OF PULMONARY

TUBERCULOSIS

Clinical Clerkcship of RadiologyDepartment

Faculty of Medicine, Universitas Pelita Harapan
Police Hospitals, Bhayangkara Tk.I Raden Said
Sukanto
Period of October 26th 2015- November 13th
2015

 Tuberculosis

infectious disease
caused by Mycobacterium tuberculosis

a rod-shaped
non- spore-forming
aerobic bacterium
often neutral to Grams staining.

Pulmonary

tuberculosis

Primary tuberculosis
post-primary tuberculosis

Primary tuberculosis
occurs

in patients not previously exposed to

Mycobacterium tuberculosis.
Within 2 years after the infection, primary tuberculosis
usually results in active disease

Post-primary or reactivated tuberculosis

occurs in patients who have been previously infected

and have developed a certain degree of acquired

immunity.
Reactivated tuberculosis may result from both
endogenous reactivation (more often) and exogenous
re-infection (super-infection)

EPIDEMIOLOGY
The

burden of disability and death due to tuberculosis is

immense, with an estimated 8.7 million incident cases of
tuberculosis in 2011 in the world
among these, about 15% were human immunodeficiency
virus (HIV)-positive

There

were estimated 170 per 100,000 population rates

prevalent cases of tuberculosis in 2011.

However,

because of insufficient case detection and incomplete

notification, reported cases represent only 60% of the total
number of new cases.
About 60% of cases are in the South-East Asia and Western
Pacific regions.
The African region has 24% of the world cases, and the
highest rates of cases and deaths per capita

Clinical signs and symptoms of pulmonary tuberculosis in adults are

often nonspecific, whereas complete absence of symptoms occurs
in approximately 5% of adult cases.

The most frequent respiratory symptom :

cough for more than 2 weeks
Hemoptysis
pleuritic chest pain
dyspnea may be present in case of extensive lung involvement.

Systemic manifestations :
low-grade fever
anorexia,
fatigue,
night sweats
weight loss that may persist for weeks to months

The
most
common
hematologic
associated
manifestations
high white blood cells count and anemia (both occurring in
10% of patients)

Diagnosis of tuberculosis in elderly is frequently delayed

because classic symptoms rarely occur or may be confused
by other chronic diseases.

The clinical manifestations of tuberculosis in HIV-infected

people depend on the severity of their immunosuppression

In people with advanced disease, pulmonary tuberculosis is

often accompanied by extra- pulmonary involvement

Primary tuberculosis manifests with three main entities:

parenchymal disease
Lymphadenopathy
pleural effusion.

On chest film
parenchymal disease typically manifests
dense
homogeneous parenchymal consolidation
predominantly located in the middle and lower lobes
(especially in adults)

Airspace consolidation, related to bronchioloalveolar caseous

exudate, is usually unilateral and evidenced through radiographs
approximately in 70% of children with primary tuberculosis

CT studies
The appearance of the parenchymal consolidations in
primary tuberculosis is most commonly dense and
homogeneous but may also be linear, patchy, nodular, or
mass-like
In nearly two-thirds of cases, the parenchymal focus

resolves without sequelae at conventional radiography

in the remaining cases, the parenchymal focus can calcify,
thus initiating the Ghon focus

Satellite calcified foci and persistent mass-like opacities,

called Tuberculomas, can be found in approximately 9% of
patients.

Lymph node enlargement is the hallmark of primary

tuberculosis in childhood

This condition is encountered in about 95% of children affected

by tuberculosis; on the other hand, radiographic evidence of
lymph nodes enlargement is far less common in adults (43% of
cases) (10,11)

Lymphadenopathies are usually unilateral and located in the

hilum or paratracheal regions

On computed tomography (CT)

which is more sensitive than chest radiography for assessing
lymphadenopathy, enlarged nodes typically show :
central low attenuation, representing caseous necrosis, whereas peripheral
rim enhancement represents the vascular rim of the granulomatous
inflammatory tissue

The combination of a Ghon focus and a calcified hilar node is

called Ranke Complex suggestive of previous
tuberculosis infection.

Pleural tuberculosis is considered a complication of primary

tuberculosis, although in up to 19% of detected cases may
occur in association with post-primary disease

It is usually unilateral, on the same side as the primary

focus, but can also occur in patients without any evidence of
parenchymal disease.

A bronchopleural fistula must be ruled-out in the diagnosis

when an air-fluid level is identified

Tuberculous effusions contain high quantity of proteins and often

show fibrin strands and septa on thoracic ultrasound imaging

Very often septa that have been imaged by ultrasound are not
detected by CT

In these cases CT usually shows

homogeneous fluid in the pleural cavity, but is more panoramic
and therefore more sensitive than plain chest radiography and
lung ultrasound in diagnosing associated parenchymal diseases.

After contrast administration

pleural layers enhance and are revealed as a smooth thickening
of the visceral and parietal pleural surfaces separated by a
variable amount of fluid (split pleura sign)

Reactivation tuberculosis tends to involve predominantly the

apical and posterior segments of the upper lobes and the
superior segments of the lower lobes.
These specific locations are explained by relative higher
oxygen tension and impaired lymphatic drainage

An atypical distribution of the disease involving the anterior

segment of the upper lobes or the lower segment of the basal
lobes has been reported in approximately 5% of cases of postprimary tuberculosis

In most cases, more than one pulmonary segment may be

involved, while bilateral disease is encountered in one-third to
two-thirds of patients

Cavitation
which is the hallmark of this form of pulmonary
tuberculosis, may be evident in half of the patients.
The cavitation process may be single or multiple and
usually creates a lesion surrounded by thick walls with
irregular margins, which may be significantly reduced after
treatment
Postprimary pattern of
tuberculosis in a 55-year-old
woman.
(a) Axial CT scan of the upper
lobes shows an area of cavitation
in the right lung, surrounded by
thick walls with irregular
margins.

In a minority of cases, the cavity may contain a small

quantity of fluid, usually visualized as an air-fluid level

When the amount of fluid content is significantly high,

superinfection by other bacteria should be suspected

Bronchogenic spreading of the disease occurs when an area

of caseous necrosis liquefies and communicates with the
bronchial tree.

It is identified radiographically in 20% of post-primary tuberculosis cases as

multiple, ill-defined 510-mm nodules.

These nodules are in a segmental or lobar distribution involving the dependent

lung zone, distant from the cavitation process

On CT scans, bronchogenic spread can be identified in 95% of patients with postprimary tuberculosis

A significant finding on thin-section in CT is the tree-in-bud pattern, consisting

of 24- mm centrilobular nodules and sharply marginated linear branching
opacities

Tree-in-bud opacities may also be detected in other infections, even if the pattern
characterized by a combination of multiple cavitations or nodular opacities in
suggestive clinical settings, allows the diagnosis of pulmonary tuberculosis

(b) Axial CT scan at levels of main bronchi shows

centrilobular nodules and mucoid impaction of contiguous
branching bronchioles producing a tree-in-bud appearance,
which reflects the presence of endobronchial spread.

Tuberculoma
defined as a sharply marginated rounded or oval lesion
usually measuring in the range of 0.54 cm in diameter
is the predominant parenchymal lesion in 36% of cases.
Tuberculomas are typically solitary lesions, but may be

multiple and surrounded by small satellite nodules with

regular or irregular margins, often containing calcifications

Miliary tuberculosis
refers to the hematogenous dissemination of tuberculosis.
It can occur in both primary and post-primary disease, being

somewhat more frequent in reactivation tuberculosis

Chest

radiography is usually normal at the onset of

symptoms,
while
the
typical
radiographic
findings
characterized by diffuse small nodules are seen in 85% of
cases during more advanced clinical phases of the disease

CT allows accurate early diagnosis when small nodules,

typically 13mm in size or macronodules, resulting from

fusion of several granu- lomas, are detected even in
asymptomatic patients.

Other signs easily detected by high resolution CT (HRCT) are

thickening of interlobular septa and fine intralobular
networks

This latter pattern can be differentiated from the tree-inbud

because the margins of the nodules are well defined and
the distribution is uniform, on the contrary the tree-in-bud
nodules are poorly defined and have a patchy distribution.

The nodules usually resolve within 26 months of specific

treatment, in most cases without scarring or any
calcification

Bronchiectasis and residual cavities are sequelae of

pulmonary tuberculosis, detected at thin-section CT scans
(in 7186% and 1222% of patients with resolved disease)
These lesions typically involve the apical or posterior
segments of the upper lobes

A bronchial dilatation or, more commonly, a residual

tuberculous cavity may be colonized by Aspergillus with
development of a mycetoma.
The typical CT sign consists of an intracavitary mass,
usually surrounded by air (the air crescent sign)

Involvement of the tracheobronchial tree is common in the

postprimary form
if not recognized and properly treated, bronchial scar
stenosis is a frequent complication that may even lead to
obstructive atelec- tasis, pneumonia and bronchiectasis.

The plain chest film shows signs of chronic pleural disease

with pleural thickening that may show calcification.

CT shows a pleural collection associated with an abscess

located at the chest wall level

Impairement of the host immunity is a well-known

predisposing factor in tuberculosis.

Unusual or atypical manifestations are common in

immuncompromised patients.

For example, diabetic and other immunocom- promised

patients have a higher prevalence of multiple cavities and
frequent non-segmental distribution of the lesions

Miliary forms and disseminated disease are also associated

with severe immunosuppression

Tuberculosis is the first cause of death from oppor- tunistic

infections among HIV-infected patients.

The radiographic manifestations of HIV-associated to pulmonary

tuberculosis depend on the degree of immunosuppression

HIV patients with almost preserved cellular immune function

show radiographic findings similar to those of non HIV-infected
individuals.

Patients with a CD4 T-lymphocyte count <200/ mm 3 have a

higher prevalence of mediastinal or hilar lymphadenopathy,
frequent nodular or multinodular image pattern with a lower
prevalence
of
cavitations, and
often
extra-pulmonary
involvement as compared with HIV-seropositive patients with a
CD4 T-lymphocyte 200 mm3 (32).

Absence of ionizing radiation is obviously a great advantage.

However, the small number of signal generating protons,

susceptibility artifacts related to the multiple air-tissue
interfaces and motion artifacts that require fast imaging or
triggering and gating techniques are disadvantages that
should always be considered

MRI has shown an excellent contrast resolution and appears

to be more accurate than non-contrast- enhanced CT in
revealing lymph node involvement, pleural abnormalities,
and parenchymal caseation

Furthermore, signal intensity of lymph nodes may differ

depending on the degree of evolution: on T2- weighted fast
recovery fast spin-echo (FR FSE T2) FAT SAT sequence slight
hyperintensity may indicate flogistic lymphoid hyperplasia,
high hyperintensity is suggestive of liquefactive necrosis and
central isointensity associated to peripheral hyper-intensity
may indi- cate caseosis.

Excellent contrast resolution makes MRI superior to CT in

assessing pleural involvement in case of subtle or loculated
effusions, not seen on CT .

MRI can therefore be considered as an interesting

alternative to CT in subgroups of patients such as chil- dren
or pregnant women.

Differential diagnosis can be particularly challenging when

tuberculosis mimicks sarcoidosis, lymphoma, and pulmonary
neoplasms

Changes in epidemiology characteristics of the disease can

be one of the causes of difficulties in the differential
diagnosis.

While in the past primary tuberculosis was mainly a pediatric

disease, nowadays it is more common in young adults (age
1825 years).

The differential diagnosis with systemic diseases such as

sarcoidosis, Hodgkins lymphoma (HL), and some respiratory
viral conditions, on occasion may represent a real challenge
for the radiologist and the clinician.
morphologic findings of these diseases are characterized by the

presence of pathological hilar and mediastinal homogeneous enhancing

lymph nodes that can be hardly differentiated from tuberculosis
manifestations.
lymphadenopathies

in
tuberculosis
show
a
heterogeneous
enhancement with rim-enhancing and central low attenuation that may
be considered highly specific

these findings are not fully pathognomonic and, especially in cases of

tuberculosis without parenchymal lesions, lymphonodal biopsy is the

only way to reach a reliable diagnosis.

If primary tuberculosis is more common among young

adults, post-primary tuberculosis is more common among
adults.

Post-primary tuberculosis findings often determine a further

differential diagnostic problem with solid neoplasms, giving
isolated opacities on chest radiography or CT scan
accompanied by negative sputum.

Indeed, the presence of acid fast bacilli in sputum or a

positive skin test do not rule out the co-existence of
tuberculosis and cancer.

CT imaging is helpful for the accurate evaluation of the

morphologic and densitometric aspects of the lesion, detection
of lymph nodes enlargement, and the possible presence of
metastases.

Diffuse, central, or lamellar calcifications may be clues to the

imaging diagnosis of tuberculosis over malignancy.

Positron emission tomography CT (PET-CT) could be another

useful tool in case of a challenging differential diagnosis,

however, tuberculosis still remains a frequent cause of false-positive

diagnoses on PET-CT because tuberculomas may even show
hypermetabolic pattern on F18-FDG-PET raising problems of overlapping
findings with tumor masses.

Surgery or biopsy may occasionally be the only solu- tion to

obtain a correct diagnosis

Complete recovery of parenchymal abnormalities usually

require from 6 months to 2 years on radiographs and up to
15 months on CT scans .

Lymphadenopathies may persist for several years after

treatment.

However, absence of improvement of radiological findings

after 3 months of chemotherapy in adults, suggest infection
by drug-resistant organisms or a superimposed process

Imaging findings of multidrug resistant tuberculosis do not

basically differ from those of drug-sensitive tuberculosis,
although the mode of acquisition of drug-resistance seems
to influence the aspect of the radiologic pattern in multidrug resistant tuberculosis.

Patients, who show resistance without having been

previously submitted to anti-tuberculosis chemotherapy or
having performed a therapy cycle of less than 1 month
considered to have primary drug resistance and usually
present with a non-cavitary con- solidation, pleural
effusion, and a primary tuberculosis pattern.

On the other hand, patients who acquire multi- drug

resistant tuberculosis after a wrong chemotherapy treatment
lasting more than 1 month often show cavitation,
consolidation, and a reactivation pattern of the disease .

Differentiation
between
active
and
inactive
tuberculosis based on radiologic findings is reliable only
when the temporal evolution of the disease is considered.

According to the American Tuberculosis Association,

it is required a detailed observation during the time course of at least 6
months to judge the stability.
Other criteria derive from densitometric and morphological features of
the lesion.

CT patterns suggesting active disease are parenchymal

consolidations,
areas
of
ground-glass
attenuation,
endobronchial spread (centrilobular branching linear
opacities, the tree-in-bud sign), miliary pattern, and
cavitations.

Although a slow reduction in the incidence of tuberculosis

has been reported in developed countries,
tuberculosis is still a major challenge on the list of the
most serious infectious diseases in the world, even in the
21st century.

Chest radiography is the mainstay in the radiological

evaluation of suspected or proven pulmonary tuberculosis.

CT is useful in the clarification of certain misleading findings

and may also be helpful in the determination of disease
activity.

Nowadays, the radiological presentation of tuberculosis is

changing, with fading of the classical distinction between
primary and post-primary disease.

The traditional imaging concept of primary and reactivation

tuberculosis has recently been challenged on the basis of
DNA finger- prints, and radiologic features depend on the
level of host immunity rather than the elapsed time after the
infection.

Radiologists must be aware also that new forms of the

diseases may present and should be pre- pared for their
prompt recognition, thus helping to avoid a delayed
treatment, which is associated with high rates of mortality.

THANK YOU