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بسم الله الرحمن الرحيم

بسم الله الرحمن الرحيم. Radiological Imaging of Pulmonary T.B. By. Dr. Dorria Salem Prof. of Radiology Cairo University. Why is T.B. still considered a major issue?. T.B remains the major cause of death from a single infectious agent among adults in developing nations.

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بسم الله الرحمن الرحيم

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  1. بسم الله الرحمن الرحيم

  2. Radiological Imaging of Pulmonary T.B. By Dr. Dorria Salem Prof. of Radiology Cairo University

  3. Why is T.B. still considered a major issue? T.B remains the major cause of death from a single infectious agent among adults in developing nations. In 1993, the WHO declared T.B to be a global emergency. It is estimated that between 1997-2020, nearly 1 billion people will become newly infected and 70 x 106 will die from the disease(WHO, 1998)

  4. Pulmonary T.B Primary Post primary (reactivation) There is considerable overlap in radiologic manifestations of these 2 entities. Results of radiography may be normal in 15% of cases

  5. Pulmonary T.B Radiology of Primary T.B. Lymphadenopathy Parenchymal disease Pleural effusion Miliary T.B

  6. Pulmonary T.B Radiology of Primary T.B. 1) Lymphadenopathy: Is the radiological hallmark of the disease 83-96% of pediatric cases

  7. Pulmonary T.B Radiology of Primary T.B. 1) Lymphadenopathy: Is the radiological hallmark of the disease hilar lymphadenopathy

  8. Pulmonary T.B Radiology of Primary T.B. 1) Lymphadenopathy: Is the radiological hallmark of the disease 83-96% of pediatric cases Prevalence with age Rt. paratracheal + hilar stations are most common sites

  9. Pulmonary T.B Radiology of Primary T.B. 1) Lymphadenopathy: Is the radiological hallmark of the disease hilar lymphadenopathy

  10. Pulmonary T.B Radiology of Primary T.B. 1) Lymphadenopathy: Is the radiological hallmark of the disease 83-96% of pediatric cases Prevalence with age Rt. paratracheal + hilar stations are most common sites CT has a characteristic appearance

  11. Pulmonary T.B Radiology of Primary T.B. 1) Lymphadenopathy: Is the radiological hallmark of the disease Precontrast Postcontrast

  12. Pulmonary T.B Radiology of Primary T.B. 1) Lymphadenopathy: Is the radiological hallmark of the disease 83-96% of pediatric cases Prevalence with age Rt. paratracheal + hilar stations are most common sites CT has a characteristic appearance 1- Metastases 2- Lymphoma 3- other infections e.g. 4- Sarcoidosis D.D.: - Varicella pneumonia - histopalmsmosis

  13. Pulmonary T.B Radiology of Primary T.B. 2) Parenchymal disease: Affects areas of greatest ventilation upper lobe 38-81% of adult cases Rt. Sided predominance Homogenous consolidation in segmental or lobar pattern

  14. Pulmonary T.B Radiology of Primary T.B. 2) Parenchymal disease: consolidation Para.T LN hilar LN consolidation Displaced OF

  15. Pulmonary T.B Radiology of Primary T.B. 2) Parenchymal disease: Affects areas of greatest ventilation, middle & lower lobes & anterior segment of upper lobe 38-81% of adult cases Rt. Sided predominance Homogenous consolidation in segmental or lobar pattern Tuberculoma • Round or oval sharply marginated • 0.5- 4 cm • + calcifications • Surrounding satellites

  16. Pulmonary T.B Radiology of Primary T.B. 2) Parenchymal disease: nodule • DD: Nodule • Tuberculoma • Hamartoma • Metastases • Hydatid nodule nodule

  17. Pulmonary T.B Radiology of Primary T.B. 2) Parenchymal disease: Affects areas of greatest ventilation, middle & lower lobes & anterior segment of upper lobe 38-81% of adult cases Rt. Sided predominance Homogenous consolidation in segmental or lobar pattern Tuberculoma Obstructive atelectasis2ry compression of adjacent enlarged LN

  18. Pulmonary T.B Radiology of Primary T.B. 2) Parenchymal disease: cavity collapse LNs Displaced OF LNs collapse

  19. Pulmonary T.B Radiology of Primary T.B. 3) Pleural effusion: Unilateral pleural effusion hilar LNs Enhancing parietal pleura pleural effusion

  20. Pulmonary T.B Radiology of Primary T.B. 4) Miliary T.B.: Innumerable 1-3 mm, non-calcified nodules scattered through both lung fields with basal predominance High resolution CT.

  21. Pulmonary T.B Post Primary T.B. Exclusively a disease of adolescens + adults 90% Results from Reactivation of a previously dormant 1ry infection 10% Continuation of 1ry disease Radiological features: 1- Parenchymal disease with cavitation 2- Air way involvement 3- Pleural extension 4- Complications Endo bronchial spread Aspergilosis

  22. Pulmonary T.B Radiology of Post Primary T.B. 1) Parenchymal disease : Consolidation: Patchy, ill-defined, segmental Predilection * to upper lobes * Apical segment of lower lobe a- O2 tension b- Impaired lymphatic drainage Tw0 or more segments are involved in most of cases Bilateral upper lobe disease may be present Cavitations: • Multiple with thick irregular walls • May show air fluid level

  23. Pulmonary T.B Radiology of Post Primary T.B. 1) Parenchymal disease with cavitations: thick-walled cavity Cavitary postprimary TB

  24. Pulmonary T.B Radiology of Post Primary T.B. 1) Parenchymal disease with cavitation: cavity nodule cavity air-fluid level

  25. Pulmonary T.B Radiology of Post Primary T.B. 1) Parenchymal disease with cavitation: Thick walled cavity air-fluid level

  26. Pulmonary T.B Radiology of Post Primary T.B. 2) Air way involvement: Bronchial stenosis Collapse Hyperinflation Consolidation 1- direct extension from TB LN 2- Endobronchial spread of infection 3- lymphatic dissemination to the airway due to

  27. Pulmonary T.B Radiology of Post Primary T.B. 2) Air way involvement: narrowing Tuberculous bronchostenosis.

  28. Pulmonary T.B Radiology of Post Primary T.B. 2) Air way involvement: partial atelectasis calcified LN calcified LN calcified LN Eroding into bronchus calcified LN Tuberculous broncholithiasis

  29. Pulmonary T.B Radiology of Post Primary T.B. 2) Air way involvement: D.D. Carcinoma 1- Longer segment of involvement 2- Circumferential luminal narrowing 3- No intraluminal mass

  30. Pulmonary T.B Radiology of Post Primary T.B. 3) Pleural extension: Pleural effusion Small associated with parenchymal disease Empyema  loculated Subpleural cavitation Air fluid level in pleura = bronchopleural fistula

  31. Pulmonary T.B Radiology of Post Primary T.B. 3) Pleural extension: Pleural effusion bronchus air Enhancingpleura Subpleural cavitating nodule TB empyema with bronchopleural fistula

  32. Pulmonary T.B Radiology of Post Primary T.B. 4) Complications: If left untreated disease progress to Lobar or complete lung opacification + destruction bronchiectatic changes bronchiectatic changes Lung destruction in postprimary TB

  33. Pulmonary T.B Radiology of Post Primary T.B. 4) Complications: If left untreated disease progress to Lobar or complete lung opacification + destruction Coarse reticular + nodular opacified areas fibroproliferative dse

  34. Pulmonary T.B Radiology of Post Primary T.B. 4) Complications: volume loss + apical pleural thickening reticulonodular infiltrates Cavitating nodule Fibroproliferative disease.

  35. Pulmonary T.B Radiology of Post Primary T.B. 4) Complications: If left untreated disease progress to Lobar or complete lung opacification + destruction Coarse reticular + nodular opacified areas fibroproliferative dse Healing of lesions  traction bronchiactasis

  36. Pulmonary T.B Radiology of Post Primary T.B. 4) Complications: bronchiectasis bronchiectasis fungal ball Complications of TB Bronchiectasis in postprimary TB.

  37. Pulmonary T.B Radiology of Post Primary T.B. 4) Complications: If left untreated disease progress to Lobar or complete lung opacification + destruction Coarse reticular + nodular opacified areas fibroproliferative dse Healing of lesions  traction bronchiactasis Endobronchial spread commonest complication of T.B cavitation

  38. Pulmonary T.B Radiology of Post Primary T.B. 4) Complications: LN endobronchial spread cavities cavity Cavitary postprimary tuberculosis

  39. Pulmonary T.B Radiology of Post Primary T.B. 4) Complications: If left untreated disease progress to Lobar or complete lung opacification + destruction Coarse reticular + nodular opacified areas fibroproliferative dse Healing of lesions  traction bronchiactasis Endobronchial spread commonest complication of T.B cavitation Small, poorly defined centrilobular nodules + branching centrilobular areas of increased opacity “tree-in-bud” appearance

  40. Pulmonary T.B Radiology of Post Primary T.B. 4) Complications: bronchiolar wall thickening tree-in-bud Endobronchial spread of tuberculosis

  41. Pulmonary T.B Radiology of Post Primary T.B. 4) Complications: If left untreated disease progress to Lobar or complete lung opacification + destruction Coarse reticular + nodular opacified areas fibroproliferative dse Healing of lesions  traction bronchiactasis Endobronchial spread commonest complication of T.B cavitation Mycetoma Aspergillus superimposed infection

  42. Pulmonary T.B Radiology of Post Primary T.B. 4) Complications: nodule in the cavity Complications of TB

  43. Pulmonary T.B Radiology of Post Primary T.B. 4) Complications: Cavitary TB associated with aspergilloma Post primary TB air crescent sign air crescent sign aspergilloma aspergilloma

  44. Pulmonary T.B Radiology of Post Primary T.B. 4) Complications: If left untreated disease progress to Lobar or complete lung opacification + destruction Coarse reticular + nodular opacified areas fibroproliferative dse Healing of lesions  traction bronchiactasis Endobronchial spread commonest complication of T.B cavitation Mycetoma Broncholithiasis Calcified T.B LN in the mediastinum may occasionally erode into adjacent airway.

  45. Pulmonary T.B Radiology of Post Primary T.B. 4) Complications: Tuberculous broncholithiasis calcified LN calcified LN Eroding into a bronchus

  46. Can X-ray D.D. active / inactive T.B? NO 1-D.D can be reliably made on basis of temporal evolution i.e. lack of radiographic change over 4-6 months. Thus radiology can say that the dse. is stable rather than inactive . 2-Fibrosis +calcification are found in both healed + active disease

  47. Can X-ray D.D. active + inactive T.B? NO  Sputum culture–positive TB Fibrosis +calcification are found in bothhealed + active dse Fibrosis retroclavicular calcifications calcified nodules Fibrosis Close-up radiographic view CT scan with 1-mm collimation

  48. Can X-ray play role in assessing treatment response? Yes confluent consolidation nodules  Postprimary TB Pre-Treatment 3 months Post- treatment Regression of radiographic abnormalities in pulmonary TB is a slow process

  49. Can X-ray play role in assessing treatment response? Yes 1st 3 months of treatment Worsening of X-Ray findings : - Progress of parenchymal involvement -development or enlargement of LN cause Unknown , may be due to: development of hypersensitivity reaction 2-10 weeks after initial infection

  50. Can X-ray play role in assessing treatment response? Yes 1st 3 months of treatment worsening of the radiographic findings i.e. extension of parenchymal involvement +development or enlargement of LN 6m-2 years of treatment resolution of parenchymal abnormalities on X-ray this is seen earlier on CT (15 months) Failure of improvement of radiographic findings after 3 months of treatment drug resistant organism superimposed infection

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