abdominal manifestations in tuberculosis torfs

A 52-year old man with dyspnea, fatigue

and loss of weightM. TORFSB. CORTHOUTSB. OP DE BEECKSTAFF MEETING RADIOLOGY, 09-12-2014

Case presentation

Medical history:- HIV (stopped treatment 3 years before, lost to

follow-up by the ITM)- Depression

Current medical problems:- Dyspnoea- Extreme fatigue- Weight loss (15 kgs in 3-4 months)- Diarrhea- Right testis ‘problem’ (R/ ciprofloxacin)

Case presentation

Clinical examination:- Cachexia- Tachycardia- Bilateral crepitations on auscultation- Red, swollen right testis

Chest radiograph

Chest radiograph: imaging findings

Hilar lymphadenopathy

Chest radiograph: imaging findings

Miliary pattern

CT thorax

CT thorax

CT thorax

CT thorax

CT thorax

CT thorax

CT thorax

CT thorax

CT thorax

CT thorax

CT thorax

CT thorax

CT thorax

CT thorax

CT thorax

CT thorax

CT thorax

CT thorax

CT thorax

CT thorax

CT thorax

CT thorax

CT thorax

CT thorax: imaging findings

Hypodense mediastinal lymphadenopathy with rim

enhancement

Hypodense right hilar lymphadenopathy

CT thorax: imaging findings

Pericardial effusion

Splenomegaly with numerous hypodense splenic lesions

(miliary pattern)

CT thorax: imaging findings

Small right adrenal calcifications

CT thorax: imaging findings

Micronodules, tree-in-bud pattern

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen

CT abdomen: imaging findings

Splenomegaly with numerous hypodense splenic lesions

(miliary pattern)

Inflammation of the right seminal vesicles

CT abdomen

Hyperenhancement of the right spermatic cord

Intussusception

Diagnosis?

R/ Right orchidectomy

Pathology:- Abcedation and necrosis- Presence of numerous acid fast bacteria

Diagnosis: Disseminated tuberculosis

Tuberculosis: epidemiology Leading cause of death from infection worldwide

1/3 of world population infected 2010: 8.8 million incident cases worldwide, 1.4 million deaths 1.2 million cases among HIV-infected persons Largest number of incident cases: India, China, South Africa, Indonesia,

Pakistan Highest prevalence rates (> 300 cases/100,000 population) in African

region

Increased susceptibility in patients with impaired cellular immunity HIV infection, elderly, prisoners, congregate settings, indigent/homeless

Tuberculosis: pathology

M. tuberculosis: Aerobic, nonmotile bacillus Stains red with Ziehl-Neelsen stain Acid-fast: Resists discoloration with acid alcohol

Granulomatous infection/inflammation Macrophage aggregates transform into

epithelioid cells, epithelioid cells fuse to form multinucleated Langhans giant cells

Central necrosis, satellite granulomas May heal as fibrous scar or calcified lesion

ABDOMINAL MANIFESTATIONS IN

TUBERCULOSIS

Abdominal manifestations in tuberculosis Abdomen is the most common site of extrapulmonary TB (can be involved

without lung disease)

Abdominal lymphadenopathy is most common manifestation of abdominal TB

Any abdominal or pelvic organ or structure may be involved

Tuberculosis peritonitis

Gastrointestinal tuberculosis

Hepatosplenic tuberculosis

Renal tuberculosis

Abdominal lymphadenopathy Enlarged nodes with hypoattenuating centers and

hyperattenuating enhancing rims on CT (40-60%)

With healing, nodes calcify

Enteric TB probably most common cause of mesenteric nodal calcification

26-year old patient with disseminated TB

Tuberculous peritonitis

Wet type: Large amount of free or loculated ascites (higher than water density due to protein and cellular content)

Dry type: Mesenteric and omental thickening, fibrous adhesions, and caseous nodules

Difficult to distinguish from peritoneal carcinomatosis

Gastrointestinal tuberculosis

Ileocecal region most commonly affected Cecum & terminal ileum are usually contracted

with wall thickening; ileocecal valve is "gaping" Regional lymphadenopathy with central caseation

Colon tuberculosis less common

24-year old patient with intestinal TB and

enterocutaneous fistula

Gastrointestinal tuberculosis

42-year old patient with TB colitis

Hepatosplenic tuberculosis• Micronodular, miliary• Macronodular

CT Acute lesions are hypoattenuating nodules with ill-defined, enhancing

margins Chronic: Hepatic and splenic tuberculomas tend to calcify as they heal

MR T1WI: Hypotense, minimally enhancing, honeycomb lesions T2WI: Hyperintense with less intense rim relative to surrounding liver

Renal tuberculosis• 75% unilateral

• Most common CT finding is renal calcification (50%)

• IVP: "Moth-eaten" calix due to erosions and progression to papillary necrosis

• Caliectasis & hydronephrosis with irregular margins and filling defects due to caseous debris

• Irregular pools of contrast due to renal parenchymal cavitation

• Strictures of renal pelvis and infundibula www.statdx.com

Ureteric and bladder tuberculosis

• Ureteric tuberculosis:- Thickened ureteric wall with

strictures- Most common in distal 1/3 of

ureter- Hydronephrosis &

hydroureter can occur upstream

• Bladder tuberculosis:- Decreased bladder volume

with wall thickening, ulceration, and filling defects

http://www.isradiology.org/tropical_deseases/tmcr/chapter5/lymphadenopathy2.htm

Genital tuberculosis

Male genital tuberculosis- Affects seminal vesicles or prostate

gland, rarely testes- Occasional calcification

Female genital tuberculosis- Involves fallopian tubes in 94% of

cases- Bilateral salpingitis with strictures ±

occlusion

Differential diagnosis• Abdominal lymphadenopathy:

- Metastases or lymphoma- Whipple disease- MAI infection

• Tuberculosis peritonitis:- Nontuberculous peritonitis- Peritoneal metastases and lymphoma- Mesothelioma

• Ileocecal lesions:- Amebiasis- Crohn disease- Primary cecal malignancy

• Miliary hepatic lesions:- Hepatic metastases and

lymphoma- Hepatic opportunistic infection- Sarcoidosis

• Renal Lesions:- Renal papillary necrosis- Renal transitional cell

carcinoma- Other infections

DD: abdominal lymphadenopathy

41-year old man with Hodgkin lymphoma

DD: abdominal lymphadenopathy

68-year old man with Whipple diseaseCourtesy of Dr. Tom Seerden (Amphia Ziekenhuis Breda) and Dr. Bart Op De Beeck

DD: ileocecal lesions

55-year old female with M. Crohn

Take home messages

Tuberculosis is leading cause of death from infection worldwide

TB lymphadenitis is characterised by enlarged nodes with hypoattenuating centers and hyperattenuating enhancing rims on CT (tend to calcify with healing)

Disseminated TB: look at the whole picture!

Remember this patient?

References

Statdx.com

Radiopaedia.org

http://www.isradiology.org/tropical_deseases/tmcr/chapter5/lymphadenopathy2.htm