imaging: endobronchial tb
TRANSCRIPT
PROF.DR.G.SUNDARAMURTHY’S UNIT M7DR.BHARGAVI.K
HISTORY IN BRIEF
48 yr old male was admitted With c/o hemoptysis for 1 day-10 episodes c/o giddiness k/c/o HT on Rx not a k/c/o PT On examination:Gen exmn- was normal Cvs-NAD Rs-fine crepts + right interscapular and
subscapular areas.
INVESTIGATIONS Rbs,Rft- within normal limits Hb-9.2 gms, complete profile- normal Sputum AFB- negative Further imaging ensued…….
Lung parenchyma shows TREE IN BUD OPACITY S/O ENDOBRONCHIAL SPREAD OF INFECTION, noted in R UPPER LOBE INVOLVING AZYGOUS LOBE ,LIMITED BY AZYGOUS fissure, apical anterior segment.
Tiny nodular opacities noted in throughout lung tissues on both sides.
?TB etiology.
.
Figure 1. High-resolution CT scan (far left) and drawings of the lung (middle left), a budding tree (middle right), and tree buds (far right) show the tree-in-bud pattern.
Rossi S E et al. Radiographics 2005;25:789-801
©2005 by Radiological Society of North America
THE TERMINAL TUFTS -inflammation with caseous material in the respiratory bronchioles and alveolar ducts
STALKS -caseous material within the terminal bronchiole
Secondary PULMONARY lobule is supplied by a lobular bronchiole and a lobular artery that are located in the center of the lobule.
Under normal circumstances, the intralobular bronchiole is less than 1 mm in diameter and is not normally visible on CT scans
However, diseased bronchioles with mucous plugging with pus,fluid, wall thickening, or dilatation and peribronchiolar inflammation can be visualized on thin-section CT scans, often displaying the tree-in-bud phenomenon
Abnormal – tree in bud Normal ct section
TREE IN BUD PATTERN
Infection Bacterial
Tuberculosis(72%) Non-tuberculosis-MAC,staph aureus,H.influenzae.
Fungal Aspergillus
Viral Cytomegalovirus Respiratory syncytial virus
Idiopathic disorders Obliterative bronchiolitis Diffuse panbronchiolitis
CONGENITAL DISORDERS Cystic fibrosisKartagener’s syndrome
IMMUNOLOGICAL DISORDERS Allergic bronchopulmonary aspergillosis
CONNECTIVE TISSUE DISORDER Rheumatoid arthritisSjogren’s syndrome
MISCELLANEOUS AspirationInhalation of toxic fumes of gasesLangerhans cell histocytosisSarcoidosis
TUMOURSPERIPHERAL PULMONARY VASCULAR DISEASEThrombotic micro-angiography
ENDOBRONCHIAL TB
-TUBERCULOUS INFECTION OF THE TRACHEOBRONCHIALTREE WITH MICROBIAL AND HISTOPATHOLOGICAL EVIDENCE-10-40% OF PATIENTS WITH ACTIVEPULMONARY TUBERCULOSIS.
ENDOBRONCHIAL TBPATHOGENESIS
direct implantation of tubercle bacilliinto the bronchus from an adjacent pulmonary parenchymal lesiondirect airway infiltration from anadjacent tuberculous mediastinal lymph nodeErosion and protrusion of an intrathoracic tuberculous lymphnode into the bronchushematogenous spreadextension to the peribronchial region by lymphaticdrainage.
CLASSIFICATION OF ENDOBRONCHIAL TB (chung n lee)
ACTIVELY CASEATING(43%) EDEMATOUS-HYPEREMIC, FIBROSTENOTIC TUMOROUS GRANULAR ULCERATIVE NONSPECIFIC
CLINICAL SYMPTOMS
COUGH DYSPNEA LOCAL WHEEZE HEMOPTYSIS HOARSENESS ANOREXIA
SEQUELAE….
BRONCHOSTENOSIS BRONCHOSTRICTURES bronchiolitis obliterans bronchocentric granulomatosis BRONCHIECTASIS
DIAGNOSIS
SPUTUM EXAMINATION is the essential and first step .
C X-RAY: NORMAL IN 10-20%
BRONCHOSCOPY(BRONCHIAL BIOPSY/BRUSHING/ WASHINGS) AND CTare the methods of choice for accurate diagnosis of Bronchial involvement . Typical bronchoscopic finding is the presence of white gelatinous granulation tissue. The mucosa is nodular, red, vascular and some times ulcerated. It may simulate a bronchogenic Carcinoma
Nucleic acid amplification tests, such as PCRand other methods for amplifying DNA
TREATMENT
ATT-conventional chemotherapy containing INH, rifampicin, pyrazinamide and ethambutol.
CORTICOSTERIODS
balloon dilatation, self expanding metallic stent(FOR BRONCHIAL STENOSIS)
laser, curettage, resection and anastomosis