بسم الله الرحمن الرحيم

Introduction

Up until the mid 1980s, there was a steady decline in the prevalence of T.B.Since then, there has been a resurgence of T.B. due to AIDS epidemics

Increasing no. of resistant strains of mycobacterium T.B.

Groups of increased risk e.g. poor, alcoholics, homeless

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)

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

Primary T.B.

Lymphadenopathy

Radiology of Primary T.B.

Parenchymal disease

Pleural effusion

Miliary T.B

Is the radiological hallmark of the disease

Radiology of Primary T.B.1) Lymphadenopathy:

83-96% of pediatric cases

Is the radiological hallmark of the disease

Radiology of Primary T.B.1) Lymphadenopathy:

hilar lymphadenopathy

Is the radiological hallmark of the disease

Radiology of Primary T.B.1) Lymphadenopathy:

83-96% of pediatric cases

Prevalence with age

Rt. paratracheal + hilar stations are most common sites

Is the radiological hallmark of the disease

Radiology of Primary T.B.1) Lymphadenopathy:

hilar lymphadenopathy

Is the radiological hallmark of the disease

Radiology of Primary T.B.1) Lymphadenopathy:

83-96% of pediatric cases

Prevalence with age

Rt. paratracheal + hilar stations are most common sitesCT has a characteristic appearance

Is the radiological hallmark of the disease

Radiology of Primary T.B.1) Lymphadenopathy:

PrecontrastPostcontrast

Is the radiological hallmark of the disease

Radiology of Primary T.B.1) Lymphadenopathy:

83-96% of pediatric cases

Prevalence with age

Rt. paratracheal + hilar stations are most common sitesCT has a characteristic appearance

D.D.: 1- Metastases2- Lymphoma3- other infections e.g. 4- Sarcoidosis

- Varicella pneumonia

- histopalmsmosis

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

Radiology of Primary T.B.2) Parenchymal disease:

Para.T LN

Displaced OF

consolidation

hilar LN

consolidation

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 patternTuberculoma

- Round or oval sharply marginated- 0.5- 4 cm- + calcifications- Surrounding satellites

Radiology of Primary T.B.2) Parenchymal disease:

nodule

nodule

nodule

DD: Nodule

1. Tuberculoma2. Hamartoma3. Metastases4. Hydatid

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 patternTuberculomaObstructive atelectasis 2ry compression of adjacent enlarged LN

Radiology of Primary T.B.2) Parenchymal disease:

cavityLNs

collapse

Displaced OF LNs

collapse

Radiology of Primary T.B.3) Pleural effusion:

Unilateral

hilar LNs

pleural effusion

pleural effusion

Enhancing parietal pleura

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.

Exclusively a disease of adolescens + adults

Post Primary T.B.

Results from

Radiological features:

10%

Reactivation of a previously dormant 1ry infection

Continuation of 1ry disease

90%

1- Parenchymal disease with cavitation2- Air way involvement3- Pleural extension 4- Complications Endo bronchial spread

Aspergilosis

Radiology of Post Primary T.B.1) Parenchymal disease :

Predilection

Consolidation: Patchy, ill-defined, segmental

* to upper lobes

a- O2 tensionb- Impaired lymphatic drainage

* Apical segment of lower lobe

Tw0 or more segments are involved in most of casesBilateral upper lobe disease may be present

Cavitations: • Multiple with thick irregular walls• May show air fluid level

Radiology of Post Primary T.B.1) Parenchymal disease with cavitations:

Cavitary postprimary TB

thick-walled cavity

Radiology of Post Primary T.B.1) Parenchymal disease with cavitation:

cavitynodule

cavity

air-fluid level

Radiology of Post Primary T.B.1) Parenchymal disease with cavitations:

Predilection

Consolidation: Patchy, ill-defined, segmental

* to upper lobes

a- O2 tensionb- Impaired lymphatic drainage

* Apical segment of lower lobe

Tw0 or more segments are involved in most of casesBilateral upper lobe disease may be present

Cavitations:•Multiple with thick irregular walls•May show air fluid level

Radiology of Post Primary T.B.1) Parenchymal disease with cavitation:

air-fluid level

Thick walled cavity

Radiology of Post Primary T.B.2) Air way involvement:

Bronchial stenosis

CollapseConsolidation

Hyperinflation

due to 1- direct extension from TB LN2- Endobronchial spread of infection3- lymphatic dissemination to the airway

Radiology of Post Primary T.B.2) Air way involvement:

Tuberculous bronchostenosis.

narrowing

Radiology of Post Primary T.B.2) Air way involvement:

Tuberculous broncholithiasis

partial atelectasis

calcified LN

calcified LN

Eroding into bronchuscalcified LN

calcified LN

Radiology of Post Primary T.B.2) Air way involvement:

D.D.

1- Longer segment of involvement2- Circumferential luminal narrowing3- No intraluminal mass

Carcinoma

} TB

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

Radiology of Post Primary T.B.3) Pleural extension: Pleural effusion

TB empyema with bronchopleural fistula

Subpleural cavitating nodule

bronchusair

Enhancing pleura

Radiology of Post Primary T.B.4) Complications:If left untreated disease progress to

Lobar or complete lung opacification + destruction

Lung destruction in postprimary TB

bronchiectatic changes

bronchiectatic changes

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

Radiology of Post Primary T.B.4) Complications:

Fibroproliferative disease.

Cavitating nodule

volume loss + apical pleural

thickening

reticulonodular infiltrates

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 dseHealing of lesions traction bronchiactasis

Radiology of Post Primary T.B.4) Complications:

fungal ball

Complications of childhood TB

bronchiectasis

Bronchiectasis in postprimary TB.

bronchiectasis

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 dseHealing of lesions traction bronchiactasis

Endobronchial spread commonest complication of T.B cavitation

Radiology of Post Primary T.B.4) Complications:

Cavitary postprimary tuberculosis

LN

endobronchial spread

cavity

cavities

tree-in-bud”

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 dseHealing of lesions traction bronchiactasis

Endobronchial spread commonest complication of T.B cavitationSmall, poorly defined centrilobular nodules +

branching centrilobular areas of increased opacity “tree-in-bud” appearance

Radiology of Post Primary T.B.4) Complications:

Endobronchial spread of tuberculosis

bronchiolar wall thickening

tree-in-bud

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 dseHealing of lesions traction bronchiactasis

Endobronchial spread commonest complication of T.B cavitationMycetomaAspergillus superimposed infection

Radiology of Post Primary T.B.4) Complications:

Complications of childhood TB

nodule in the cavity

Radiology of Post Primary T.B.4) Complications:  Cavitary TB associated with aspergilloma

Post primary TB

air crescent sign

aspergilloma

aspergilloma

air crescent sign

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 dseHealing of lesions traction bronchiactasis

Endobronchial spread commonest complication of T.B cavitationMycetomaBroncholithiasisCalcified T.B LN in the mediastinum may occasionally erode into adjacent airway.

Radiology of Post Primary T.B.4) Complications:

calcified LN

calcified LN

Eroding into a bronchus

Tuberculous broncholithiasis

Can X-ray D.D. active / inactive T.B?

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

Can X-ray D.D. active + inactive T.B? Sputum culture–positive TB

Close-up radiographic view CT scan with 1-mm collimation

retroclavicular calcifications

calcified nodules

Fibrosis +calcification are found in both healed + active dse

Fibrosis

Fibrosis

Can X-ray play role in assessing treatment response?

 Postprimary TB Pre-Treatment 3 months Post- treatment

confluent consolidation

nodules

Regression of radiographic abnormalities in pulmonary TB is a slow process

Can X-ray play role in assessing treatment response?

1st 3 months of treatmentWorsening 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

Can X-ray play role in assessing treatment response?

1st 3 months of treatmentworsening of the radiographic findings i.e. extension of parenchymal involvement +development or enlargement of LN

6m-2 years of treatmentresolution of parenchymal abnormalities on X-ray this is seen earlier on CT (15 months)

Failure of improvement of radiographic findings after 3 months of treatmentdrug resistant

organismsuperimposed infection

2ry to

Characterized by

1.Pleural disease +empyema2.Haematogenous spread of

disease

1.Destruction of bone or costal cartilage2.Soft tissue masses may show

calcifications + rim enhancement3.Fistulation

TB of the sternoclavicular J

Clavical with irregular margin

soft-tissue mass

Rarely involves the heartTuberculoma of the Rt atrium in a patient with miliary T.B.

mass

pleural effusion

MRI-Axial T2WI

Rarely involves the heart

Pericardial involvement may be seen with mediastinal + pulmonary TB

Tuberculous pericarditis in a patient with pleuropulmonary T.B.

pericardial thickening

tuberculomapleural effusion

Axial CT scan

Spine is the comment site of osseous involvement in T.B

T.B. spondylitis (Pott’s disease):

Upper lumbar + lower dorsal are most frequently involvedVertebral body is more commonly affected than post. elementsDisease process begins in ant. part of the vertebral bodyinfection spread to disc space by

extension beneath the ant./

post. L. L.

or

penetration of subchondral bone

plateCollapse of

disc

Spine is the comment site of osseous involvement in T.B

T.B. spondylitis (Pott’s disease):

Upper lumbar + lower dorsal are most frequently involvedVertebral body is more commonly affected than post. elementsDisease process begins in ant. part of the vertebral bodyDisease progression vertebral collapse

T.B. spondylitis (Pott’s disease):

Tuberculous spondylitis. Lateral radiograph

Obl

itera

ted

disk

spa

ce

Destructed end plates

Spine is the comment site of osseous involvement in T.B

T.B. spondylitis (Pott’s disease):

Upper lumbar + lower dorsal are most frequently involvedVertebral body is more commonly affected than post. elementsDisease process begins in ant. part of the vertebral bodyDisease progression vertebral collapse

with ant. wedging gibbus deformity Extension may be subligamentous to distant vertebra

T.B. spondylitis (Pott’s disease):

Subligamentous spread of spinal T.B. Lateral radiograph

erosion

Spine is the comment site of osseous involvement in T.B

T.B. spondylitis (Pott’s disease):

Upper lumbar + lower dorsal are most frequently involvedVertebral body is more commonly affected than post. elementsDisease process begins in ant. part of the vertebral bodyDisease progression vertebral collapse

Paravertebral abscess In the thoracic region =Post.mediastinal mass

T.B. spondylitis (Pott’s disease):

Tuberculous spondylitis. Axial CT scan

lytic destruction

soft-t

issue absc

ess

Spine is the comment site of osseous involvement in T.B

T.B. spondylitis (Pott’s disease):

Upper lumbar + lower dorsal are most frequently involvedVertebral body is more commonly affected than post. elementsDisease process begins in ant. part of the vertebral bodyDisease progression vertebral collapse

Paravertebral abscess In the thoracic region =Post.mediastinal muscles

In the lumbar region =Psoas abscess

T.B. spondylitis (Pott’s disease):

Iliopsoas abscess. Axial CT scan

absc

esse

sabscesses

presacral abscess

erosion

Spine is the comment site of osseous involvement in T.B

T.B. spondylitis (Pott’s disease):

Upper lumbar + lower dorsal are most frequently involvedVertebral body is more commonly affected than post. elementsDisease process begins in ant. part of the vertebral bodyDisease progression vertebral collapse

Paravertebral abscess In the thoracic region =Post.mediastinal muscles

In the lumbar region =Psoas abscess

may calcify when healed

T.B. spondylitis (Pott’s disease):

Calcified psoas abscess. Axial CT scan

abscesses +

calcificationabscesses +

calcification

Spine is the comment site of osseous involvement in T.B

T.B. spondylitis (Pott’s disease):

Upper lumbar + lower dorsal are most frequently involvedVertebral body is more commonly affected than post. elementsDisease process begins in ant. part of the vertebral bodyDisease progression vertebral collapse

Paravertebral abscess

MR helps in diagnosis =focal area of low T1 + high T2 SI with increased SI of

disc

T.B. spondylitis (Pott’s disease):

Tuberculous spondylitis. Sagittal T2WI

disk

nar

row

ing intraspinal

extension

D.D.

1- Pyogenic vertebral osteomyelitis2- Metastases3- Sarcoid4- Tumor = lymphoma, multiple myeloma, chordoma5- Other infections = brucellosis, fungus, hydatid