224:493
16 patients with TB pleurisy
14 men, mean 27 yrs
New pulmonary nodule(s) during anti-TB Tx.
All ipsilateral peripheral nodules
Transient worsening but ultimately improve with
treatment
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23/M TB pleurisy 2 mo later
21/F
Cough, dyspnea
2008-02-16 2008-07-082009-05-08
Immunologic rebound ?
Hypersensitivity to dying AFB ?
TB in Patients with IPF
143 patients with IPF (mean age: 58.4 yr)
9/143 (6.3%) had activeTB
5.4 x of age adjusted AFB (+) prevalence)
CT: Mimic Cancer or Pneumonia
Subpleural nodule (6)
Lobar or lobular consolidation (3)
Location: RLL (4), LLL (3), UL (2)
•Chung MJ, et al. Eur J Radiol 2004;52:175-9 61/M IPF
6 months later
73/M IPF
1998.11
2000.03
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