TB Intensive

Minneapolis, Minnesota
September 23-26, 2008
Diagnosis of Tuberculosis
Disease: Radiology
Patricio Escalante, MD, MSc
September 23, 2008
Diagnosis of Tuberculosis
Disease: Radiology
Patricio Escalante, M.D., M.Sc.
Division of Pulmonary & Critical Care Medicine
Mayo Clinic
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Goal: Goal:
To describe the timely diagnosis of To describe the timely diagnosis of
tuberculosis (TB) using radiology as a tool tuberculosis (TB) using radiology as a tool
Objectives: Objectives:
Primary TB Primary TB
Reactivated TB Reactivated TB
Less common radiographic presentations Less common radiographic presentations
Primary TB Primary TB
Reactivated TB Reactivated TB
TB in HIV TB in HIV- -infected adults infected adults
TB in children TB in children
Extrapulmonary TB Extrapulmonary TB
CT scan findings CT scan findings
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Necrotizing Necrotizing
granulomatous granulomatous
reaction reaction is the is the
hallmark of hallmark of
host host s tissue s tissue
immune immune
response response
against TB against TB
TB Presentation TB Presentation
Host factors Host factors
Environmental factors? Environmental factors?
Bacterial factors? Bacterial factors?
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Clinical Manifestations: Clinical Manifestations:
Primary TB Primary TB
Can occur at any age, usually in children but Can occur at any age, usually in children but
also in the elderly also in the elderly
Usually affects the lower and middle lungs Usually affects the lower and middle lungs
and heals with no clinical symptoms in more and heals with no clinical symptoms in more
than 90% of cases than 90% of cases
Can heal by fibrosis and calcification Can heal by fibrosis and calcification
Other radiographic appearances: Other radiographic appearances:
patchy bilateral infiltrates patchy bilateral infiltrates
no obvious infiltrates no obvious infiltrates
mediastinal lymphadenopathy, signs of pleural mediastinal lymphadenopathy, signs of pleural
disease, miliary pattern, etc. disease, miliary pattern, etc.
Radiological Manifestations: Radiological Manifestations:
Primary TB Primary TB
Ghons focus and Rhanke complex
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Primary TB Primary TB
Clinical Manifestations: Clinical Manifestations:
Active (Reactivated) Pulmonary TB Active (Reactivated) Pulmonary TB
Upper lobes Upper lobes and the apical and the apical
segment of the lower lobes segment of the lower lobes
Progression is variable Progression is variable
Granulomatous Granulomatous broncho broncho- -
pneumonic infiltration pneumonic infiltration
c caseation aseation cavity cavity in the lung in the lung
Infected sputum can be Infected sputum can be
aspirated to other segments in aspirated to other segments in
the lung the lung bronchogenic bronchogenic
spread spread
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Reactivated Pulmonary TB Reactivated Pulmonary TB
Chronic parenchymal lesions: Chronic parenchymal lesions:
upper upper lobe lobe destruction, destruction,
fibrosis, and overdistended fibrosis, and overdistended
emphysema emphysema
Hemoptysis: Hemoptysis: erosion of blood erosion of blood
vessels within the TB lesion vessels within the TB lesion
The lesions can also erode The lesions can also erode
into blood vessels into blood vessels
hematogenous hematogenous
dissemination dissemination: : lungs, lungs,
CNS, CNS, genito genito- -urinary, skeletal, urinary, skeletal,
lymph nodes, etc lymph nodes, etc
Pulmonary Reactivated TB Pulmonary Reactivated TB
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Less Common Presentations Less Common Presentations
Miliary TB Miliary TB
Insidious in onset, with Insidious in onset, with
general malaise, fever, general malaise, fever,
weight loss, and sweats weight loss, and sweats
Typical diffuse miliary Typical diffuse miliary
pattern often appears in the pattern often appears in the
chest x chest x- -ray ray
Sputum smear for AFB are Sputum smear for AFB are
only positive in 30% of only positive in 30% of
cases cases
Other organ involvement is Other organ involvement is
not uncommon not uncommon
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Miliary TB Miliary TB
Active pulmonary TB: Active pulmonary TB:
HIV vs. Non HIV vs. Non- -HIV HIV
Patients with HIV and TB: Patients with HIV and TB:
Normal chest x Normal chest x- -ray ray, or with , or with
infiltrates in any lobes and infiltrates in any lobes and
any location any location
No radiological appearance is No radiological appearance is
pathognomonic of TB pathognomonic of TB
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Pulmonary TB and HIV infection Pulmonary TB and HIV infection
Pediatric TB Pediatric TB
Usually progression from primary TB Usually progression from primary TB
Lower lobes Lower lobes
Bulky lymphadenopathy Bulky lymphadenopathy
LAD compression of bronchi LAD compression of bronchi
Non Non- -apical cavities apical cavities
Miliary forms Miliary forms
Extrapulmonary Extrapulmonary
Head and neck LAD (60%) Head and neck LAD (60%)
Meningeal (10%) Meningeal (10%)
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Pediatric TB Pediatric TB
Pediatric TB Pediatric TB
Haller JO, Ginsberg KL. Pediatr Rad 1997
Kim WS, et al. AJR 1997
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Extrapulmonary TB Extrapulmonary TB
Pleural TB Pleural TB
CNS TB CNS TB
Spinal TB Spinal TB
TB Lymphadenopathy TB Lymphadenopathy
Others Others
Pleural TB Pleural TB
Peripheral Peripheral subpleural lesions subpleural lesions
pleural cavity pleural cavity tubercles tubercles
effusion effusion and empyema and empyema
Pleural fluid: Pleural fluid: exudate with exudate with
lymphocyte predominance lymphocyte predominance
Pleural fluid Pleural fluid smear and smear and
culture culture is only positive in 1/3 is only positive in 1/3
Pleural tissue Pleural tissue culture and culture and
granulomatous histology granulomatous histology: :
diagnostic yield >70% diagnostic yield >70%
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Pleural TB Pleural TB
CNS TB CNS TB
TB meningitis the most common presentation TB meningitis the most common presentation
Radiologic findings Radiologic findings
Hydrocephalus with or without other lesion Hydrocephalus with or without other lesion
Tuberculomas single or multiple Tuberculomas single or multiple
Leptomeningitis with basal cisterns Leptomeningitis with basal cisterns
involvement involvement
Infarction, usually MCA Infarction, usually MCA
Abscess Abscess
Kilani B, et al. Rev Med Interne 2003
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CNS TB CNS TB
Spinal TB or Pott Spinal TB or Pott s disease s disease
Vertebral Vertebral disc space involvement disc space involvement
Location Location
Cervical (10%) Cervical (10%)
Thoracic (60%), Thoracolumbar (15%) Thoracic (60%), Thoracolumbar (15%)
Lumbar (20%) Lumbar (20%)
# of vertebral bodies # of vertebral bodies
Mean 2.5, range 1 Mean 2.5, range 1-6 6
Characteristics Characteristics
Disc space involvement: 85% (usually occur later) Disc space involvement: 85% (usually occur later)
Paraspinal mass: 95% Paraspinal mass: 95%
Epidural compression: 65% Epidural compression: 65%
Angulation : 50% Angulation : 50%
Cooper PR et al. In Tuberculosis, 1996
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Pott Pott s disease s disease
TB Lymphadenopathy TB Lymphadenopathy
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CASE
Patient from Burma with h/o liver transplant, ill-
defined infiltrates and persistent fever
How would you approach
the pulmonary infiltrates?
Dx FOB with BALs:
AFB (-) smear from
RLL/RML
CT Chest CT Chest
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- - -
-

CT Guided Biopsy CT Guided Biopsy
CT Scan Findings CT Scan Findings
Detection of occult disease Detection of occult disease
More sensitive than CXR More sensitive than CXR
Miliary TB Miliary TB
Early infiltrates Early infiltrates
Subtle adenopathy Subtle adenopathy
Occult bronchiectasis and small cavities Occult bronchiectasis and small cavities
Disease extension Disease extension
Mediastinum, pleural spaces, chest wall, etc. Mediastinum, pleural spaces, chest wall, etc.
Disease activity Disease activity
Centrolobular branching + nodules of 5 Centrolobular branching + nodules of 5-8 mm: 8 mm: Tree Tree-in in-bud bud
Non Non-calcified nodules calcified nodules
Consolidation Consolidation
Cavities Cavities
Im JG, et al. Radiology 1990
Tozkoparan E, et al. Arch Med Res 2005
McGuinness G, Naidich DP. In Tuberculosis 1996
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CT correlation CT correlation
CT correlation CT correlation
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Conclusions Conclusions
Primary TB usually involves lower lobes Primary TB usually involves lower lobes
Reactivation TB usually involve upper lobes Reactivation TB usually involve upper lobes
TB TB- -HIV co HIV co- -infected can present with normal infected can present with normal
chest x chest x- -ray, or with infiltrates in any lobes and ray, or with infiltrates in any lobes and
any location any location
No radiological appearance is pathognomonic No radiological appearance is pathognomonic
of TB of TB
CT scan can improve chest X CT scan can improve chest X- -ray evaluation ray evaluation
Other image modalities such as MRI can be Other image modalities such as MRI can be
helpful helpful
Questions? Questions?
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