New England TB Intensive

The Radiology of Tuberculosis Ronald J. Karpick, M.D. Fairfax County Health Department 9/15/09

Fairfax County, VA Population 10.5 Million 400 square miles

The Nations Capitol is 9.6 miles from my office

Today’s Objectives • Learn how Radiation is produced and how much an individual receives during a CXR • Learn the major landmarks of the CXR • Learn to distinguish Primary and Post primary Pulmonary TB on the CXR • Review the appearance of TB infection in other organ systems

Posterior-Anterior (PA) Chest X-ray

Film

Lead Shield

X-ray tube

Grant’s Atlas of Anatomy 11th Ed

F.J. Netter, Respiratory System, Ciba Collection, 1980

F.J. Netter, Respiratory System, Ciba Collection, 1980

Primary Tuberculosis • • • • • •

First infection with M. tuberculosis Most commonly by way of inhaled air Primary or Ghon focus Lymphatic spread Hematogenous spread Development of Delayed Hypersensitivity and Cell Mediated Immunity within 8 weeks

Ghon focus a calcified granuloma

Primary TB

Ghon focus and enlarged ipsilateral LN=Ranke Complex/Ghon Complex FJC 2.1

PRIMARY TB MEDIASTINAL AND HILAR LN

FJC 2.9a

CAT Scan w Contrast Subcarinal LN

Right Hilar LN

L

post

PET Scan Positive Emission Tomography Radiolabeled Glucose

PRIMARY TB, LN & INFILTRATE

FJC 2.11

PRIMARY TB CONSOLIDATED RIGHT UPPER LOBE, NO AIR BRONCHOGRAMS

FJC 2.4

PRIMARY TB-PLEURAL EFFUSION

FJC 2.12

Pleural Effusion pushing mediastinum to the left

Primary Tuberculosis

in adolescents and young adults

Post-Primary or Reactivation TB • Reactivation of a previously dormant primary infection, though in a small number of cases, it is the extension of the primary infection if it occurs within a year of the initial infection. • It is a disease of adolescents and adults • It affects primarily the upper lobes with a propensity to cavitate, • Extra pulmonary sites include the LN, Pleura, bone, CNS, GU, Peritoneum

POST PRIMARY or REACTIVATION TUBERCULOSIS FJC 2.13a

REACTIVATION TB WITH RUL CAVITY AND BRONCHIAL SPREAD TO THE LEFT LUNG FJC 2.16

Tree-in-bud appearance Tree-in-Bud of TB in a High Resolution appearance CAT scan

Tree-in-Bud

Respiratory bronchiole

Alveolar duct

Eisenhuber, Radiology 2002;222:771-72

Dense calcification in Right Upper Lobe

Post Primary Tuberculosis Reactivation TB

Miliary Tuberculosis

CAT Scan

Miliary Tuberculosis

Millet seeds

CENTRAL NERVOUS SYSTEM

Infiltrating process

MRI

Infiltrating process with pressure compressing the brain edema

Tuberculosis mass CAT Scan

Tuberculomas in the Brain

MRI

TB Meningitis on cortex and Sylvian fissure, MRI with contrast

R

Skeletonal TB

Anterior

Collapsed Vertebrae

Spinal Cord

MRI

Abscess

CAT scan with contrast

TB Osteomyelitis (Pott’s Disease)

TB of the head of the Femur

Moore & Rafii,Radiol.Cl. N.A 2001;39(2): 336

TB of the Head and Neck of the Femur

Tuberculosis Arthritis of the knee

TB of the Elbow Moore & Rafii,Radiol.Cl .N.A 2001;39(2): 336

Gastrointestinal TB

M. Tb of the colon

Mixed ulcerohypertrophic

CAT Scan with contrast

12-7-07

CAT scan with Contrast

HIV +, liver and Spleen

TW

Peripheral Lymph Node Tuberculosis

Lymph Node

3-27-09

Genital-Urinary TB

Renal TB

IVP

TW

Pericardial TB

Water Bottle Heart

CAT Scan

Today’s Objectives • Learned how Radiation is produced and how much an individual receives during a CXR • Learned the major landmarks of the CXR • Learned to distinguish Primary and Post primary Pulmonary TB on the CXR • Reviewed the appearance of TB infection in other organ systems

References • Radiographic Manifestations of Tuberculosis, 2nd Ed., Daley et al., 2006, Francis J. Curry National Tuberculosis Center • Diagnosis of Diseases of the Chest, Fraser & Pare’ WB Saunders, 1970 • Tuberculosis from Head to Toe, Harisinghani et al., RadioGraphics 2000; 20: 449-470 • Introduction to Chest Radiology; SB Gay et al., UVA Health Science Center, Department of Radiology, 2003 www.med-ed.virginia.edu/courses/rad/

References • Atlas Radiologic Anatomy; L.Wicke, 7th English Edition, Icon Learning Systems, 2004 • Blueprints Radiology; A. Uzelac and RW Davis, Lippincott Williams & Wilkins, 2006 • Introduction to Diagnostic Imaging; G. Stimac, WB Saunders 1992 • Getting Started in Clinical Radiology; G. Eastman, Wald and Crossin, Thieme, 2006

Questions ???