radiology of tuberculosis

Radiology of Tuberculosis

Mohit Goyal

Under the guidance of: Sr. Prof. Dr. V.K. Goyal

Department of Medicine, R.N.T. Medical College, Udaipur

13th February, 2014


Common Roentgenograms

Summary of Roentgenographic manifestations of TB

An extremely rare case

Some CT and MRI findings in TB

XR01 Ra

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Presentation

This patient, a 32-year-old male presented with insidious onset,

progressive, productive cough for 3 months; feverish feeling for a

month and loosening of clothes over time.

Past history: No history of any other illnesses.

Over the counter medications taken on and off over the past month

for cough and fever.

The patient had difficulty producing sputum for the examination.

The sample mainly contained saliva and was found negative for AFB.

The patient was referred to Dept. of TBCD. BAL sample was taken,

subjected to microbiological examination and found positive for AFB.

XR01

Miliary shadows/mottling

Millet seed sized opacities ~ 2mm

Miliary densities are seen in: Miliary TB, Anthracosis, Sarcoidosis,

Tropical eosinophilia, Fibrosing alveolitis, Allergic alveolitis,

Histoplasmosis, Coccidioidomycosis, Blastomycosis, Cryptococcosis.

Pulmonary haemosiderosis and Silicosis are also seen as milliary

mottling but the radiodensity is more than soft tissue.

Carcinomatosis, lymphoma and sarcoidosis have discrete but slightly

larger shadows (> 2mm).

Some pneumonias, fat emboli and pulmonary oedema can present as

shadows > 2mm that tend to coalesce.

Metastasis from Papillary ca Miliary Tuberculosis

XR01

XR02 Ra

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Presentation

This patient, a 23-year-old male presented with fever, productive

cough and weight loss for one month.

Past history: No history of any other illnesses.

Over the counter medications taken over the past month for fever.

The patient’s sputum was sent for examination and found to be

positive for acid fast bacilli.

XR02

Cavity

A gas containing space in the lungs surrounded by a wall whose

thickness is >1mm.

In bullae, the wall thickness is <1mm.

Thin walled cavities may be seen in tuberculous cavity, infected

bullae, staphylococcus, Klebsiella, post-traumatic cysts,

Coccidioidomycosis, Mycobacterium kansasii infection, metastatic

cavitating squamous cell ca of cervix.

Thick walled cavities may be seen in lung abscess, metastatic

carcinoma, bronchogenic carcinoma, Wegener’s granulomatosis,

fungal cavity, necrotising squamous cell carcinoma, Blastomycosis.

XR02

Cavity

The cavity wall is irregular or nodular in carcinoma, rugged or

shaggy in acute lung abscess and smooth in other cavitating lesions.

Cavity with wall thickness <5mm is likely to be benign; 5-15mm may

be benign or malignant and >15mm is likely to be malignant.

Lung abscess - superior segment of the lower lobe and axillary sub

segments of anterior and posterior segment of the upper lobe.

Tubercular – superior segments of upper and lower lobes.

Klebsiella, SCC – upper lobes.

Cystic bronchiectasis, hydatid cyst – lower lobes

Note: when a cavity in the anterior segment is encountered, strong

suspicion for lung cancer should be raised.

XR03 Ra

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Presentation


progressive shortness of breath. No history of cough, expectoration.

Past history: Taken ATT 10 years back for pulmonary TB.

The patient’s sputum was sent for examination and was found to be

negative for acid fast bacilli. CT imaging of thorax was planned but

the patient refused.

XR03

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Presentation

This patient, a 60-year-old male presented with difficulty breathing,

pain on the right side of chest and dry cough on and off.

Past history: Taken ATT 8 years back for pulmonary TB with possibly

pleural effusion. Documents not available but the patient describes

both parenchymal disease as well as pleural effusion.


negative for acid fast bacilli. CT imaging of thorax revealed pleural

thickening and calcification. There was not evidence of activity.

XR04

XR05 Ra

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Presentation


progressive shortness of breath for 2 months.

Past history: No history of any chronic illnesses.

Pleural fluid was sent for analysis. It was found to have 800 cells,

with 90% lymphocytes. Proteins were 6 g% and the fluid was positive

for ADA. Patient’s ESR was 63.


negative for acid fast bacilli.

XR05

XR06 Ra

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Presentation

This patient, a 57-year-old male presented with acute onset

shortness of breath.

Past history: Two years back he took ATT for 6 months.

Emergency management was done. The patient’s sputum was sent

for examination and was found to be negative for acid fast bacilli.

XR06

XR07 Ra

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Presentation


progressive edema and shortness of breath.

Past history: He was diagnosed to have pericardial effusion an year

back, which was found to be tubercular, and he was given ATT for it.


negative for acid fast bacilli.

ECHO revealed pericardial calcification, constrictive pericarditis. The

patient was taken over by the Dept. of Cardio-Thoracic-Vascular

surgery for further management.

XR07

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Consolidation in primary infection

This may involve any part of the lung, and the appearance is non-

specific unless there is coincidental lymphadenopathy.

The area involved may be small or affect an entire lobe, and an air

bronchogram may be visible. Occasionally consolidation appears as a

well-defined nodule or nodules.

Healing is often complete without any sequelae on the chest

radiograph although fibrosis and calcification may occur.

Tuberculous bronchopneumonia may occur in both primary and

post-primary infection, causing patchy, often nodular, areas of

consolidation.

Consolidation in post-primary infection

This usually appears in the apex of an upper or lower lobe, and

almost never in the anterior segments of the upper lobes.

The consolidation is often patchy and nodular and may be bilateral.

A minimal apical lesion can easily be overlooked because of

overlapping shadows of ribs and clavicle. Comparison with the

opposite side is then helpful, looking for asymmetries of density. The

apical projection was designed to overcome this difficulty, but is

rarely useful.

Progressive infection is indicated by extension and coalescence of the

areas of consolidation, and the development of cavities.

Consolidation in post-primary infection

Simultaneously there may be fibrosis and volume loss indicating

healing.

Cavities may be single or multiple, large or small and thin or thick

walled. Fluid levels are sometimes visible within cavities.

With fibrosis there is often obliteration of cavities; however, larger

cavities may persist and areas of bronchiectasis and emphysema

may develop. Healed lesions often calcify.

Because the upper lobes are predominantly involved, the effects of

fibrotic contraction are seen as the trachea being pulled away from

the midline, elevation of the hila and distortion of the lung

parenchyma.

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Miliary tuberculosis

This is due to haematogenous spread of infection and may be seen in

both primary and post-primary disease. In the former the patient is

often a child, and in the latter case the patients are often elderly,

debilitated or immunocompromised.

At first the chest radiograph may be normal, but then small, discrete

nodules, 1-2 mm in diameter, become apparent, evenly distributed

throughout both lungs.

These may enlarge and coalesce, but with adequate treatment they

slowly resolve. Occasionally, some may calcify.

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Tuberculoma

This is a localized granuloma due to either primary or post-primary

infection. It usually presents as a solitary well-defined nodule, up to

5 cm in diameter. Calcification is common but cavitation is unusual.

Lymphadenopathy

Hilar and mediastinal lymphadenopathy is a common feature of

primary infection and may be seen in the presence or absence of

peripheral consolidation. Following healing, involved nodes may

calcify. Lymphadenopathy is usually unilateral but may be bilateral

where the differential diagnoses of lymphoma and sarcoidosis come

in. It is often more pronounced in children.

Pleural changes

Pleural effusion complicating primary infection is usually unilateral

and due to subpleural infection. Pulmonary consolidation and/or

lymphadenopathy may or may not be apparent.

At presentation the effusion may be large and relatively

asymptomatic. These effusions usually resolve without complication.

Pleural effusion in post-primary infection, however, often progresses

to empyema. Healing is then complicated by pleural thickening and

often calcification. Uncommon complications of tuberculous

empyema are bronchopleural fistula , osteitis of a rib,

pleurocutaneous fistula and secondary infection. Previous

thoracoplasty may also complicate the appearances.

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Pleural changes

Pleural thickening over the apex of the lung often accompanies the

fibrosis of healing apical tuberculosis. Pneumothorax may complicate

subpleural cavitatory disease.

Airway Involvement

This may be secondary to lymphadenopathy or endobronchial

infection and may therefore complicate both primary and post-

primary disease. Compression of central airways by enlarged nodes

may cause pulmonary collapse or air trapping. Healing of

endobronchial infection with fibrosis may result in bronchostenosis.

The lung distal to bronchial narrowing may develop bronchiectasis.

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Rare Case Ra

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Presentation


progressive dysphagia for 5 months.

Past history: ATT taken 1 year back for pulmonary TB.

Endoscopic biopsy and CT thorax and abdomen were planned.

Biopsy examination revealed casseating epitheloid granuloma and

positive acid fast staining.

The oesophagus was dilated and the patient has been put on ATT.

Rare Case

Rare Case Ra

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XR08 Ra

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Presentation

This patient presented with fever for one month, altered behavior for

3 days and loss of consciousness for 6 hours.

Past history: No history of any chronic illnesses.

CSF examination revealed 100 cells, mainly lymphocytes. Proteins

were 6.4 g% and the fluid was positive for Adenosine deaminase.

CT09

Neuroimaging findings in TB

Hydrocephalus – seen in 50-80% cases

Enhancement of basal meninges – 60%

Cerebral infarctions – 28%

Tuberculomas – 10%

Mass effects due to tuberculomas and abscess

Vasculitis

Thrombosis

THANK YOUfor the patience

Department of Medicine, R.N.T. Medical College, Udaipur

Acknowledgements:

Dept. of Radiodiagnosis, R.N.T. Medical College

Dr. Rambir Singh, MRI Centre, M.B. Govt. Hospital

Dr. Vinita Goyal, M.D. Radiodiagnosis

Sources:

Harrison’s Principles of Internal Medicine

Textbook of Radiology and Imaging, David Sutton

Tuberculosis, Surendra K. Sharma

radiology of tuberculosis

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