Flip - Flop TB R1

1. JK Amorosa Flip - Flop TB R1

2. Tuberculosis • Primary –selflimiting • Infection in patients previously not exposed to M tuberculosis (under age 5 in the past, now common in adults also) • Postprimary-progressive • Reactivation and reinfection

3. Chest X-ray is normal in TB in • 50% • 75% • 15%

4. Manifestations of Primary TB are: • Parenchymal disease • Lymphadenopathy • Miliary disease • Pleural Effusion

5. Manifestations of Postprimary TB are: • Upper lobe distribution • Cavity • Absence of adenopathy • Airway involvement

6. Human disease causing mycobacteria are more likely: • Slow growing • Fast growing

7. Mycobacteria – aerobic rods • Categories by disease cause: 1.tuberculosis complex: causes human disease 2.nontuberculous or atypical • Categories by rate of growth: 1.rapid growing: < 7 days 2.slow growing:> 7 days • Rapid: M.abscessus, M.fortiutum, M.chelonae • Slow: MTB, MAC, M.Kansasii

8. Transmission • Respiratory • Desiccated bacilli remain airborne for long time – indoor close many months contact is necessary for transmission • Laryngeal, transbronchial, cavitary disease produce most bacilli • Ventillation reduces infectiousness

9. Lung Parenchymal involvement Primary

10. 57 yo f with chronic cough

11. Value of thin section

12. Tuberculousmediastinaladenopathy

13. 19 f TB mediastinaladenopathy

14. TB mediastinaladenopathy is seen as part of • Reactivation TB • HIV • Primary TB usually in children

15. TB mediastinaladenopathy is seen as part of • Reactivation TB • HIV • Primary TB usually in children

16. TB Lymphadenopathy • Central low attenuation • Active disease • Necrosis • R hilar is most common

17. Pathogenesis • TB bacilli in the body elicit acute inflammatory response – no symptoms • Macrophages ingest bacilli and transport them to regional lymph nodes • If not contained in local LNs, hematogenous dissemination of bacilli occurs and usually is contained, if not, then: miliary, meningeal, GU, MSK

18. Miliary

19. 60 f smoker LangerhansHistiocytosis

20. Miliary • Chickenpox pneumoniaTuberculosis, disseminatedBlastomycosis, disseminatedCoccidioidomycosis, disseminatedCryptococcosisHistoplasmosis, disseminatedMelioidosisBlastomycosisCoccidioidomycosis, pulmonary, chronicCryptococcosis, pulmonaryFilariasisFungal lung infectionHistoplasmosisHistoplasmosis, pulmonaryParasitic lung infectionPulmonary larval infestation/nematodesPulmonary larval migransSchistosomiasis • Granulomatous, Inflammatory Disorders Bronchiocentric granulomatosis/lungGranulomatous lung diseaseSarcoidosisSarcoidosis, pulmonary Neoplastic Disorders LymphomasMetastatic lung lymphatics/carcinomaAlveolar cell carcinoma, lungCarcinoma, thyroid, anaplastic

21. Miliary cont • Allergic, Collagen, Auto-Immune Disorders Pulmonary arteritis/vasculitisRheumatoid lung disease Metabolic, Storage Disorders Histiocytosis, pulmonaryHistiocytosis X Hereditary, Familial, Genetic Disorders Tuberous Sclerosis • Anatomic, Foreign Body, Structural Disorders Atelectasis, pulmonary Reference to Organ System Respiratory distress (newborn) syndromePulmonary fibrosisPulmonary microlithiasis, alveolar Poisoning (Specific Agent) Silicosis Organ Poisoning (Intoxication) Pneumoconiosis

22. Pleural Effusion TB

23. TB pleurisy • Unilateral • Exudative: high protein content, High WBC, low glucose • Lymphocyte predominance • Complications: B-P fistula, empyema • 1/3 negative TB skin test

24. Pleural Effusion exudative • Malignancy • Pneumonia • Tuberculosis • Pulmonary embolism • Fungal infection • Pancreatic pseudocyst • Intra-abdominal abscess • After coronary artery bypass graft surgery • Postcardiac injury syndrome • Pericardial disease • Meigs syndrome • Ovarian hyperstimulation syndrome • Rheumatoid pleuritis • Lupus erythematosus • Drug-induced pleural disease • Asbestos pleural effusion • Yellow nail syndrome • Uremia • Trapped lung • Chylothorax • Pseudochylothorax • Acute respiratory distress syndrome • Chronic pleural thickening • Malignant mesothelioma

25. Pleural Effusion transudate: <3 g protein, low WBC, normal glucose • Congestive heart failure (most common) • Cirrhosis with hepatic hydrothorax • Nephrotic syndrome • Peritoneal dialysis/continuous ambulatory peritoneal dialysis • Hypoproteinemia • Glomerulonephritis • Superior vena cava obstruction • Fontan procedure • Urinothorax • CSF leak to the pleural space

26. 83 f

27. TB bacilli spread to meninges via: • Inhalation to lymphnodes to bloodstrean to meninges • Inhalation to lymphnodes to meninges • Ingestion to peritoneum to CSF • Intravenous introduction to meninges

28. TB bacilli spread to meninges via: • Inhalation to lymphnodes to bloodstream to meninges • Inhalation to lymphnodes to meninges • Ingestion to peritoneum to CSF • Intravenous introduction to meninges

29. Manifestations of Postprimary TB are: • Upper lobe distribution • Cavity • Absence of adenopathy • Airway involvement

30. 53 m

31. 37 m

33. 40 m with cough

37. Cavity vs cyst vs bulla • Cavity: Gas-filled space in an area of lung consolidation or mass or nodule produced by the expulsion of a necrotic part of the lesion via the bronchial tree; wall thickness varies • Cyst: wall thickness is 4 mm or less • Bulla: wall thickness < 4 mm • Often difficult to distinguish the 3 Clin Microbiol Rev. 2008 April; 21(2): 305–333

38. Cavity - causes • Abscess • TB • Ischemic necrosis (infarct) • PCP • Fungal process • Malignancy • Wegener’s granulomatosis • Sarcoidosis – rare • COP (Cryptogenic Organizing Pneumonia -rare

40. 38 51

41. Cavity • T bacilli grow in cavities which communicate with bronchi and spread infection • MDR bacilli grow in cavities exclusively • Hydrolytic enzymes break down lung • TuberculosisVolume 89, Issue 4 , Pages 243-247, July 2009

43. 54 m

44. 48 m

46. Cryptococcus

47. 35 f

49. Aspergillus AML

50. 57 f