PRESENTATION MATERIALS

Basic Chest
Radiology
for the TB
Clinician
Adapted from the ISTC TB Training
Modules 2009

Basic Radiology for the TB

Clinician
Objectives: At the end of this presentation,
participants will be able to:
Analyze the technical quality of chest Xrays (CXRs) using simple parameters
Identify basic normal CXR anatomy on
both frontal and lateral views
Recognize radiographic patterns of disease
and describe using appropriate
terminology
Describe both the typical and atypical
patterns of radiographic presentation for
pulmonary tuberculosis
ISTC TB Training Modules 2009

Basic Radiology for the TB

Clinician (2)
Overview:
Technical aspects of chest
radiography
Systematic approach to
reading CXR
Basic CXR anatomy
Patterns of disease
Radiographic manifestations of
tuberculosis (TB)

ISTC TB Training Modules 2009

Chest Radiography: Basic

Principles
X-ray
X-rayphoton:
photon:Absorbed
Absorbed//scattered
scattered//
transmitted
transmitted
X-ray
X-rayabsorption
absorptiondepends
dependson:
on:

Beam
Beamenergy
energy(constant)
(constant)
Tissue
density
Tissue density

Maximum X-Ray
Transmission
(least dense tissue)

Maximum X-Ray
Absorption
(densest tissue)
ISTC TB Training Modules 2009

Blackest
air
fat
soft tissue
calcium
bone
X-ray contrast
metal
Whitest

Differential X-Ray Absorption

Why we see what we see:
Structures are visible on a
radiograph because of the
juxtaposition of two
different densities
creating an interface
Silhouette Sign
Loss of an expected
interface
No boundary can be
seen between two
structures because they
now are similar in density
Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

Silhouette
Silhouette Sign:
Sign: RLL
RLL Pneumonia
Pneumonia

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

Silhouette
Silhouette Sign:
Sign: RLL
RLL Pneumonia
Pneumonia

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

Assess CXR Technical Quality

Inspiratory effort
9-10 posterior ribs
Penetration
thoracic intervertebral disc space
just visible
Positioning / rotation
medial clavicle heads equidistant
from spinous process

ISTC TB Training Modules 2009

Image credit: Curry International Tuberculosis Center, University of California, San

ISTC TB Training Modules 2009

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Image credit: Curry International Tuberculosis Center, University of California, San

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Image credit: Curry International Tuberculosis Center, University of California, San

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Image credit: Curry International Tuberculosis Center, University of California, San

ISTC TB Training Modules 2009

Inspiratory Effort
Low Lung Volumes

Full Inspiration

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

Exposure
Overexposure

Proper Exposure

Image credit: Curry International Tuberculosis Center, University of California, San

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Overexposure Proper Exposure

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Rotated (Oblique)
Image credit: Curry International Tuberculosis Center, University of California, San

ISTC TB Training Modules 2009

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Basic Radiology for the TB

Clinician

A systematic
approach to
reading a CXR

Image
Credit:
Lung
ISTC TB Training
Modules
2009 Health Image Library/Gary Hampton

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Approach to Reading a
CXR
Be
Systematic
Lungs
Pleural surfaces
Cardiomediastin
al contours
Bones and soft
tissues
Abdomen
Image credit: Curry International Tuberculosis Center, University of California, San

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Worth a Second Look

Apices
Retrocardiac areas (left and
right)
Hilar regions
Below diaphragm

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Apical TB
Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Apical TB (2)
Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Left Retrocardiac Opacity

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Nodule Behind Diaphragm

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Basic Radiology for the TB

Clinician

Basic CXR
Anatomy

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Basic CXR Anatomy

Frontal and Lateral Views
Heart
Aorta
Pulmonary
arteries
Airways

Image Credit: Lung Health Image Library/Pierre Virot

ISTC TB Training Modules 2009

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Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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 Aortic arch
Right
pulmonary
artery
Left pulmonary
artery
Trachea &
bronchi

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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 Aortic arch

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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 Aortic arch
Right
pulmonary
artery

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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 Aortic arch
Right
pulmonary
artery
Left pulmonary
artery

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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 Aortic arch
Right
pulmonary
artery
Left pulmonary
artery
Trachea &
bronchi

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Basic Radiology for the TB

Clinician

Patterns of
disease

ISTC TB Training Modules 2009

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Chest Radiographic Patterns of

Disease

Consolidation / air-space opacity

Interstitial opacity
Nodules and masses
Lymphadenopathy
Cysts and cavities
Pleural abnormalities

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Consolidation / Air-Space
Opacity
Caused by filling of alveoli with fluid,
pus, blood, cells (tumor), etc.
May be diffuse, or isolated to
segments or lobes of the lung
May be associated with air
bronchograms (air-filled bronchus
surrounded by opacified lung)

ISTC TB Training Modules 2009

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Pneumonia

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Interstitial Opacity
Disease localized to pulmonary
interstitium, i.e., the alveolar septae and
connective tissues that support the alveoli
Hallmarks:
Lines and/or reticulation
Small, well-defined nodules
Miliary pattern

DDX: Pulmonary edema, interstitial lung

diseases (e.g., idiopathic pulmonary
fibrosis), sarcoidosis, infection, tumor
(lymphangitic spread), etc.
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Interstitial Opacity: Lines

Image2009
credit:
ISTC TB Training Modules

Curry International Tuberculosis Center, University of California, San

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Interstitial Opacity: Lines

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Interstitial Opacity: Lines & Reticulatio

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Nodules and Masses

Nodule: discrete pulmonary lesion,
sharply defined, nearly circular opacity
0.2 - 3 cm
Mass: larger than 3 cm
Describe with qualifiers:
Single or multiple
Size
Border characteristics
Presence or absence of calcification
Location
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Well-Defined

Calcification

Ill-Defined

Mass

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Lymphadenopathy (LAN)
Non-specific terms:
Mediastinal widening
Hilar prominence
Specific patterns:
Particular station enlargement
(location)
Important to know what normal
should look like in order to recognize
abnormal
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Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Lymphadenopathy
Infrahilar
window (right
hilar and/or
subcarinal)
Left hilar
Subcarinal

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Lymphadenopathy
Infrahilar
window (right
hilar and/or
subcarinal)

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Lymphadenopathy

Left hilar

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Lymphadenopathy

Subcarinal

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Right Paratracheal & Bilateral LAN

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Right Hilar LAN

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Right Hilar LAN

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Subcarinal LAN

*
Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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AP Window LAN

Image
credit:
Curry
ISTC TB Training
Modules
2009 International Tuberculosis Center, University of California, San

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Cysts & Cavities

Abnormal pulmonary parenchymal spaces
(holes), filled with air and/or fluid, with a
definable wall (>1 mm)
Cyst: congenital or acquired
Cavity: caused by tissue necrosis,
(inflammatory and/or neoplastic)
Characterize:
Wall thickness at thickest portion
Inner lining
Presence / absence of air / fluid level
Number and location
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TB or Not TB? Cysts and

Cavities
Are there
radiographi
c features
that
suggest
benign vs.
malignant
diagnoses?

A
C

45 year old man

from China with
B
cough, weight
D
Imageloss
credit: Curry International Tuberculosis Center, University of California, San 42
ISTC TB Training Modules 2009

TB or Not TB? Cysts and

Cavities (2)
Are there radiographic features that
suggest benign vs. malignant diagnoses?
Benign cysts: uniform wall
thickness, 1mm, smooth
inner lining (e.g., PCP)

ISTC TB Training Modules 2009

Benign
cavities: max.
wall thickness
4 mm, minimally
irregular inner
lining (e.g., TB)
Malignant cavities:
max. wall thickness
16 mm, irregular
inner lining

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Pleural Disease: Basic

Patterns
Effusion
Angle
blunting to
massive
Thickening
Mass
Air
Calcification

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Pleural Effusion

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Post-TB Pleural Calcification

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Plombage with Lucite balls

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Basic Radiology for the TB

Clinician

Radiographic
Manifestation
s of TB

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Can this be TB?

Typical Pattern:
Post-primary TB
Distribution
Apical / posterior
segments of upper lobes
Superior segments of
lower lobes
Isolated anterior
segment involvement
unusual for M.tb (think
M. avium complex)

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Typical pattern: Post-Primary

TB
Patterns of disease

Air-space consolidation
Cavitation, cavitary nodule
Endobronchial spread
Miliary
Bronchostenosis
Tuberculoma
Pleural effusions
(empyema most likely in
post-primary disease)

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Can this be TB?

Atypical pattern:
Primary TB
Distribution : any lobe
involved (slight lower lobe
predominance)
Air-space consolidation
Cavitation is uncommon
(<10%)
Adenopathy is common
(esp. children and HIV),
predilection for right side
Miliary pattern
Pleural effusions
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Can this be TB? Miliary TB

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Radiographic Patterns: Pulmonary

TB
Typical
TB Pattern (Post-Primary)

Atypical
(Primary)

Infiltrate

85% upper

Upper : Lower
60 : 40
Usually upper in
children

Cavitation

Common

Uncommon

Adenopathy

Uncommon

Children common
Adults ~30%
Unilateral >
bilateral

Effusion

May be present

May be present

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CXR Pattern: Early vs. Advanced

HIV
Early HIV

Advanced HIV

(CD4>200)

(CD4<200)

Typical
(Post-primary)

Atypical
(Primary)

Infiltrate

Upper lobes

Lower lobes,
multiple sites, or
miliary

Cavitation

Common

Uncommon

Adenopathy

Uncommon

Common

Effusion

Uncommon

More common

Pattern

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Can this be TB?

Old / Healed TB
Ca++ granulomaGhon lesion
Ca++ granuloma and hilar
node calcificationRanke
complex
Apical pleural thickening
Fibrosis and volume loss

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Basic Radiology for the TB

Clinician
Summary:
Remember: Technical quality
can significantly impact your
CXR interpretation
Develop a systematic
approach (and use it every time!)
Practice identifying normal
CXR anatomy
Important to characterize and describe lesions
this can help with your differential diagnosis
Whether typical or atypical
TB can always fool you!
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