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  • 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 outwardsNormal or abnormalDescribe 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 12 Mediastinum

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    Lymphoma

    AbnormalNormal

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    Metastatic disease (unknown primary)Normal Abnormal

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    Slide 15

    Lung CancerNormal Abnormal

    AO

    PA

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  • Slide 16 Heart

  • 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 granulomasB. Non-caseating

    granulomasC. Atypical cells with high

    nuclear/cytoplasmic ratioD. Fibrosis

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    Slide 24

    SarcoidosisNormal Abnormal

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    Pulmonary HypertensionNormal 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 31

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    Slide 32 Q2. Where is this lesion located?

    A. LungB. MediastinumC. PleuraD. Chest wall

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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 Dont 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 wideningB. Diffuse lung opacitiesC. Pleural effusionD. Normal

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  • Slide 43 Inspiration: (10 posterior ribs)

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    Slide 45

    1st rib

    2nd rib3rd rib

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  • Slide 46 2nd3rd

    4th5th

    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 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. TuberculosisB. AspergillosisC. MalignancyD. 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 opacityFluffy around the peripheryAir bronchograms

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    Slide 59 ARDS

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    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 64 Airways disease

    Circular

    Tubular

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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 patternsTB patterns overlap with each otherTB patterns overlap with other diseases If there is an abnormality, it could be due to

    TBBut, if it doesnt fit into a typical TB

    pattern, it is unlikely to be TB Its 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 cavitiesPleural diseaseVolume loss/scarring early in diseaseDiff 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 lobeB. Azygous lobeC. Right middle lobeD. Right lower lobe

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    Slide 75 Lobar anatomy

    Left Lung

    LLL

    LUL

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    Right Lung

    RLLRML

    RUL

    Lobar anatomy

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    Right Lung

    RLLRML

    RUL

    Lobar anatomy

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    Slide 78 RUL Pneumonia

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    Right Lung

    RLLRML

    RUL

    Lobar anatomy

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    Right Lung

    RLLRML

    RUL

    Lobar anatomy

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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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    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 Potts disease

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  • Slide 100 Case #4

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    Slide 101

    Q6. What is the primary abnormality?1. Consolidation2. Emphysema3. Airway enlargement4. Fibrosis

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    Slide 102 Abnormal Normal

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  • Slide 103 Prior reactivation tuberculosis

    Upper lobe scarringVolume lossRetraction of hila superiorlyBand-like (linear) opacitiesArchitectural distortion

    Asymmetric > symmetricBronchiectasisCystic changesDiff 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 fibrosisConsolidation with cavitationLower lobe abnormalitiesNon-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. 20%

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    Slide 110

    Solitary nodule/mass- the top 5

    GranulomaHamartomaSolitary metastasisBronchogenic carcinomaLots 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-upHigh 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 months18-24 months

    6-8 mm 6-12 months18-24 months

    3-6 months9-12 months24 months

    >8 mm 3 months9 months

    24 months

    3 months9 months24 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 predominanceCan be anywhereNodule: Ghon focusNodule + lymph node: Ranke complexCalcification 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. TuberculosisB. BacteriaC. AdenovirusD. Mycoplasma

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  • Slide 130 Primary tuberculosis

    Difficult radiologic diagnosisMimics other diseasesFindings

    Nonspecific consolidationNoduleLymphadenopathy

    Cavitation unusualLAD 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. TuberculosisB. Hypersensitivity

    pneumonitisC. Fungal infectionD. Sarcoidosis

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    Slide 135

    Miliary pattern CXR

    Miliary tuberculosisFungal infection (histo, cocci, blasto)MetastasesSarcoidosis

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  • Slide 136

    Miliary tuberculosis

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    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. LymphadenopathyB. Pericardial effusionC. Lytic bony lesionD. Normal

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    Slide 146 Case #11

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    Slide 147

    LymphomaLeukemiaGerm cell tumorBacterial mediastinitisFungal infectionTuberculosis

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  • Slide 148 Lymphadenopathy with TB

    Kids >> adultsPrimary >> secondaryAsymmetric (right > left)Most common locations

    HilarRight 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

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