radiology case 1 final

RADIOLOGYCase Discussion 1

JACINTO, Ma. TheresaJEONG, Kyung Sun

JOSE, NiñaJUNIA, Christine Joy

KING KAY, Caroline BernadetteLAO, Eugene

LAO, Kriselle MarisLAO, Lawrence Edeniño

LAO, Sharlene MarieLAUS, Lady Diana Rose

III - C

CASE

RR, 70 years old, male, seaman Chief complaint: Cough

History of Present Illness

3 years PTC Productive cough with whitish phlegmAccompanied by fever and body malaiseSelf-medicated with paracetamol and

amoxicillin (unrecalled dosage)


2 years PTCPersistence of cough, now blood tingedSought consult, was advised to have chest x-

ray. Was given anti-TB regimen but unable to

comply with the full course of treatment


1 year PTCOccasional cough and febrile episodes No medications taken

3 days PTCExpectorated bloodAdvised to have chest CT scan

Review of Systems

(+) weight loss (+) loss of appetite (+) body malaise (+) night sweats

Past Medical History

(+) Hypertension

Physical Examination

Hyposthenic Normal Vital Signs Lagging of the left lung Diminished breath sounds on the left

Normal Patient

Chest PA Lateral

Learning Issues

Radiographic signs of PTB What is a tuberculoma? Distinguish between primary vs re-infection

tuberculosis Explain the presence of atelectasis, cavitations

and bronchiectasis in PTB What is the role of follow-up chest x-ray? Radiographic findings of healed PTB What is the role of CT scan?

OUTLINE

Pathophysiology of Tuberculosis Radiographic Signs of PTB

Tuberculoma Bronchiectasis Cavitation Atelectasis

Primary vs. Re-infection PTB Active vs. Healed PTB Role of Chest X-Ray in Follow-up Role of CT Scan

Infection with M. tuberculosis

Alveolar macrophage ingestion of bacilli

Unchecked bacillary multiplication

Lysis of the macrophage

Activated monocytes ingest the bacilli from lysed

macrophage

Alveolar macrophages secrete cytokines

IL1

IL6

TNF-ά

Fever

Hyperglobulinemia

• Killing of Mycobacteria• Granuloma formation• Fever• Weight loss

Activation of more hostresponses

Tissue-damagingresponse

Macrophage-activatingresponse

Formation of solid necrosis in the center of the

tubercle

• Development of specific immunity• Accumulation of activated macrophage

Caseating granuloma Tubercle formation

Some lesions heal byfibrosis and calcification

• Lagging of the left lung• Breath sounds

Treatment failure

Intensified DTH

Tissue-damagingresponse

Caseous materialliquefies

Invasion & destructionOf BV and bronchial walls

Cavity formation

Drained throughbronchi

Multiplication &spread of thebacilli into the

airways

• Cough• Hemoptysis

OUTLINE




Tuberculoma Primary, post-primary

tuberculosis Form of lesion commonly

seen in TB Well circumscribed,

round/oval opacities caused by acid-fast bacilli

1-4 cm or more in diameter

mostly in upper lobe, right more than the left

Tuberculoma

OUTLINE




Bronchiectasis

Localized, irreversible dilatation of the bronchial tree

Associated with acute, chronic or recurrent infection (bacteria and mycobacteria)

Bronchiectasis

Tram line Ring shadows with thickened bronchial walls Mucus plugs

Bronchiectasis

Air fluid levels Watch for dextrocardia Diffuse lung fibrosis

Due to recurrent infections

Bronchiectasis

Bronchial dilatation Tram lines Thickened bronchial walls Mucus plugs

OUTLINE




Robbins and Kutran. Pathologic basis of disease. 7th ed pp. 384-386

Cavitations

Cavitation, usually in the apices of the lungs, occurs readily in the secondary form of PTB, resulting in dissemination of mycobacteria along the airways

Robbins and Kutran. Pathologic basis of disease. 7th ed pp. 384-386

Expansion in the area of caseation erosion into a bronchus evacuation of the caseous center (cough) irregular cavity lined by caseous material and fibrous tissue

Radiology of the chest. Regional roentgen pathology. pp. 358-364

Early stages Cavity is usually irregular, often showing air-fluid level


Early stages Small areas of infiltration, consolidation adjacent to a

cavity is highly suggestive of PTB (differentiate from lung abcess)

Early lesions: posterior portion of upper lobe, below level of the clavicle

CAVITY

CAVITY

OUTLINE





Thoracic Imaging: Pulmonary and Cardiology. pp. 47-65

Atelectasis “Incomplete

stretching”, loss of volume of lung tissue because of decreased amount of gas

Destructive process in the walls of the bronchi and plugging of the lumina by exudate



Direct Signs ( due to lobar volume loss) Displacement of interlobular fissures: best sign of

atelectasis Crowding of vessels, bronchi or air bronchograms


Thoracic Imaging: Pulmonary and Cardiology. Pp. 47-65

Indirect Signs Diaphragmatic elevation: due to ipsilateral volume

loss: more common lower lobe Juxtaphrenic Peak (upper lobe atelectasis)



Indirect Signs Mediastinal shift:

more common upper lobe collapse (Trachea); more common lower lobe collapse (heart)

Thoracic Imaging: Pulmonary and Cardiology. Pp 47-65

Indirect signs Compensatory overinflation of normal lung on the same side;

increased volume with decreased density of lung Hilar displacement: Hilum ELEVATED with ULA; Hilum

DEPRESSED with LLA



Indirect signs Reorientation of

hilum or bronchi ULA: hilum rotates

outward and descending pulmonary artery is less vertical and easily seen

LLA: hila are depressed and bronchi appear more vertical



Indirect Signs Approximation of the ribs: ipsilateral ribs appear

closer together Flat waist sign: flattening of the left heart border due

to rotation of heart and great vessels



Indirect Signs Increased lung opacity: reflects replacement of

alveolar air with fluid or compressed airless tissue Absence of air bronchograms



Indirect signs Absence of air bronchograms suggests central

bronchial obstruction Mucus bronchograms Shifting granuloma sign: parenchymal lesions of prior

film shifts in location

OUTLINE




Primary Tuberculosis Pulmonary imaging findings in individuals with

primary tuberculosis are nonspecific Note that chest radiographic findings may be

normal in as many as 15% of patients with primary pulmonary tuberculosis

Primary Tuberculosis

Parenchymal consolidationPredilection for the lower lobes, middle lobe

and lingula, and anterior segments of the upper lobes

Homogeneous, with ill-defined marginsCaseous necrosis occurs centrally within the

lung parenchymal opacity, decreasing its sizeBecome rounded with healing, continues to

shrink until only a small nodule remains → calcified or ossified → calcified granuloma

(Lee KS et al, 1003)

PTB with bronchogenic spread in 34 y/o woman CXR: Nodules, right lower lobe HRCT: Peribronchial (arrows) and large acinar (arrowheads) nodules CT: Lobular consolidations (arrows) and acinar nodules (arrowheads)

Tuberculoma may be a manifestation of either primary or postprimary tuberculosis



Lymphadenopathy Distinguishing feature of primary TB vs.

recurrent TBMore common with immune incompetent hostsMost common in the ipsilateral hilar regionMay involve the airways Indistinguishable from that of sarcoid or

lymphoma

Tuberculosis, lymphadenopathy in a 19 y/o male CXR: Bilateral widening of superior mediastinum and

enlargement of right hilum CT: Extensive mediastinal adenopathy with central low

density and peripheral rim enhancement


Airway involvement Airway compression with resultant atelectasisMucosal infectionBroncholithiasis Endobronchial spread of infectionBronchiectasis

Traction bronchiectasis in a 52 y/o male HRCT: Dilatation of right upper lobe bronchi and

granuloma in left upper lobe

(Hyae Young Kim, 2001)

Tracheobronchial stenosis in a 40 y/o female Contrast-enhanced CT: narrowing of left main

bronchus(Hyae Young Kim, 2001)

Broncholithiasis in a 58 y/o male Contrast-enhanced CT: broncholith within lateral segmental

bronchus of right middle lobe Distal obstructive atelectasis and calcified lymph nodes Right pleural effusion

(Hyae Young Kim, 2001)

Re-infection Tuberculosis

Often on the apical and posterior segments of the upper lobes or superior segments of the lower lobes

Associated with progressive disease


Most common clinical finding is poorly defined areas of consolidation in involved segments


There may be cavitation, with visible endobronchial spread


In 20-45% of patients with active post-primary TB, cavitation is visible on chest radiographs, with numerous small nodules


Pleural involvement Uncommon in children, seen more frequently

in adultsMore frequently identified in post-primary

tuberculosis


Tuberculosis with pleural effusion in a 38 y/o female CT: Pleural effusion in anterior and lateral pleural spaces

and right major fissure Parenchymal tuberculous focus in right middle lobe


Miliary TB is a disseminated systemic infection from a pulmonary nidus spread hematogenously

May also be seen in primary TB

OUTLINE




Active PTB

Infiltrate or consolidation Cavitary lesion Nodule with poorly defined margins Pleural effusion Hilar or mediastinal lymphadenopathy Linear, interstitial disease (in children only) Miliary findings

Healed PTB

Discrete fibrotic scar or linear opacity Discrete nodule(s) without calcification Discrete fibrotic scar with volume loss or

retraction Discrete nodule(s) with volume loss or

retraction Upper lobe bronchiectasis

OUTLINE




ROLE OF FOLLOW-UP CHEST X-RAY To determine presence of late complications

at completion of therapyRelapseAspergillomaBronchiectasisBroncholithiasisFibrothoraxCarcinoma

eMedicine: Tuberculosis by Thomas Herchline, MD

OUTLINE




ROLE OF CT SCAN Better define abnormalities in patients with vague

findings on chest radiography More sensitive in the detection of:

Cavitation Hilar and mediastinal lymphadenopathies Endobronchial spread Malignancy Complications in the course of the disease

eMedicine: Tuberculosis by Thomas Herchline, MD; Eisenhuber E, et al. Radiologic Diagnosis of Lung Tuberculosis (abstract), Der Radiologe Vol.37 No.5 May 2007

ROLE OF CT SCAN

Valuable technique in the assessment of tuberculosis activity, especially in patients where M. tuberculosis has not been detected in the sputum or in patients with multi drug-resistant tuberculosis

eMedicine: Tuberculosis by Thomas Herchline, MD; Eisenhuber E, et al. Radiologic Diagnosis of Lung Tuberculosis (abstract), Der Radiologe Vol.37 No.5 May 2007

THANK YOU FOR YOUR KIND ATTENTION

radiology case 1 final

Documents

healed ptb role of chest

suggestive of ptb

reinfection ptb active

role of followup chest

secondary form of ptb

chest xray

recurrent infection

presence of atelectasis