18/10/55

1

Pulmonary TB:

HRCT findings

Jung-Gi Im, MD

Department of Radiology Seoul National

University Hospital

Tuberculosis: History

BC 5000: Evidence of

TB in neolithic man

BC 2900: Pyramid

builders

BC 1000 : Pott’s dis.

in mummies

Frederic Chopin (1810-1849)

Victims of tuberculosis

Fyodor Mikhailovich Dostoevsky

(1821-1881)

Writer : Goethe, Schiller, Dostoevsky,

Chekhov, Laurence, Poe,

Kafka, Rousseau

Philosopher : Spinoza, S.Johnson

Artist : Modigliani, Gauguin

Musician : Chopin, Paganini

Physician : Laennec

Victims of tuberculosis

M. tuberculosis: Genome Sequence

Determination of genome sequence

: help new prophylatic & therapeutic intervention

M. tuberculosis, H37RV

4,411,529 base pairs: 4,000 genes

Cole ST Nature 1998;393:537

Estimates of the global burden caused by TB in 2010

12 million prevalent cases

8.8 million new TB cases (128 cases/100,000 population)

1.7 million death from TB (4700 deaths/day)

Most cases were in the Asia (59%), African (26%) and smaller cases were in Europe (5%).

Towards universal access to diagnosis and treatment of multidrug-resistant

and extensively drug-resistant tuberculosis by 2015

WHO PROGRESS REPORT 2011

18/10/55

2

Estimated TB incidence rates, 2010

WHO REPORT 2010 GLOBAL TUBERCULOSIS CONTROL

Diagnosis of tuberculosis

Prompt Dx of TB

–Public health infection control

–Ensure appropriate Tx of TB patient

• Conversion to noninfectious condition

• Cure

–Limited sensitivity of culture test

Imaging Dx would provide opportunity of

prompt Dx. & appropriate Tx.

Tuberculosis Primary vs Reactivation

Primary TB

Disease developing after initial exposure

atypical radiologic presentation

Reactivation TB

Disease developing as a result of reactivation of a previous focus typical radiologic presentation

TuberculosisMolecular epidemiology concept

Based on DNA fingerprinting

–Restriction fragment length polymorphism (RFLP) analysis of M. TB isolates

TB isolates in terms of space & time

Identification of primary & reactivation TB

–Clustered isolates (primary)

–Unique isolates (reactivation)

Alland D, et al. N Engl J Med 1994

Radiographic manifestation of TB New concept

• No difference in radiographic features bet. primary & reactivation TB

• Significant predictors of radiographic appearance of TB

• Patients’ Immune status

– Immunocompromised patients: tendency toward primary TB form

– Immunocompetent patients tend to have the reactivation TB form

Geng E, et al. JAMA 2005

M/20, private soldier

No respiratory symptom

Share a room with soldier diagnosed with active TB

18/10/55

3

Radiologic features of

Tuberculosis:

Atypical vs Typical

Atypical radiologic features:Primary pattern

Lymphadenopathy

Pleural effusion

Miliary nodules

Lower lobe disease

Primary Tuberculosis in Children

Unsensitized host

Airborne droplets (2 - 10μ)

Necrotizing pneumonitis

Spread by lymphatics

Spontaneous resolution : over

90%

13 mo/m. Prim. TB : consolidation & LN

Pulmonary TB in Children : CT

41 patients (mean age, 6 yrs)

CT findings :

Mediast. & hilar lymphad. : 83%

Seg. or lobar consolidation : 49%

Bronchogenic spread : 29%

Miliary nodule : 17%

CT is useful in Dx. and detection of Cx.

Kim WS et al. AJR 1997;168:1005

24/F

Fever, weakness

18/10/55

4

Miliary Tuberculosis : HRCT

25 patients

Millary nodules : 88%

Ground-glass opacity : 92%

large GGO : dyspnea, impending ARDS

Intralobul. reticulation, septal line: 40%

Hong SW et al JCAT 1998;22:220

Miliary TB

Random

Uniform

Abut pleura

Miliary TB with DIC & ARDSMiliary TB with DIC & ARDS

Typical radiologic features:Reactivation pattern

Caseating granuloma

Bronchogenic spread

Cavitation

Upper lobe disease

18/10/55

5

Postprimary or Reactivation Tuberculosis

Sensitized host

Tendency to be localized

Rare lymphatic spread

: mainly bronchogenic

Apex, Sup. segment of lower lobe

Typical radiologic features

Caseating granuloma

Bronchogenic spread

Cavitation

Upper lobe disease

50/F

Incidentally-detected mass Typical radiologic features

Caseating granuloma

Bronchogenic spread

Cavitation

Upper lobe disease

Tuberculosis

Chronic debilitating granulomatous disease

Early lesions?

Advanced lesions?

N.T 1976.2.13

Pulmonary TB

Courtesy

of Dr. Itoh

18/10/55

6

R

Highly contrasted lesionsN.T

Tuberculosis

Highly contrasted centrilobular lesions

N.T

Tuberculosis

TB: Highly contrasted lesions

Why?

Bronchiole

AD

PA

Pulmonary TB

: fill the bronchiole and alveolar ducts

55

Caseous materials

Bronchogenic

Spread:

“Tree-in-bud”

18/10/55

7

Bronchogenic spread TB

Centrilobular: tree-in-bud

K.A

1976.7.1

Bronchopneumonia

Multiple nodulesCourtesy of Dr. Itoh

K.A

R

Centrilobular inflammatory nodulesK.A

5 mm

ILS

PV

ILS

Bronchiole

Centrilobular inflammatory nodule

K.A

1 mm

Bronchiole

Paraseptal parenchyma

Pulmonary vein

43

Hypersensitivity pneumonitis

18/10/55

8

19/F

Productive cough

Diffuse PanbronchiolitisTB Sarcoid

Bronchogenic spread TB DPB

Tuberculosis: HRCT of Early Bronchogenic Spread Lesions

Tree-in-bud appearance

High contrasted lesions

Caseation Necrosis: Good & Bad

Tissue damage

Delayed type

hypersensitivity

Activated mono/macroph,

cytokines, chemotactic factor

Homo sapiens M. TB

Unable to multiplywithin solid caseum

Tsuyuguchi I. Dialogue between M tb & H sapiens. Tuberculosis 2001

Recent Bronchogenic Spread of Tuberculosis : HRCT

Centrilobular lesion (97%)

Tree-in-bud

Bronchial wall thickening (79%)

Poorly-defined nodule (76%)

(5-8mm)

Cavitary nodules (66%)

Lobular consolidation (52%)

Im G-J, et al. Radiology 1993. Cited 159 x

18/10/55

9

Miliary Tuberculosis : HRCT

25 patients

Millary nodules : 88%

Ground-glass opacity : 92%

large GGO : dyspnea, impending ARDS

Intralobular reticulation, septal line : 40%

Hong SW et al JCAT 1998;22:220

Random

Uniform

Abut pleura

Coal worker’s pneumoconiosis with

PMF

Centrilobular nodule

Miliary TB with DIC & ARDSMiliary TB with DIC & ARDS

Immunologic Balance btw

H.sapiens & M.TB

Homo sapiens

Cell mediated

immunity

Delayed type

hypersensitivity

Anti-TB drug

M. TB

Armour-plated with

lipid cover

Genetic mutation

Tsuyuguchi I. Tuberculosis 2001 39/M . Multi-Drug Resistant TB

18/10/55

10

31/M. MDR TB 1°

peumonectomy, menigitis

Typical radiologic features

Caseating granuloma

Bronchogenic spread

Cavitation

Upper lobe disease

Courtesy of Dr. Itoh Courtesy of Dr. Itoh

TB cavity

Centrilobular cavity evolution

5 mo

Anti-TB Rx

9 mo

Anti-TB Rx

Cavities in MDR-TB

M/19

18/10/55

11

Healing process of tuberculosis

Healing of tuberculous lesion

Resolution

Fibrosis

Calcificationbu

BE

Anti-TB 2 wks Anti-TB 7 months

brochiolar stricture

Tuberculosis in subsets of patients

Tuberculosis in Altered Immunity

● Acquired Immune Deficiency Syndrome

● Diabetes Mellitus

● SLE

● Myelodysplastic synrome

● Alcoholics

Impaired granuloma formation atypical findings

18/10/55

12

Pulmonary tuberculosisAIDS

Risk : 50 - 200 times

Radiology : depends on CD4 count

200 : post-primary

200 : primary

Pathology : Extensive necrosis but few cavity

Poorly organized or no granuloma

Numerous bacilli

TB in AIDS CD4 : 47/mm³

Pulmonary tuberculosis Diabetes Mellitus

Pathophysiology :

Phagocytosis & intracellular killing Suppress granuloma formation

Radiology:

Large airspace consolidation

Multiple small cavities

Extensive local & bronchog. spread

59/F, DM

Dyspnea

62/M DM

Incidental mass

Pulmonary tuberculosisSLE

22 pt. with active TB (8.8%) /256 consecutive SLE pts., all on steroid

HRCT findings: Miliary TB : 54%

CLN in upper lobe: 36%

Consolidation in LL: 18%

Lymphadenitis: 18%

Cavity: 0%

Immunity: Steroid (lymphokine, chemotaxis ↓) Inherent cell-mediated immunity↓

•Kim HY, et al. AJR 1999

18/10/55

13

Pulmonary tuberculosis Myelodysplastic Syndrome

Acquired blood disorders

- May progress to acute leukemia

- Pancytopenia in spite of having a cellular marrow

12 TB/ 195 MDS

Common extrapulmonary involvement

–50%

Primary pattern (50%)

•Kim HC, et al. Clin Radiol 2001

21/F, Myelodysplastic syndrome

Fever, weight lossChronic Alcohol Abuse vs

Immunity

Humoral immunity ↓

Neutropenia

Marrow suppression

Chemotaxis

Cell-mediated immunity ↓

Lymphopenia

T-cell, natural killer cells

Delayed hypersensitivity

sensitization

•MacGregor RR. JAMA 1986;256:1474

Reversible Cystic Pulmonary TB

3 women with TB and respiratory failure

no underlying disease

HRCT: Multiple thin-walled cysts

at area of consolidation

Disappeared 6-8 mo. of chemo.

Mechanism: Bronchiolar narrowing with

cystic dilatation

•Ko KS, et al. Radiology 1997;204:165-169

18/10/55

14

24/F previous healthy. AFB(+)

Dyspnea, fever

„01.04.03 „01.04.13

’01-04-14

2001-04-14 2001-07-30

2003-07-04 2003-12-19

TB Pleural Effusion: Paradoxical Response

•Choi YW, et al. Radiology 2002;224:493

16 patients with TB pleurisy

14 men, mean 27 yrs

New pulmonary nodule(s) during anti-TB Tx.

All ipsilateral peripheral nodules

Transient worsening but ultimately improve with

treatment

18/10/55

15

23/M TB pleurisy 2 mo later

21/F

Cough, dyspnea

2008-02-16 2008-07-082009-05-08

Immunologic rebound ?

Hypersensitivity to dying AFB ?

TB in Patients with IPF

143 patients with IPF (mean age: 58.4 yr)

9/143 (6.3%) had activeTB

5.4 x of age adjusted AFB (+) prevalence)

CT: Mimic Cancer or Pneumonia

Subpleural nodule (6)

Lobar or lobular consolidation (3)

Location: RLL (4), LLL (3), UL (2)

•Chung MJ, et al. Eur J Radiol 2004;52:175-9 61/M IPF

6 months later

73/M IPF

1998.11

2000.03

18/10/55

16

3rd WCTI WebsitePlease visit at www.wcti2013.org

Click to join 3rd WCTI mailing list

and receive updated news !