PRESENTATION MATERIALS

Basic Chest
Radiology for
the TB Clinician
Adapted from the ISTC TB Training Modules 2009
 Basic Radiology for the TB Clinician
Objectives: At the end of this presentation,
participants will be able to:
Analyze the technical quality of chest X-rays (CXRs)
using simple parameters
Identify basic normal CXR anatomy on both frontal
and lateral views
Recognize radiographic patterns of disease and
describe using appropriate terminology
Describe both the typical and atypical patterns of
radiographic presentation for pulmonary
tuberculosis

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 Basic Radiology for the TB Clinician (2)

Overview:
Technical aspects of chest
radiography
Systematic approach to
reading CXR
Basic CXR anatomy
Patterns of disease
Radiographic manifestations of tuberculosis (TB)

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 Chest Radiography: Basic Principles
X-ray
X-rayphoton:
photon:Absorbed
Absorbed//scattered
scattered//transmitted
transmitted
X-ray
X-rayabsorption
absorptiondepends
dependson:
on:
Beam
Beamenergy
energy(constant)
(constant)
Tissue
Tissuedensity
density

Maximum X-Ray Blackest

Transmission air
(least dense tissue)
fat
soft tissue
calcium
bone
X-ray contrast
Maximum X-Ray metal
Absorption
(densest tissue) Whitest
ISTC TB Training Modules 2009 4
 Differential X-Ray Absorption
Why we see what we see:
Structures are visible on a
radiograph because of the
juxtaposition of two different
densities
creating an interface

Silhouette Sign
Loss of an expected interface
No boundary can be seen
between two structures because
they now are similar in density

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 5
 SilhouetteSign:
Silhouette Sign: RLL
RLL Pneumonia
Pneumonia

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 6
 SilhouetteSign:
Silhouette Sign: RLL
RLL Pneumonia
Pneumonia

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 6
 Assess CXR Technical Quality
Inspiratory effort
9-10 posterior ribs
Penetration
thoracic intervertebral disc space just
visible
Positioning / rotation
medial clavicle heads equidistant from
spinous process

ISTC TB Training Modules 2009 7

 Image credit: Curry International Tuberculosis Center, University of California, San Francisco
ISTC TB Training Modules 2009 8
 2
1
3

10
Image credit: Curry International Tuberculosis Center, University of California, San Francisco
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 2
1
3

10
Image credit: Curry International Tuberculosis Center, University of California, San Francisco
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 2
1
3

10
Image credit: Curry International Tuberculosis Center, University of California, San Francisco
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 Inspiratory Effort
Low Lung Volumes Full Inspiration

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 9
 Exposure
Overexposure Proper Exposure

Image credit: Curry International Tuberculosis Center, University of California, San Francisco
ISTC TB Training Modules 2009 10
 Overexposure Proper Exposure

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 11
 Rotated (Oblique)
Image credit: Curry International Tuberculosis Center, University of California, San Francisco
ISTC TB Training Modules 2009 12
 Basic Radiology for the TB Clinician

A systematic
approach to
reading a CXR

Image
ISTC TBCredit: Lung Health
Training Modules 2009 Image Library/Gary Hampton 13
 Approach to Reading a CXR
Be Systematic
Lungs
Pleural surfaces
Cardiomediastinal
contours
Bones and soft
tissues
Abdomen

Image credit: Curry International Tuberculosis Center, University of California, San Francisco
ISTC TB Training Modules 2009 14
 Worth a Second Look

Apices
Retrocardiac areas (left and right)
Hilar regions
Below diaphragm

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 Apical TB
Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 16
 Apical TB (2)
Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 17
 Left Retrocardiac Opacity

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 18
 Nodule Behind Diaphragm

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 19
 Basic Radiology for the TB Clinician

Basic CXR
Anatomy

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 20
 Basic CXR Anatomy
Frontal and Lateral Views
Heart
Aorta
Pulmonary
arteries
Airways

Image Credit: Lung Health Image Library/Pierre Virot

ISTC TB Training Modules 2009 21
Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 22
 Aortic arch
Right pulmonary
artery
Left pulmonary
artery
Trachea & bronchi

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 23
 Aortic arch

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 23
 Aortic arch
Right pulmonary
artery

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 23
 Aortic arch
Right pulmonary
artery
Left pulmonary
artery

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 23
 Aortic arch
Right pulmonary
artery
Left pulmonary
artery
Trachea & bronchi

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 23
 Basic Radiology for the TB Clinician

Patterns of
disease

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 Chest Radiographic Patterns of Disease

Consolidation / air-space opacity

Interstitial opacity
Nodules and masses
Lymphadenopathy
Cysts and cavities
Pleural abnormalities

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 Consolidation / Air-Space Opacity

Caused by filling of alveoli with fluid, pus,

blood, cells (tumor), etc.
May be diffuse, or isolated to segments or
lobes of the lung
May be associated with air bronchograms (air-
filled bronchus surrounded by opacified lung)

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 Pneumonia

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 27
 Interstitial Opacity
Disease localized to pulmonary interstitium, i.e., the
alveolar septae and connective tissues that support
the alveoli
Hallmarks:
Lines and/or reticulation
Small, well-defined nodules
Miliary pattern
DDX: Pulmonary edema, interstitial lung diseases
(e.g., idiopathic pulmonary fibrosis), sarcoidosis,
infection, tumor (lymphangitic spread), etc.

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 Interstitial Opacity: Lines

Image
ISTC TB Training credit:
Modules Curry
2009 International Tuberculosis Center, University of California, San Francisco 29
 Interstitial Opacity: Lines

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 29
 Interstitial Opacity: Lines & Reticulation

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 30
 Nodules and Masses
Nodule: discrete pulmonary lesion, sharply
defined, nearly circular opacity 0.2 - 3 cm
Mass: larger than 3 cm
Describe with qualifiers:
Single or multiple
Size
Border characteristics
Presence or absence of calcification
Location

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 Well-Defined Calcification

Ill-Defined Mass

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 32
 Lymphadenopathy (LAN)
Non-specific terms:
Mediastinal widening
Hilar prominence
Specific patterns:
Particular station enlargement (location)

Important to know what normal should

look like in order to recognize abnormal

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Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 34
Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 34
Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 34
Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 34
Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 34
 Lymphadenopathy
Infrahilar window
(right hilar and/or
subcarinal)
Left hilar
Subcarinal

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 35
 Lymphadenopathy
Infrahilar window
(right hilar and/or
subcarinal)

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 35
 Lymphadenopathy

Left hilar

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 35
 Lymphadenopathy

Subcarinal

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 35
 Right Paratracheal & Bilateral LAN

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 36
 Right Hilar LAN

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 37
 Right Hilar LAN

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 38
 Subcarinal LAN

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 39
 AP Window LAN

Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 40
 Cysts & Cavities
Abnormal pulmonary parenchymal spaces (holes),
filled with air and/or fluid, with a definable wall (>1
mm)
Cyst: congenital or acquired
Cavity: caused by tissue necrosis, (inflammatory
and/or neoplastic)
Characterize:
Wall thickness at thickest portion
Inner lining
Presence / absence of air / fluid level
Number and location
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 TB or Not TB? Cysts and Cavities

Are there
radiographic
features that
suggest A
benign vs. C
malignant
diagnoses?

45 year old man

from China with B
cough, weight loss D
Image
ISTC TBcredit: Curry International
Training Modules 2009 Tuberculosis Center, University of California, San Francisco 42
 TB or Not TB? Cysts and Cavities (2)
Are there radiographic features that suggest benign
vs. malignant diagnoses?
Benign cysts: uniform wall thickness,
1mm, smooth inner lining (e.g., PCP)

Benign cavities:
max. wall thickness
4 mm, minimally
irregular inner lining
(e.g., TB)
Malignant cavities:
max. wall thickness 16
mm, irregular inner lining
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 Pleural Disease: Basic Patterns
Effusion
Angle blunting to
massive
Thickening
Mass
Air
Calcification

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 Pleural Effusion

ISTC TB Training Modules 2009 45

 Post-TB Pleural Calcification

ISTC TB Training Modules 2009 46

 Plombage with Lucite balls

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 Basic Radiology for the TB Clinician

Radiographic
Manifestations of
TB

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 Can this be TB?
Typical Pattern:
Post-primary TB
Distribution
Apical / posterior segments of
upper lobes
Superior segments of lower
lobes
Isolated anterior segment
involvement unusual for M.tb
(think M. avium complex)

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 Typical pattern: Post-Primary TB
Patterns of disease
Air-space consolidation
Cavitation, cavitary nodule
Endobronchial spread
Miliary
Bronchostenosis
Tuberculoma
Pleural effusions
(empyema most likely in
post-primary disease)

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 Can this be TB?
Atypical pattern: Primary TB
Distribution : any lobe involved
(slight lower lobe predominance)
Air-space consolidation
Cavitation is uncommon (<10%)
Adenopathy is common
(esp. children and HIV),
predilection for right side
Miliary pattern
Pleural effusions

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 Can this be TB? Miliary TB

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 Radiographic Patterns: Pulmonary TB

TB Pattern Typical Atypical

(Post-Primary) (Primary)

Upper : Lower
Infiltrate 85% upper 60 : 40
Usually upper in
children

Cavitation Common Uncommon

Children common
Adenopathy Uncommon Adults ~30%
Unilateral > bilateral

Effusion May be present May be present

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 CXR Pattern: Early vs. Advanced HIV

Early HIV Advanced HIV

(CD4>200) (CD4<200)

Pattern Typical Atypical

(Post-primary) (Primary)

Infiltrate Upper lobes Lower lobes, multiple

sites, or miliary

Cavitation Common Uncommon

Adenopathy Uncommon Common

Effusion Uncommon More common

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 Can this be TB?
Old / Healed TB
Ca++ granulomaGhon lesion
Ca++ granuloma and hilar node
calcificationRanke complex
Apical pleural thickening
Fibrosis and volume loss

ISTC TB Training Modules 2009 55

 Basic Radiology for the TB Clinician

Summary:
Remember: Technical quality
can significantly impact your
CXR interpretation
Develop a systematic
approach (and use it every time!)
Practice identifying normal
CXR anatomy
Important to characterize and describe lesionsthis can
help with your differential diagnosis
Whether typical or atypical
TB can always fool you!

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