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JK Amorosa
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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
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Chest X-ray is normal in TB in
50% 75% 15%
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Manifestations of Primary TB are:
Parenchymal disease Lymphadenopathy Miliary disease Pleural Effusion
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Manifestations of Postprimary TB are:
Upper lobe distribution Cavity Absence of adenopathy Airway involvement
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Human disease causing mycobacteria are more likely:
Slow growing Fast growing
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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
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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
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Lung Parenchymal involvement Primary
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57 yo f with chronic cough
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Value of thin section
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Tuberculous mediastinal adenopathy
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TB mediastinal adenopathy 19 f
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TB mediastinal adenopathy is seen as part of Reactivation TB HIV Primary TB usually in children
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TB mediastinal adenopathy is seen as part of Reactivation TB HIV Primary TB usually in children
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TB Lymphadenopathy
Central low attenuation Active disease Necrosis R hilar is most common
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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
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Miliary
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60 f smoker Langerhans Histiocytosis
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Miliary Chickenpox pneumonia
Tuberculosis, disseminated Blastomycosis, disseminated Coccidioidomycosis, disseminated Cryptococcosis Histoplasmosis, disseminated Melioidosis Blastomycosis Coccidioidomycosis, pulmonary, chronic Cryptococcosis, pulmonary Filariasis Fungal lung infection Histoplasmosis Histoplasmosis, pulmonary Parasitic lung infection Pulmonary larval infestation/nematodes Pulmonary larval migrans Schistosomiasis
Granulomatous, Inflammatory Disorders Bronchiocentric granulomatosis/lung Granulomatous lung disease Sarcoidosis Sarcoidosis, pulmonary Neoplastic Disorders Lymphomas Metastatic lung lymphatics/carcinoma Alveolar cell carcinoma, lung Carcinoma, thyroid, anaplastic
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Miliary cont
Allergic, Collagen, Auto-Immune Disorders Pulmonary arteritis/vasculitis Rheumatoid lung disease Metabolic, Storage Disorders Histiocytosis, pulmonary Histiocytosis X Hereditary, Familial, Genetic Disorders Tuberous Sclerosis
Anatomic, Foreign Body, Structural Disorders Atelectasis, pulmonary Reference to Organ System Respiratory distress (newborn) syndrome Pulmonary fibrosis Pulmonary microlithiasis, alveolar Poisoning (Specific Agent) Silicosis Organ Poisoning (Intoxication) Pneumoconiosis
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Pleural Effusion TB
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TB pleurisy
Unilateral Exudative: high protein content, High
WBC, low glucose Lymphocyte predominance Complications: B-P fistula, empyema 1/3 negative TB skin test
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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
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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
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83 f
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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
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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
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Manifestations of Postprimary TB are:
Upper lobe distribution Cavity Absence of adenopathy Airway involvement
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53 m
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37 m
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40 m with cough
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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
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Cavity - causes Abscess TB Ischemic necrosis (infarct) PCP Fungal process Malignancy Wegener’s granulomatosis Sarcoidosis – rare COP (Cryptogenic Organizing
Pneumonia -rare
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38 51
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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
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54 m
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48 m
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Cryptococcus
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35 f
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Aspergillus AML
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57 f
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Primary lung ca with mets
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67 f
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43 m
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34 m
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43 m
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Bronchopneumonia
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Invasive bronchiolar aspergillosis in a patient who underwent bone marrow transplantationRadioGraphics, http://pubs.rsna.org/doi/abs/10.1148/rg.253045115Aspergillus
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Five causes of tree-in-bud are: Bronchopneumonia Fungal Viral ABPA TB
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Tree –in-bud pattern
Rossi, SE et al: May/June 2005 Radiographics 25,3
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Cocaine 23 m
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25 m
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TB in HIV
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TB & HIV
Clinical features depend on the severity immunosuppression
Relatively intact cellular immunity = non–HIV-infected individuals- TB remains localized to the lung.
HIV (CD4 T-lymphocyte count: <200/mm3), pulmonary TB with extra-pulmonary involvement: lymphadenitis, miliary
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46 m
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76 m emphysematous pericarditis, streptococcal
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TB - healing
Lung destruction: bronchiectasis Bronchial stenosis
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LUL atelectasis, bronchiectasis TB
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77 m
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Radical mastectomy & rad Rx
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80 f
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The History of Tuberculosis
• The Hebrew word for phthisis or consumption (schachepheth) means to waste away occurs twice in the Bible:
• Leviticus 26:16• I, in turn, will do this to you: I will appoint over you
a sudden terror, consumption and fever that will waste away the eyes and cause the soul to pine away; also you will sow your seed uselessly, for your enemies will eat it up.
• Deuteronomy 28:22• The Lord will smite you with consumption and with
fever and with inflammation and with fiery heat and with the sword and with blight and with mildew and they will pursue you until you perish.
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The History of Tuberculosis
By 1650 consumption was the leading cause of mortality and became a reference in some of Shakespeare's plays- one of the consumptive lovers, in "Much A Do About Nothing" , as well as scrofula in "Macbeth"
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The History of Tuberculosis
• Early attempts at treatment can be found throughout history Greeks believed cutting off cool air eventuated in a
burning up of the tissues Romans put importance of diet Hebrews control disease from diet to the destruction of
clothing• Early "cures" from physicians
Warm sea air Milk from pregnant women Seaweed placed under the pillow Cold baths Deep breathing
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The History of Tuberculosis
The first breakthrough came when German bacteriologist named Robert Koch isolated the infectious agent known as tuberculosis bacteria or tubercle bacilli in 1882. He was later awarded the Nobel Prize for physiology or medicine in 1905
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The History of Tuberculosis The first sanatorium opened in 1854 in Gorbersdorf,
Germany. Sick patients were given wholesome food and plenty of fresh air. This became the modern way to fight the disease. The sanatoriums provided medical care for almost 100 years and became one of the most remarkable and unique periods of medical care in history.
By 1889 in the USA the National Tuberculosis Association fully realized that TB was distinctly preventable and not directly inherited
No real progress was made until new antibiotics were used between 1945-1960
It has taken almost three thousand years to understand the full nature of Tuberculosis
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58 m
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References Joshua Burrill, Christopher J. Williams, Gillian Bain,
Gabriel Conder, Andrew L. Hine, Rakesh R. Misra RadioGraphics, 2007, Vol.27: 1255-1273, 10.1148/rg.275065176
Santiago Enrique Rossi, Tomas Franquet, Mariano Volpacchio, Ana Giménez, Gabriel Aguilar RadioGraphics, 2005, Vol.25: 789-801
JR Cohen, JK Amorosa, PR Smith –The air-fluid level in cavitary pulmonary TB, Radiology, 1978 - radiology
JK Amorosa, PR Smith, JR Cohen, C Ramsey… - …, Tuberculous mediastinal lymphadenitis in the adult
1978 – radiology Medscape Tuberculosis (TB), a multisystemic
disease ….JK Amorosa….
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Famous people who had TB Gaius Valerius Cat
ullus (ca. 84 BC – ca. 54 BC), Roman poet
Bronte sisters Elizabeth Barrett
Browning Albert Camus Anton Chekhov Maxim Gorky Franz Kafka Eugene O'Neill
Eugene O'Neill Molière Robert Louis
Stevenson Dylan Thomas Voltaire Paul Gauguin Amedeo Modigliani Frédéric Chopin Niccolò Paganini Igor Stravinsky Cardinal Richelieu Simón Bolívar
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Opera, Theatre, Novels - TB Puccini: La
boheme Verdi: La Traviata Thomas Mann: The
Magic Mountain Victor Hugo: Les
Miserables Upton Sinclair:
The Jungle
Johnny Nolan: A Tree Grows in Brooklyn
W.Somerset Maugham: Sanatorium
Frank McCourt: Angela’s Ashes
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am 9-13-11
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a.m. 3-19-12
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