PULMONARY TUBERCULOSIS - RADIOLOGICAL IMAGES - Dr. Miron Ramona Conf Dr Antigona Trofor

PULMONARY TUBERCULOSIS

- RADIOLOGICAL IMAGES -

Dr. Miron Ramona

Conf Dr Antigona Trofor

TUBERCULOSIS RADIOLOGY

• Pulmonary tuberculosis, especially postprimary disease, nearly always causes abnormalities on chest radiographs.

• Typically, the disease is parenchymal without nodal enlargement, and it manifests as cavitary lesions.

• Upper-lobe involvement with cavitation and the absence of lymphadenopathy are helpful in distinguishing postprimary TB from primary TB.

• In addition to the usually involved pulmonary segments—namely, the apical or posterior segments of the upper lobe or the superior segment of a lower lobe—anterior or basal segments may be involved in as many as 75% of cases.

http://emedicine.medscape.com/article/358735-imaging

PRIMARY TUBERCULOSIS RADIOLOGY

• Radiographic screening for active TB in high-risk populations may demonstrate findings consistent with prior and/or current infection.

• A Ghon focus refers to the initial site of parenchymal involvement at the time of first infection;

• A Ranke complex is the combination of a Ghon focus and enlarged or calcified lymph nodes;

• Lymphadenopathy is the radiologic hallmark of primary TB

• Simon focus are apical nodules that are often calcified and result from hematogenous seeding at the time of initial infection

PRIMARY PULMONARY TB

• Initial pulmonary lesions

GOHN-RANKE complex

• Focus Gohn• Lymphangitis Ranke

Complex• Lymphadenopathy

• Image in “halter”

Afect

Limfangita

Adenita

Complexul Ranke

Complexul primar Ranke:1. GOHN focus

(alveolitis)=basal subpleural nodular opacities (most often on right), flou contour

2. Lymphangitis: radiological expression, in some case appear fibrosis; fine linear opacities that connect the Gohn focus with hilum

3. Homolateral adenopathy: hilary, interbronchial or paratracheal rounded shape, massive polyciclic aspect,

1

2

3

Complex forms• Excavation of caseous

alveolitis focus– primary cavern (cavity) transparent thin wall or anfractuous circumscribed, usually localized on the basal or middle lung fields, is accompanied by hilary adenopathy.

• Voluminous adenophaties: cause ventilation modifications by extrabronchial compression, obstructive emphysema or

systematized atelectasis

Vouluminous right hilar Vouluminous right hilar adenopathyadenopathy

Segmental atelectasis in Segmental atelectasis in upper right lobeupper right lobe

Complicated formsLarge cavitary tuberculosis with forms:

A.A. Pneumonia: triangular Pneumonia: triangular opacityopacity

- Can do to excavation- Can do to excavation

Is accompanied by adenopathy

Pneumonie TB lob superior

drept

B. Bronchopneumonia: Macronodulare alveolar opacities, various sizes, unequal distribution, with a tendency to confluence

Associated adenopathies!

Right paratracheal adenopathyMiliary nodules

C. Miliary tuberculosis- Complication of Primary TB - Radiological: miliary

opacities with diameter < 3 mm, equal in size, homogeneous distribution

Secondary tuberculosis

• Occurs due to reactivation of primary tuberculosisOccurs due to reactivation of primary tuberculosis• Reactivation of fibrotic lesions from apical territory• Reinfection by exogenous contaminationReinfection by exogenous contamination

Can occur after primary infection, Can occur after primary infection,

Radiology- polymorphic semiology! Radiology- polymorphic semiology!

Alveolar opacities systematized/nonsystematized;

Nodular images, cavitary lesions, fibrous lesions, associated lesions

The affected territories predilection: The affected territories predilection: dorsal and apical segments of upper dorsal and apical segments of upper lobes and apical segments of lower lobes and apical segments of lower lobes!lobes!

1. INFILTRATIVE TUBERCULOSIS

2. PLEURAL TB

3. CAVITARY CHRONIC TUBERCULOSIS

4. MYLIAR TUBERCULOSIS

5. FIBROTIC TUBERCULOSIS

6. TUBERCULOMA

1. INFILTRATIVE TUBERCULOSIS

- Lesions of exudative alveolitis- Early infiltrates localize subclavicular - RADIOLOGY:

NODULAR INFILTRATE NODULAR INFILTRATE

ROUND INFILTRATE(ASSMAN)ROUND INFILTRATE(ASSMAN)

NEBULOUS INFILTRATE NEBULOUS INFILTRATE

SEGMENTAL INFILTRATE SEGMENTAL INFILTRATE

Beginning of secondary TB can be: pneumonia, lobar or Beginning of secondary TB can be: pneumonia, lobar or segmental opacities , bronchopneumonisegmental opacities , bronchopneumoni

Nodular infiltrate LUL

infiltrative TB RUL

Bilateral INFILTRATIVE LESIONS

Disseminated nodular opacities in both lung fields, most commonly in middle and basal lung fields, moderate intensity, different size, shape removed, the tendency to confluence

TBBronchopneumonia

Triangular opacity localized RUL

TB Pneumonia

Segmental infiltrate occupying almost the entire RUL and central tendency to excavation

Massive left pneumonia – etiology TB

Opacity nonhomogeneous RUL

Pneumonia LUL

TB PLEURAL EFFUSION

In a patient with pleural exudate, TB is the first etiology to be taken into consideration!

Radiological aspect of cavities(caverns) depends on the stage in which there are:

Cavity grade 1

Cavity grade 2

Cavity grade 3

Cavity grade 1:Lucency (darkened area) within the lung parenchyma, with or without irregular margins

Cavern with net wall

localized RUL subclavicular

CAVITY GRADE 2 :wall has its own thin, elastic, net contour

Between cavern and hilum- drainage bronchia

Cavity grade 2

Cavity grade 2

Cavity grade 3: old cavity, net shaped, wall fibrosis, cavitary sclerosis may be due to irregular shape, around the cavity disabling injuries.

Calcification can exist around a cavity.

Old cavity, net contour, fibrosis of wall, sclerosis around cavity

Cavity grade 3

Radiological aspects of cavitary TB

Multiple cavities in different stages of evolution

Radiological aspects of cavitary TB

Radiological aspects of cavitary TB

Radiological aspects of cavitary TB

small, multiple aspects in different stages of evolution

Complications of Complications of cavitary cavitary

• SEROFIBRINOUS PLEURESY• PACHIPLEURITIS(PLEURAL ADHESIONS)

(AFTER RESORBTION OF EXUDATE)• PLEURAL EMPYEMA

(INFECTION OF EXUDATE)• PARTIAL/TOTAL SPONTANEOUS

PNEUMOTHORAX • BRONCHOGENIC DISEMINATIONS

Complications Complications of cavitary TBof cavitary TB

TB infiltrative lesions of RULMixed image horizontal line of the air-fluid level right hemithorax

PLEURAL EMPYEMA

•TB left empyema•Infiltrative lesions of right lung

Complications Complications of cavitary TBof cavitary TB

Complications of cavitary TBComplications of cavitary TB

Pulmonary hiperlucency design collapsed lung to hilum (right lung field), large infiltrative lesions (left lung field)

•Bilateral infiltrative lesions•RIGHT Pneumothorax

Complications of cavitary TBComplications of cavitary TB

• Right hydro-pneumothorax

Complications of cavitary TBComplications of cavitary TB

•Bilateral infiltrative lesions

Complications of cavitary TB – bronchogenic Complications of cavitary TB – bronchogenic disseminationdissemination

”

Micronodular opacities, diffuse shape, vaguely defined, tendency to confluence to delimit small areas excavated

Bronchogenic dissemination from RUL to LIL(disemination type “Cardis”)

Complications of cavitary TB – bronchogenic Complications of cavitary TB – bronchogenic disseminationdissemination

Complications of cavitary TB – Complications of cavitary TB – bronchogenic disseminationbronchogenic dissemination

Hiperlucency excluding left lung, with attraction of trachea to the left, ascension compensatory of the diaphragm, hyperinflation of contralateral lung, right lung shows extensive infiltrative lesions and a cavity to the apexImages - multi-drug resistance TB

Miliary TB - miliary nodules distributed homogenous in both lung fields

POSTUBERCULOSIS FIBROSIS

• Retraction of LUL with fibrous lesions extended to right lung

• Basal left pachipleuritis

FIBROTHORAX-The final process of sclerosis that

interested entirely the lung

• Sclerosis of right lung

• Retraction of left hemithorax

• Nodular lesions of left lung

- Radiological: round, oval, encapsulated opacity, homogeneous or heterogeneous structure, net shape, can be solitary or multiple lesions

- Seriate radiographs show stability in time!

5. Tuberculoma