TB Radiology Webinar · TB patterns overlap with each other TB tt l ith th diTB patterns overlap with other diseases If there is an abnormality, it could be due to TB But, if it doesn’t

TB Radiology - Brett Elicker Webinar - July 16, 2012

Curry International TB Center 1

TB Radiology Webinar

Topics

How to read a chest x-ray

Radiographic findings of tuberculosisRadiographic findings of tuberculosis

Mimics of TB

When to get a CT scan

Case #1



Evaluating the TB CXR

Be systematic!!!

QualityQ y

Start centrally and work outwards

Normal or abnormal

If abnormal consider the significance of abnormality

Mediastinum and hila

Normal Abnormal



Question #1: What is the most likely diagnosis in this case?

Tuberculosis

Fungal infection

Lung cancer

Sarcoidosis

Normal Abnormal

Sarcoid: R paratracheal + hilar LAD

aorta

PA

Normal Abnormal

AP window



aorta

PA

Normal Abnormal

AP window

AP window LAD: lung cancer

Heart

<55% thoracic diameter

Technique important

Larger in: AP film AP film

Poor inspiration

Rotation

Children

True enlargement Chamber enlargement

Pericardial effusion

Mass




Dilated cardiomyopathy

Mitral regurgitation

Pericardial effusion

These cannot be differentiated on a CXR

TB pericarditis

Lungs



Pleura & diaphragm



Don’t forget soft tissue & bones

TB osteomyelitis

Case #2



Inspiration: (≥10 posterior ribs)

1st rib



2nd rib

3rd rib

2nd3rd

4th

5th

6th

7th

1st

8th

9th

10th



Poor inspiration

Poor inspiration

Good inspiration



Rotation

Rotation





Penetration

Penetration

Vertebral body



PenetrationIntervertebralDisks

Over-penetrated



Case #3


Tuberculosis

Fungal infection

Lung cancer

Sarcoidosis

Categories of lung opacities

1. Nodules/masses

2 Consolidation (alveolar or airpace)2. Consolidation (alveolar or airpace)

3. Interstitial (diffuse nodules or lines)

4. Airways (tubular or circular opacities)



Nodule < 3cm, Mass ≥3 cm

2.7 cm3.4 cm

Consolidation

Confluent opacity

Consolidation

Confluent opacity

Fluffy around the periphery



Consolidation

Confluent opacity

Fluffy around the periphery

Air bronchograms

Normal Nodular Reticular

Interstitial disease

Miliary TB



Airways Disease

Ring-like

Tram-track

Tubular

Case #3

Radiology of TB

TB can look like anything

Classic TB patterns have been described

TB patterns overlap with each other

TB tt l ith th diTB patterns overlap with other diseases

If there is an abnormality, it could be due to TB

But, if it doesn’t fit into a typical TB pattern, it is unlikely to be TB

Clinical-radiographic correlation



Reactivation TB

Reactivaton TB- radiology

LocationApical/posterior segments upper lobes

Superior segment lower lobesp g

Presence of cavities

Pleural disease

Volume loss/scarring early in disease

Diff dx: fungal, bacterial infections

Is this likely TB?



Question #4: Which lobe is involved by this process?

Right upper lobe

Right middle lobe

Right lower lobe

Entire right lung

LUL

Lobar anatomy

Left Lung

LLL

RUL

Lobar anatomy

Right Lung

RLLRML



Lobar anatomy

RUL

Right Lung

RLLRML

RUL Pneumonia

RUL

Lobar anatomy

Right Lung

RLLRML



RUL

Lobar anatomy

Right Lung

RLLRML

Silhouette sign

A B A B



Silhouette sign

A B A B

RUL

Lobar anatomy

RLLRML

Diaphragm

RLL pneumonia

RLL

ObscuredDiaphragm

ClearHeartBorder



? Which lobe is involved

RUL

Lobar anatomy

Right Lung

RLLRML

RML pneumonia

RML

ClearDiaphragm

ObscuredHeartBorder



? pneumonia

? pneumonia

Lateral Viewof the Chest

Anterior

Posterior




Heart


S iSpine


Diaphragm




Diaphragm

Normal LLL Pneumonia

Normal Pleural effusion



Normal Nodule

Case #4

Question #5: What is the predominant abnormality?

Cavitary consolidation in the upper lobes

Mediastinal lymphadenopathy

Miliary nodules

Upper lobe scarring



Abnormal Normal

Prior reactivation tuberculosis

Upper lobe scarringVolume loss

Retraction of hila superiorly

Band-like (linear) opacitiesBand like (linear) opacities

Architectural distortion

Asymmetric > symmetric

Bronchiectasis

Cystic changes

Diff dx: fungal, sarcoid, pneumoconioses



Warning signs

Consolidation outside areas of fibrosis

Consolidation with cavitation

Lower lobe abnormalities

Non-calcified nodules (ill-defined)

Change from prior CXR

Reactivation TB



Case #5

Case #5


Tuberculosis

Fungal infection

Lung cancer

Sarcoidosis



Solitary nodule/mass- the top 5

Granuloma

Hamartoma

Solitary metastasis

Bronchogenic carcinoma

Lots of others

When to get a CT scan?

Questionable CXR findings

Further characterization of CXR findings

Concern for cancer



Role of CT in evaluating nodules Prove benignity

Calcification (benign pattern)

Fat

Likelihood of malignancy Size

Spiculation

Cavitation with thick wall

Determine next step in management Follow-up CT

PET-CT

Biopsy

Surgery

< 4 mm: 0%

4 7 mm: 1%

Size and likelihood of cancer

4-7 mm: 1%

8-20 mm: 15%

> 20 mm: 81%

Swensen. Radiology 2005; 235: 259

Old tuberculosis





Case #6



Case #6

Case #6Ghonfocus

Case #6Rankecomplex



Prior tuberculosis

Mid to lower lung predominance

Can be anywhere

Nodule: Ghon focus

Nodule + lymph node: Ranke complex

Calcification indicative of inactivity

Case #7


Tuberculosis

Fungal infection

Lung cancer

Sarcoidosis



Case #7

Case #7

Primary tuberculosis

Difficult radiologic diagnosis

Mimics other diseases

FindingsN ifi lid iNonspecific consolidation

Nodule

Lymphadenopathy

Cavitation unusual

LAD more common than with 2° TB (particularly kids + HIV)



Case #8


Tuberculosis

Fungal infection

Malignancy

Sarcoidosis



Miliary pattern CXR

Miliary tuberculosis

Fungal infection (histo cocci blasto)Fungal infection (histo, cocci, blasto)

Metastases

Sarcoidosis

Miliary tuberculosis

Case #9



Question #9

What does this CT finding most closely resemble?A. The moon with a surrounding halo: (the halo

sign)

B. A coral atoll: (the atoll sign)

C. English paving stones laid in a haphazard fashion and fixed with mortar (the crazy paving pattern)

D. Branches of a tree in the spring when the flower buds begin to swell (the tree-in-bud sign)

Tree in bud



Tree-in-bud

Almost always infection

Bacterial > Mycobacterial >>> Others

One tree-in-bud is diagnostic

Must see convincing example

Diagnosis in sputum

Atypical mycobacterium

Case #10



Pleural + pericardial disease

Primary or secondary

May be only manifestation in 1° TBMay be only manifestation in 1 TB

Empyema more common in secondary

Adults >> kids

Left decubitus viewof the chest

Patient lyingleft side down

Camera shoots frombehind patient, parallelto floor

Right decubitus viewof the chest

Patient lyingright side down

Camera shoots frombehind patient, parallelto floor



Suspected pleural effusion

Case #11



Question #10: What is the predominant abnormality?

Cavitary consolidation in the upper lobes

Mediastinal lymphadenopathy

Miliary nodules

Upper lobe scarring

Case #11

Case #11



Lymphoma

Leukemia

Germ cell tumor

Bacterial mediastinitis

Fungal infection

Tuberculosis

Lymphadenopathy with TB

Kids >> adults

Primary >> secondary

Asymmetric (right > left)Asymmetric (right > left)

Most common locationsHilar

Right paratracheal

Necrosis very common



Case #12

thymus

heart <65% thoracic diameter



Conclusions

Be systematic when reading CXR

Typical TB patternsTypical TB patterns

Mimics of TB

Get a CT scan when appropriate

Documents

TB Radiology Webinar · TB patterns overlap with each other TB tt l ith th diTB patterns overlap with other diseases If there is an abnormality, it could be due to TB But, if it doesn’t