jurnal tb radiologi

7/24/2019 Jurnal Tb Radiologi

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TUBERCULOSIS

Clinical Clerkcship o Ra!iolo"#$epar%&en%Fac'l%# o Me!icine( Uni)ersi%as Peli%a HarapanPolice Hospi%als( Bha#an"kara Tk*I Ra!en Sai!

S'kan%o

Perio! o Oc%o+er ,-%h,./01 No)e&+er /2%h,./0


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T'+erc'losisinfectious diseasecaused by Mycobacterium tuberculosis

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

P'l&onar# %'+erc'losis Primary tuberculosis post-primary tuberculosis


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Pri&ar# %'+erc'losis

occurs in patients not previously exposed toMycobacterium tuberculosis.

Within 2 years after the infection, primary tuberculosis

usually results in active disease

Pos%1pri&ar# or reac%i)a%e! %'+erc'losis

occurs in patients ho have been previously infected

and have developed a certain degree of ac!uiredimmunity.

"eactivated tuberculosis may result from bothendogenous reactivation #more often$ and exogenousre-infection #super-infection$


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EPI$EMIOLOGY

%he burden of disability and death due to tuberculosis isimmense, ith an estimated &.' million incident cases oftuberculosis in 2()) in the orld among these, about )*+ ere human immunodeciency

virus #/$-positive

%here ere estimated )'( per )((,((( population ratesprevalent cases of tuberculosis in 2()).

oever, because of insu0cient case detection and incompletenotication, reported cases represent only 1(+ of the totalnumber of ne cases. bout 1(+ of cases are in the 3outh-4ast sia and Western

Pacic regions.

%he frican region has 25+ of the orld cases, and thehighest rates of cases and deaths per capita


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6linical signs and symptoms of pulmonary tuberculosis in adults areoften nonspecic, hereas complete absence of symptoms occursin approximately *+ of adult cases.

The &os% re3'en% respira%or# s#&p%o& 4

cough for more than 2 ee7s

emoptysis

pleuritic chest pain

dyspnea may be present in case of extensive lung involvement.

S#s%e&ic &anies%a%ions 4

lo-grade fever

anorexia,

fatigue,

night seats

eight loss that may persist for ee7s to months


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The &os% co&&on he&a%olo"ic associa%e!&anies%a%ionshigh hite blood cells count and anemia #both occurring in)(+ of patients$

8iagnosis of tuberculosis in elderly is fre!uently delayedbecause classic symptoms rarely occur or may be confusedby other chronic diseases.

%he clinical manifestations of tuberculosis in /-infectedpeople depend on the severity of their immunosuppression

n people ith advanced disease, pulmonary tuberculosis isoften accompanied by extra- pulmonary involvement


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Primary tuberculosis manifests ith three main entities9 parenchymal disease

:ymphadenopathy

pleural e;usion.

On ches% 5l&

parenchymal disease typically manifests

dense

homogeneous parenchymal consolidation predominantly located in the middle and loer lobes

#especially in adults$


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irspace consolidation, related to bronchioloalveolar caseousexudate, is usually unilateral and evidenced through radiographsapproximately in '(+ of children ith primary tuberculosis


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CT s%'!ies %he appearance of the parench#&al consoli!a%ions in

pri&ar# %'+erc'losis is most commonly dense andhomogeneous but may also be linear, patchy, nodular, or

mass-li7e

n nearly to-thirds of cases, the parenchymal focusresolves ithout se!uelae at conventional radiography

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

3atellite calcied foci and persistent mass-li7e opacities,called T'+erc'lo&as, can be found in approximately


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:ymph node enlargement is the hallmar7 of primarytuberculosis in childhood

%his condition is encountered in about + ofcases$ #)(,))$

:ymphadenopathies are usually unilateral and located in thehilum or paratracheal regions

?n computed tomography #6%$

hich is more sensitive than chest radiography for assessinglymphadenopathy, enlarged nodes typically sho 9

central lo attenuation, representing caseous necrosis, hereas peripheral

rim enhancement represents the vascular rim of the granulomatousin@ammatory tissue


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%he combination of a Ghon focus and a calcied hilar node iscalle! Ranke Co&ple6 suggestive of previoustuberculosis infection.

Pleural tuberculosis is considered a complication of primarytuberculosis, although in up to )


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%uberculous e;usions contain high !uantity of proteins and oftensho brin strands and septa on thoracic ultrasound imaging

/ery often septa that have been imaged by ultrasound are notdetected by 6%

n these cases 6% usually shos

homogeneous @uid in the pleural cavity, but is more panoramicand therefore more sensitive than plain chest radiography andlung ultrasound in diagnosing associated parenchymal diseases.

fter contrast administration

pleural layers enhance and are revealed as a smooth thic7eningof the visceral and parietal pleural surfaces separated by avariable amount of @uid 7spli% ple'ra si"n8


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"eactivation tuberculosis tends to involve predominantly theapical and posterior segments of the upper lobes and thesuperior segments of the loer lobes.

%hese specic locations are explained by relative higheroxygen tension and impaired lymphatic drainage

n atypical distribution of the disease involving the anteriorsegment of the upper lobes or the loer segment of the basal

lobes has been reported in approximately *+ of cases of post-primary tuberculosis

n most cases, more than one pulmonary segment may be

involved, hile bilateral disease is encountered in one-third toto-thirds of patients


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Ca)i%a%ion hich is the hallmar7 of this form of pulmonary

tuberculosis, may be evident in half of the patients.

%he cavitation process may be single or multiple and

usually creates a lesion surrounded by thic7 alls ithirregular margins, hich may be signicantly reduced aftertreatment

Postprimary pattern of

tuberculosis in a **-year-oldoman.#a$ xial 6% scan of the upperlobes shos an area of cavitationin the right lung, surrounded bythic7 alls ith irregular

margins.


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n a minority of cases, the cavity may contain a small!uantity of @uid, usually visualiAed as an air-@uid level

When the amount of @uid content is signicantly high,superinfection by other bacteria should be suspected


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Broncho"enic sprea!in" o %he !isease occ'rs 9hen an areao caseo's necrosis li3'e5es an! co&&'nica%es 9i%h %he+ronchial %ree* t is identied radiographically in 2(+ of post-primary tuberculosis cases as

multiple, ill-dened *B)(-mm nodules.

%hese nodules are in a segmental or lobar distribution involving the dependent

lung Aone, distant from the cavitation process

?n 6% scans, bronchogenic spread can be identied in


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#b$ xial 6% scan at levels of main bronchi shoscentrilobular nodules and mucoid impaction of contiguousbranching bronchioles producing a tree-in-bud appearance,hich re@ects the presence of endobronchial spread.


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T'+erc'lo&a dened as a sharply marginated rounded or oval lesion

usually measuring in the range of (.*B5 cm in diameter

is the predominant parenchymal lesion in >B1+ of cases.

%uberculomas are typically solitary lesions, but may bemultiple and surrounded by small CCsatellite nodules ith

regular or irregular margins, often containing calcications


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Miliar# %'+erc'losis refers to the hematogenous dissemination of tuberculosis.

t can occur in both primary and post-primary disease, being

somehat more fre!uent in reactivation tuberculosis

6hest radiography is usually normal at the onset ofsymptoms, hile the typical radiographic ndingscharacteriAed by di;use small nodules are seen in &*+ of

cases during more advanced clinical phases of the disease

6% allos accurate early diagnosis hen small nodules,typically )B>mm in siAe or macronodules, resulting fromfusion of several granu- lomas, are detected even inasymptomatic patients.


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?ther signs easily detected by high resolution 6% #"6%$ arethic7ening of interlobular septa and ne intralobularnetor7s

%his latter pattern can be di;erentiated from the %ree1in1+'!

because the margins of the nodules are ell dened andthe distribution is uniform, on the contrary the tree-in-budnodules are poorly dened and have a patchy distribution.

%he nodules usually resolve ithin 2B1 months of specictreatment, in most cases ithout scarring or anycalcication


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Dronchiectasis and residual cavities are se!uelae ofpulmonary tuberculosis, detected at thin-section 6% scans

#in ')B&1+ and )2B22+ of patients ith resolved disease$

%hese lesions typically involve the apical or posterior

segments of the upper lobes

bronchial dilatation or, more commonly, a residualtuberculous cavity may be coloniAed by spergillus ithdevelopment of a mycetoma.

%he typical 6% sign consists of an intracavitary mass,usually surrounded by air 7%he ::air crescen% si"n;;8


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nvolvement of the tracheobronchial tree is common in thepostprimary form

if not recogniAed and properly treated, bronchial scarstenosis is a fre!uent complication that may even lead toobstructive atelec- tasis, pneumonia and bronchiectasis.

%he plain chest lm shos signs of chronic pleural diseaseith pleural thic7ening that may sho calcication.

6% shos a pleural collection associated ith an abscesslocated at the chest all level


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mpairement of the host immunity is a ell-7nonpredisposing factor in tuberculosis.

Enusual or atypical manifestations are common inimmuncompromised patients.

For example, diabetic and other immunocom- promisedpatients have a higher prevalence of multiple cavities andfre!uent non-segmental distribution of the lesions

Miliary forms and disseminated disease are also associatedith severe immunosuppression


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%uberculosis is the rst cause of death from oppor- tunisticinfections among /-infected patients.

%he radiographic manifestations of /-associated to pulmonarytuberculosis depend on the degree of immunosuppression

/ patients ith almost preserved cellular immune functionsho radiographic ndings similar to those of non /-infectedindividuals.

Patients ith a 685 %-lymphocyte count 2((H mm> have ahigher prevalence of mediastinal or hilar lymphadenopathy,fre!uent nodular or multinodular image pattern ith a loerprevalence of cavitations, and often extra-pulmonaryinvolvement as compared ith /-seropositive patients ith a

685 %-lymphocyte I2(( mm> #>2$.


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bsence of ioniAing radiation is obviously a great advantage.

oever, the small number of signal generating protons,susceptibility artifacts related to the multiple air-tissueinterfaces and motion artifacts that re!uire fast imaging or

triggering and gating techni!ues are disadvantages thatshould alays be considered

M" has shon an excellent contrast resolution and appearsto be more accurate than non-contrast- enhanced 6% in

revealing lymph node involvement, pleural abnormalities,and parenchymal caseation


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Furthermore, signal intensity of lymph nodes may di;erdepending on the degree of evolution9 on %2- eighted fastrecovery fast spin-echo #F" F34 %2$ F% 3% se!uence slighthyperintensity may indicate @ogistic lymphoid hyperplasia,high hyperintensity is suggestive of li!uefactive necrosis and

central isointensity associated to peripheral hyper-intensitymay indicate caseosis.

4xcellent contrast resolution ma7es M" superior to 6% inassessing pleural involvement in case of subtle or loculatede;usions, not seen on 6% .

M" can therefore be considered as an interestingalternative to 6% in subgroups of patients such as children

or pregnant omen.


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8i;erential diagnosis can be particularly challenging hentuberculosis mimic7s sarcoidosis, lymphoma, and pulmonaryneoplasms


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6hanges in epidemiology characteristics of the disease canbe one of the causes of di0culties in the di;erentialdiagnosis.

While in the past primary tuberculosis as mainly a pediatric

disease, noadays it is more common in young adults #age)&B2* years$.


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%he di;erential diagnosis ith systemic diseases such assarcoidosis, odg7ins lymphoma #:$, and some respiratoryviral conditions, on occasion may represent a real challengefor the radiologist and the clinician. morphologic ndings of these diseases are characteriAed by the

presence of pathological hilar and mediastinal homogeneous enhancinglymph nodes that can be hardly di;erentiated from tuberculosismanifestations.

lymphadenopathies in tuberculosis sho a heterogeneousenhancement ith rim-enhancing and central lo attenuation that maybe considered highly specic

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

tuberculosis ithout parenchymal lesions, lymphonodal biopsy is theonly ay to reach a reliable diagnosis.


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f primary tuberculosis is more common among youngadults, post-primary tuberculosis is more common amongadults.

Post-primary tuberculosis ndings often determine a further

di;erential diagnostic problem ith solid neoplasms, givingisolated opacities on chest radiography or 6% scanaccompanied by negative sputum.

ndeed, the presence of acid fast bacilli in sputum or apositive s7in test do not rule out the co-existence oftuberculosis and cancer.


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6% imaging is helpful for the accurate evaluation of themorphologic and densitometric aspects of the lesion, detectionof lymph nodes enlargement, and the possible presence ofmetastases.

8i;use, central, or lamellar calcications may be clues to theimaging diagnosis of tuberculosis over malignancy.

Positron emission tomography 6% #P4%-6%$ could be anotheruseful tool in case of a challenging di;erential diagnosis,

hoever, tuberculosis still remains a fre!uent cause of false-positivediagnoses on P4%-6% because tuberculomas may even shohypermetabolic pattern on F)&-F8G-P4% raising problems of overlappingndings ith tumor masses.

3urgery or biopsy may occasionally be the only solu- tion toobtain a correct diagnosis


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6omplete recovery of parenchymal abnormalities usuallyre!uire from 1 months to 2 years on radiographs and up to)* months on 6% scans .

:ymphadenopathies may persist for several years after

treatment.

oever, absence of improvement of radiological ndingsafter > months of chemotherapy in adults, suggest infectionby drug-resistant organisms or a superimposed process

maging ndings of multidrug resistant tuberculosis do notbasically di;er from those of drug-sensitive tuberculosis,although the mode of ac!uisition of drug-resistance seemsto in@uence the aspect of the radiologic pattern in multi-

drug resistant tuberculosis.


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Patients, ho sho resistance ithout having beenpreviously submitted to anti-tuberculosis chemotherapy orhaving performed a therapy cycle of less than ) month

considered to have primary drug resistance and usuallypresent ith a non-cavitary consolidation, pleurale;usion, and a primary tuberculosis pattern.

?n the other hand, patients ho ac!uire multi- drugresistant tuberculosis after a rong chemotherapy treatment

lasting more than ) month often sho cavitation,consolidation, and a reactivation pattern of the disease .


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$i


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lthough a slo reduction in the incidence of tuberculosishas been reported in developed countries,

tuberculosis is still a maJor challenge on the list of themost serious infectious diseases in the orld, even in the2)st century.

6hest radiography is the mainstay in the radiologicalevaluation of suspected or proven pulmonary tuberculosis.

6% is useful in the clarication of certain misleading ndingsand may also be helpful in the determination of diseaseactivity.

Koadays, the radiological presentation of tuberculosis ischanging, ith fading of the classical distinction beteenprimary and post-primary disease.


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%he traditional imaging concept of primary and reactivationtuberculosis has recently been challenged on the basis of8K nger- prints, and radiologic features depend on thelevel of host immunity rather than the elapsed time after theinfection.

"adiologists must be aare also that ne forms of thediseases may present and should be pre- pared for theirprompt recognition, thus helping to avoid a delayedtreatment, hich is associated ith high rates of mortality.


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