Nodules and infiltrates

Pulmonary TB, main radiological aspects and differential diagnoses Common TB in adults Miliary Serous membrane TB Node TB Pleural TB Sequela

Tuberculosis and AIDS: AIDS modifies the clinical and radiological course of TB. Differential diagnoses are many. It is important to know them, in order to chose the adapted treatment

Common adult TB Basic radiological images:

• Nodule • Infiltrate• Cavity • Tuberculous pneumonia

- These images can follow in time : nodule macronodule excavated nodule caverna

- These elements are very often associated in the same patient

- The association of several images of different ages and different aspects is very indicative for TB

- Round picture with a diameter > 3 cm, non- excavated, is very rarely TB

Nodule: isolated or grouped in the superior lobes or in the apical segment of the inferior lobes.

Infiltrate: group of various-sized nodules with unequal dimensions.The excavation is not always visible on the chest x-ray.

If the excavation exists, the bacterial analysis of the sputum is generally positive: TPM+.

(The TDM could show the excavation even if it is not visible on the chest x-ray)

.For the supra clavicles area analysis, the chest x-ray with antero posterior incidence is usefull.

Tuberculine skin test 5U = 15mmGood performance status, FS = 0, Physical signs = 0Inflammatory S = 0Expectoration: AFB - Cultures -

Probable TB infiltrate

TB infiltrateTPM-

Non productive cough Good performance status, FS = 0, Physical signs = 0Inflammatory S = 0Expectoration: AFB - Cultures -

Probable TB infiltrate

Cough, chronic fever. Hemoptoïc sputum. AFB neg. in sputum

Man, 55 years oldAntecedent of pleural effusionFever, cough, weight lossHemoptoic sputum

Chest x-ray: left pleural sequela, retractileRight nodular infiltrate. AFB+ in sputum

© OFCP© OFCP

© OFCP

© OFCP

cavited nodules >>> AFB+

Woman 48years old. Close contact with patient AFB+ in sputum.PCR positive in sputum for mycobacterium tuberculosis in sputum

San view of the previous case : microcavity in the nodule

Man ,heavy smoker, cough, dyspnea and worsening condition

AFB + in sputum

cavited nodule

Tubercular pneumonia

cavity.AFB positive in sputums

Bronchoscopic view: tubercular endobronchic lesion

With tubercular granulomas In the biopsy samplings

Small TB infiltrate TPM-

Bilateral nodules. AFB- in sputum. BK Cultures negative

nodule macronodule cavited nodule cavityIn this case, association of an infiltrate in the right superior lobeand cavity in the left inferior lobe is highly indicative of TB

- TB nodules and infiltrates are most often isolated or grouped in the superior lobes or in the apical segment of the inferior lobes.

- They are difficult to see in the retro-clavicle area

- These lesions are often AFB- because non-excavated, no communication with bronchi and pauci-bacillar

- The association of lesions with different seniority (nodules, cavity, sequelas) or with extra pulmonary

localisations is very indicative of TB.

• Nodules and infiltrates are often AFB- in sputum. So the risk of contamination is low (but not zero).

• AFB is negative in sputum, but sometimes cultures are positive.

• Even if the risk of contamination is low, it is important to detect these patients and treat them because these patients can develop severe and contaminent TB

Male, 30 years oldCough, fever, weight loss, asthenia

Amoxicillin treatment…

T left upper lobe infiltrate not noticed by the physician (not good quality

of CXR)

4 months later: left superior excavation with important infiltrate, AFB +++

Sometimes difficult to see (small, retroclavicular areas)Sometimes AFB+ if cavity (not always visible on CXR)Most often no cavitation and AFB- They are true TB on the beginning and must be treated by anti TB They are true TPM - Physicians of national TB program hesitate to treat these patients but they treat a lot of “TPM – who are not real TB (bronchial cancer, inactive sequella bronchectasis, aspergilloma…)

It is absolutely necessary to improve quality of CXR interpretation

Especially for physicians in charge of TB program.

Nodules and Infiltrate -Summary