RADIOLOGY

Case Discussion 1
JACINTO, Ma. Theresa
JEONG, Kyung Sun
JOSE, Niña
JUNIA, Christine Joy
KING KAY, Caroline Bernadette
LAO, Eugene
LAO, Kriselle Maris
LAO, Lawrence Edeniño
LAO, Sharlene Marie
LAUS, Lady Diana Rose
III - C
CASE
 RR, 70 years old, male, seaman
 Chief complaint: Cough
History of Present Illness
 3 years PTC
 Productive cough with whitish phlegm
 Accompanied by fever and body malaise
 Self-medicated with paracetamol and
amoxicillin (unrecalled dosage)
History of Present Illness
 2 years PTC
 Persistence of cough, now blood tinged
 Sought consult, was advised to have chest x-
ray.
 Was given anti-TB regimen but unable to
comply with the full course of treatment
History of Present Illness
 1 year PTC
 Occasional cough and febrile episodes
 No medications taken
 3 days PTC
 Expectorated blood
 Advised to have chest CT scan
Review of Systems
 (+) weight loss
 (+) loss of appetite
 (+) body malaise
 (+) night sweats
Past Medical History
 (+) Hypertension
Physical Examination
 Hyposthenic
 Normal Vital Signs
 Lagging of the left lung
 Diminished breath sounds on the left
 Normal Patient

Chest PA Lateral
Learning Issues
 Radiographic signs of PTB
 What is a tuberculoma?
 Distinguish between primary vs re-infection
tuberculosis
 Explain the presence of atelectasis, cavitations
and bronchiectasis in PTB
 What is the role of follow-up chest x-ray?
 Radiographic findings of healed PTB
 What is the role of CT scan?
OUTLINE
 Pathophysiology of Tuberculosis
 Radiographic Signs of PTB
 Tuberculoma
 Bronchiectasis
 Cavitation
 Atelectasis
 Primary vs. Re-infection PTB
 Active vs. Healed PTB
 Role of Chest X-Ray in Follow-up
 Role of CT Scan
OUTLINE
 Pathophysiology of Tuberculosis
 Radiographic Signs of PTB
 Tuberculoma
 Bronchiectasis
 Cavitation
 Atelectasis
 Primary vs. Re-infection PTB
 Active vs. Healed PTB
 Role of Chest X-Ray in Follow-up
 Role of CT Scan
 Infection with
M. tuberculosis

Alveolar macrophage Alveolar macrophages

ingestion of bacilli secrete cytokines

Unchecked bacillary IL1 Fever

multiplication
IL6 Hyperglobulinemia

Lysis of the macrophage

• Killing of
TNF-ά Mycobacteria
• Granuloma
Activated monocytes formation
ingest the bacilli from lysed • Fever
macrophage • Weight loss
 Activation of more host
responses

Tissue-damaging Macrophage-activating
response response

Formation of solid • Development of

necrosis in the specific immunity
center of the • Accumulation of
tubercle activated macrophage

Caseating granuloma Tubercle formation

Some lesions heal by • Lagging of the left

fibrosis and lung
calcification •  Breath sounds
 Treatment failure

Intensified DTH

 Tissue-damaging
response
Multiplication &
• Cough
Caseous material Drained through spread of the
• Hemoptysis
liquefies bronchi bacilli into the
airways

Invasion & destruction

Of BV and bronchial walls

Cavity formation
OUTLINE
 Pathophysiology of Tuberculosis
 Radiographic Signs of PTB
 Tuberculoma
 Bronchiectasis
 Cavitation
 Atelectasis
 Primary vs. Re-infection PTB
 Active vs. Healed PTB
 Role of Chest X-Ray in Follow-up
 Role of CT Scan
Tuberculoma
 Primary, post-primary
tuberculosis
 Form of lesion
commonly seen in TB
 Well circumscribed,
round/oval opacities
caused by acid-fast
bacilli
 1-4 cm or more in
diameter
 mostly in upper lobe,
right more than the left
Tuberculoma
OUTLINE
 Pathophysiology of Tuberculosis
 Radiographic Signs of PTB
 Tuberculoma
 Bronchiectasis
 Cavitation
 Atelectasis
 Primary vs. Re-infection PTB
 Active vs. Healed PTB
 Role of Chest X-Ray in Follow-up
 Role of CT Scan
Bronchiectasis
 Localized, irreversible
dilatation of the
bronchial tree
 Associated with
acute, chronic or
recurrent infection
(bacteria and
mycobacteria)
Bronchiectasis

 Tram line
 Ring shadows with thickened bronchial walls
 Mucus plugs
Bronchiectasis

 Air fluid levels

 Watch for dextrocardia
 Diffuse lung fibrosis
 Due to recurrent infections
Bronchiectasis

 Bronchial dilatation
 Tram lines
 Thickened bronchial walls
 Mucus plugs
OUTLINE
 Pathophysiology of Tuberculosis
 Radiographic Signs of PTB
 Tuberculoma
 Bronchiectasis
 Cavitation
 Atelectasis
 Primary vs. Re-infection PTB
 Active vs. Healed PTB
 Role of Chest X-Ray in Follow-up
 Role of CT Scan
Cavitations
 Cavitation, usually in the apices of the
lungs, occurs readily in the secondary
form of PTB, resulting in dissemination of
mycobacteria along the airways

Robbins and Kutran. Pathologic basis of disease. 7th ed pp. 384-386

 Expansion in the area of caseation  erosion into a
bronchus  evacuation of the caseous center (cough)
 irregular cavity lined by caseous material and fibrous
tissue
Robbins and Kutran. Pathologic basis of disease. 7th ed pp. 384-386
 Early stages
 Cavity is usually irregular, often showing air-fluid level
Radiology of the chest. Regional roentgen pathology. pp. 358-364
 Early stages
 Small areas of infiltration, consolidation adjacent to a
cavity is highly suggestive of PTB (differentiate from lung
abcess)
 Early lesions: posterior portion of upper lobe, below level
of the clavicle
Radiology of the chest. Regional roentgen pathology. pp. 358-364
CAVITY

CAVITY
OUTLINE
 Pathophysiology of Tuberculosis
 Radiographic Signs of PTB
 Tuberculoma
 Bronchiectasis
 Cavitation
 Atelectasis
 Primary vs. Re-infection PTB
 Active vs. Healed PTB
 Role of Chest X-Ray in Follow-up
 Role of CT Scan
Atelectasis
 “Incomplete
stretching”, loss of
volume of lung tissue
because of decreased
amount of gas
 Destructive process in
the walls of the
bronchi and plugging
of the lumina by
exudate
Radiology of the chest. Regional roentgen pathology. pp. 365-367
Thoracic Imaging: Pulmonary and Cardiology. pp. 47-65
 Direct Signs ( due to lobar volume loss)
 Displacement of interlobular fissures: best sign of
atelectasis
 Crowding of vessels, bronchi or air bronchograms
Radiology of the chest. Regional roentgen pathology. pp. 365-367
Thoracic Imaging: Pulmonary and Cardiology. pp. 47-65
 Indirect Signs
 Diaphragmatic elevation: due to ipsilateral volume
loss: more common lower lobe
 Juxtaphrenic Peak (upper lobe atelectasis)
Radiology of the chest. Regional roentgen pathology. pp. 365-367
Thoracic Imaging: Pulmonary and Cardiology. Pp. 47-65
 Indirect Signs
 Mediastinal shift:
more common upper
lobe collapse
(Trachea); more
common lower lobe
collapse (heart)

Radiology of the chest. Regional roentgen pathology. pp. 365-367

Thoracic Imaging: Pulmonary and Cardiology. pp. 47-65
 Indirect signs
 Compensatory overinflation of normal lung on the same side;
increased volume with decreased density of lung
 Hilar displacement: Hilum ELEVATED with ULA; Hilum
DEPRESSED with LLA
Thoracic Imaging: Pulmonary and Cardiology. Pp 47-65
 Indirect signs
 Reorientation of
hilum or bronchi
 ULA: hilum rotates
outward and
descending pulmonary
artery is less vertical
and easily seen
 LLA: hila are
depressed and bronchi
appear more vertical

Radiology of the chest. Regional roentgen pathology. pp. 365-367

Thoracic Imaging: Pulmonary and Cardiology. pp. 47-65
 Indirect Signs
 Approximation of the ribs: ipsilateral ribs appear
closer together
 Flat waist sign: flattening of the left heart border due
to rotation of heart and great vessels
Radiology of the chest. Regional roentgen pathology. pp. 365-367
Thoracic Imaging: Pulmonary and Cardiology. pp. 47-65
 Indirect Signs
 Increased lung opacity: reflects replacement of
alveolar air with fluid or compressed airless tissue
 Absence of air bronchograms
Radiology of the chest. Regional roentgen pathology. pp. 365-367
Thoracic Imaging: Pulmonary and Cardiology. pp. 47-65
 Indirect signs
 Absence of air bronchograms suggests central
bronchial obstruction
 Mucus bronchograms
 Shifting granuloma sign: parenchymal lesions of prior
film shifts in location
Radiology of the chest. Regional roentgen pathology. pp. 365-367
Thoracic Imaging: Pulmonary and Cardiology. pp. 47-65
OUTLINE
 Pathophysiology of Tuberculosis
 Radiographic Signs of PTB
 Tuberculoma
 Bronchiectasis
 Cavitation
 Atelectasis
 Primary vs. Re-infection PTB
 Active vs. Healed PTB
 Role of Chest X-Ray in Follow-up
 Role of CT Scan
Primary Tuberculosis
 Pulmonary imaging findings in individuals with
primary tuberculosis are nonspecific
 Note that chest radiographic findings may be
normal in as many as 15% of patients with primary
pulmonary tuberculosis
Primary Tuberculosis
 Parenchymal consolidation
 Predilection for the lower lobes, middle lobe
and lingula, and anterior segments of the
upper lobes
 Homogeneous, with ill-defined margins
 Caseous necrosis occurs centrally within the
lung parenchymal opacity, decreasing its size
 Become rounded with healing, continues to
shrink until only a small nodule remains →
calcified or ossified → calcified granuloma
 PTB with bronchogenic spread in 34 y/o woman
 CXR: Nodules, right lower lobe
 HRCT: Peribronchial (arrows) and large acinar (arrowheads) nodules
 CT: Lobular consolidations (arrows) and acinar nodules (arrowheads)
(Lee KS et al, 1003)
 Tuberculoma may be a manifestation of either
primary or postprimary tuberculosis
(Lee KS et al, 1003)
Primary Tuberculosis
 Lymphadenopathy
 Distinguishing feature of primary TB vs.
recurrent TB
 More common with immune incompetent
hosts
 Most common in the ipsilateral hilar region
 May involve the airways
 Indistinguishable from that of sarcoid or
lymphoma
 Tuberculosis, lymphadenopathy in a 19 y/o male
 CXR: Bilateral widening of superior mediastinum and
enlargement of right hilum
 CT: Extensive mediastinal adenopathy with central low
density and peripheral rim enhancement
Primary Tuberculosis
 Airway involvement
 Airwaycompression with resultant atelectasis
 Mucosal infection
 Broncholithiasis
 Endobronchial spread of infection
 Bronchiectasis
 Traction bronchiectasis in a 52 y/o male
 HRCT: Dilatation of right upper lobe bronchi and
granuloma in left upper lobe
(Hyae Young Kim,
 Tracheobronchial stenosis in a 40 y/o female
 Contrast-enhanced CT: narrowing of left main
bronchus
(Hyae Young Kim, 2001)
 Broncholithiasis in a 58 y/o male
 Contrast-enhanced CT: broncholith within lateral segmental
bronchus of right middle lobe
 Distal obstructive atelectasis and calcified lymph nodes
 Right pleural effusion
(Hyae Young Kim,
Re-infection Tuberculosis
 Often on the apical and posterior
segments of the upper lobes or superior
segments of the lower lobes
 Associated with progressive disease
Re-infection Tuberculosis

 Most common clinical finding is poorly defined areas of

consolidation in involved segments
Re-infection Tuberculosis

 There may be cavitation, with visible endobronchial

spread
Re-infection Tuberculosis

 In 20-45% of patients with active post-primary TB,

cavitation is visible on chest radiographs, with
numerous small nodules
Re-infection Tuberculosis
 Pleural involvement
 Uncommon in children, seen more frequently
in adults
 More frequently identified in post-primary
tuberculosis
 Tuberculosis with pleural effusion in a 38 y/o female
 CT: Pleural effusion in anterior and lateral pleural spaces
and right major fissure
 Parenchymal tuberculous focus in right middle lobe
(Lee KS et al, 1003)
Re-infection Tuberculosis

 Miliary TB is a disseminated systemic infection from a

pulmonary nidus spread hematogenously
 May also be seen in primary TB
OUTLINE
 Pathophysiology of Tuberculosis
 Radiographic Signs of PTB
 Tuberculoma
 Bronchiectasis
 Cavitation
 Atelectasis
 Primary vs. Re-infection PTB
 Active vs. Healed PTB
 Role of Chest X-Ray in Follow-up
 Role of CT Scan
Active PTB
 Infiltrate or consolidation
 Cavitary lesion
 Nodule with poorly defined margins
 Pleural effusion
 Hilar or mediastinal lymphadenopathy
 Linear, interstitial disease (in children only)
 Miliary findings
Healed PTB
 Discrete fibrotic scar or linear opacity
 Discrete nodule(s) without calcification
 Discrete fibrotic scar with volume loss or
retraction
 Discrete nodule(s) with volume loss or
retraction
 Upper lobe bronchiectasis
OUTLINE
 Pathophysiology of Tuberculosis
 Radiographic Signs of PTB
 Tuberculoma
 Bronchiectasis
 Cavitation
 Atelectasis
 Primary vs. Re-infection PTB
 Active vs. Healed PTB
 Role of Chest X-Ray in Follow-up
 Role of CT Scan
ROLE OF FOLLOW-UP
CHEST X-RAY
 To determine presence of late
complications at completion of therapy
 Relapse
 Aspergilloma
 Bronchiectasis
 Broncholithiasis
 Fibrothorax
 Carcinoma

eMedicine: Tuberculosis by Thomas Herchline, MD

OUTLINE
 Pathophysiology of Tuberculosis
 Radiographic Signs of PTB
 Tuberculoma
 Bronchiectasis
 Cavitation
 Atelectasis
 Primary vs. Re-infection PTB
 Active vs. Healed PTB
 Role of Chest X-Ray in Follow-up
 Role of CT Scan
ROLE OF CT SCAN
 Better define abnormalities in patients with vague
findings on chest radiography
 More sensitive in the detection of:
 Cavitation
 Hilar and mediastinal lymphadenopathies
 Endobronchial spread
 Malignancy
 Complications in the course of the disease

eMedicine: Tuberculosis by Thomas Herchline, MD; Eisenhuber E, et al.

Radiologic Diagnosis of Lung Tuberculosis (abstract), Der Radiologe Vol.37 No.5
May 2007
ROLE OF CT SCAN
 Valuable technique in the assessment of
tuberculosis activity, especially in patients where
M. tuberculosis has not been detected in the
sputum or in patients with multi drug-resistant
tuberculosis

eMedicine: Tuberculosis by Thomas Herchline, MD; Eisenhuber E, et al.

Radiologic Diagnosis of Lung Tuberculosis (abstract), Der Radiologe
Vol.37 No.5 May 2007
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