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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