Radiology Case 1 Final

RADIOLOGY Case Discussion 1 JACINTO, Ma. Theresa JEONG, Kyung Sun JOSE, Niña JUNIA, Christine Joy KING KAY, Caroline Bernadette LAO, Eugene LAO, Kriselle Maris LAO, Lawrence Edeniño LAO, Sharlene Marie LAUS, Lady Diana Rose III - C

CASE RR, 70 years old, male, seaman  Chief complaint: Cough 

History of Present Illness 

3 years PTC  Productive

cough with whitish phlegm  Accompanied by fever and body malaise  Self-medicated with paracetamol and amoxicillin (unrecalled dosage)

History of Present Illness 

2 years PTC  Persistence

of cough, now blood tinged  Sought consult, was advised to have chest xray.  Was given anti-TB regimen but unable to comply with the full course of treatment

History of Present Illness 

1 year PTC  Occasional

cough and febrile episodes  No medications taken 

3 days PTC  Expectorated

blood  Advised to have chest CT scan

Review of Systems (+) weight loss  (+) loss of appetite  (+) body malaise  (+) night sweats 

Past Medical History 

(+) Hypertension

Physical Examination Hyposthenic  Normal Vital Signs  Lagging of the left lung  Diminished breath sounds on the left 

Normal Patient

Chest PA

Lateral

Learning Issues       

Radiographic signs of PTB What is a tuberculoma? Distinguish between primary vs re-infection tuberculosis Explain the presence of atelectasis, cavitations and bronchiectasis in PTB What is the role of follow-up chest x-ray? Radiographic findings of healed PTB What is the role of CT scan?

OUTLINE  

Pathophysiology of Tuberculosis Radiographic Signs of PTB    

   

Tuberculoma Bronchiectasis Cavitation Atelectasis

Primary vs. Re-infection PTB Active vs. Healed PTB Role of Chest X-Ray in Follow-up Role of CT Scan

OUTLINE  

Pathophysiology of Tuberculosis Radiographic Signs of PTB    

   

Tuberculoma Bronchiectasis Cavitation Atelectasis

Primary vs. Re-infection PTB Active vs. Healed PTB Role of Chest X-Ray in Follow-up Role of CT Scan

Infection with M. tuberculosis Alveolar macrophage ingestion of bacilli Unchecked bacillary multiplication

Alveolar macrophages secrete cytokines IL1 IL6

Lysis of the macrophage TNF-ά Activated monocytes ingest the bacilli from lysed macrophage

Fever Hyperglobulinemia

• Killing of Mycobacteria • Granuloma formation • Fever • Weight loss

Activation of more host responses Tissue-damaging response

Macrophage-activating response

Formation of solid necrosis in the center of the tubercle

• Development of specific immunity • Accumulation of activated macrophage

Caseating granuloma

Tubercle formation

Some lesions heal by fibrosis and calcification

• Lagging of the left lung •  Breath sounds

Treatment failure Intensified DTH  Tissue-damaging response Caseous material liquefies Invasion & destruction Of BV and bronchial walls Cavity formation

Drained through bronchi

Multiplication & spread of the bacilli into the airways

• Cough • Hemoptysis

OUTLINE  

Pathophysiology of Tuberculosis Radiographic Signs of PTB    

   

Tuberculoma Bronchiectasis Cavitation Atelectasis

Primary vs. Re-infection PTB Active vs. Healed PTB Role of Chest X-Ray in Follow-up Role of CT Scan

Tuberculoma   

 

Primary, post-primary tuberculosis Form of lesion commonly seen in TB Well circumscribed, round/oval opacities caused by acid-fast bacilli 1-4 cm or more in diameter mostly in upper lobe, right more than the left

Tuberculoma

OUTLINE  

Pathophysiology of Tuberculosis Radiographic Signs of PTB    

   

Tuberculoma Bronchiectasis Cavitation Atelectasis

Primary vs. Re-infection PTB Active vs. Healed PTB Role of Chest X-Ray in Follow-up Role of CT Scan

Bronchiectasis 



Localized, irreversible dilatation of the bronchial tree Associated with acute, chronic or recurrent infection (bacteria and mycobacteria)

Bronchiectasis

  

Tram line Ring shadows with thickened bronchial walls Mucus plugs

Bronchiectasis

  

Air fluid levels Watch for dextrocardia Diffuse lung fibrosis 

Due to recurrent infections

Bronchiectasis

   

Bronchial dilatation Tram lines Thickened bronchial walls Mucus plugs

OUTLINE  

Pathophysiology of Tuberculosis Radiographic Signs of PTB    

   

Tuberculoma Bronchiectasis Cavitation Atelectasis

Primary vs. Re-infection PTB Active vs. Healed PTB Role of Chest X-Ray in Follow-up Role of CT Scan

Cavitations 

Cavitation, usually in the apices of the lungs, occurs readily in the secondary form of PTB, resulting in dissemination of mycobacteria along the airways

Robbins and Kutran. Pathologic basis of disease. 7th ed pp. 384-386



Expansion in the area of caseation  erosion into a bronchus  evacuation of the caseous center (cough)  irregular cavity lined by caseous material and fibrous tissue Robbins and Kutran. Pathologic basis of disease. 7th ed pp. 384-386



Early stages  Cavity

is usually irregular, often showing air-fluid level

Radiology of the chest. Regional roentgen pathology. pp. 358-364



Early stages Small areas of infiltration, consolidation adjacent to a cavity is highly suggestive of PTB (differentiate from lung abcess)  Early lesions: posterior portion of upper lobe, below level of the clavicle 

Radiology of the chest. Regional roentgen pathology. pp. 358-364

CAVITY

CAVITY

OUTLINE  

Pathophysiology of Tuberculosis Radiographic Signs of PTB    

   

Tuberculoma Bronchiectasis Cavitation Atelectasis

Primary vs. Re-infection PTB Active vs. Healed PTB Role of Chest X-Ray in Follow-up Role of CT Scan

Atelectasis 



“Incomplete stretching”, loss of volume of lung tissue because of decreased amount of gas Destructive process in the walls of the bronchi and plugging of the lumina by exudate Radiology of the chest. Regional roentgen pathology. pp. 365-367 Thoracic Imaging: Pulmonary and Cardiology. pp. 47-65



Direct Signs ( due to lobar volume loss)  Displacement of interlobular fissures: best sign of atelectasis  Crowding of vessels, bronchi or air bronchograms Radiology of the chest. Regional roentgen pathology. pp. 365-367 Thoracic Imaging: Pulmonary and Cardiology. pp. 47-65



Indirect Signs  Diaphragmatic elevation: due to ipsilateral volume loss: more common lower lobe  Juxtaphrenic Peak (upper lobe atelectasis) Radiology of the chest. Regional roentgen pathology. pp. 365-367 Thoracic Imaging: Pulmonary and Cardiology. Pp. 47-65



Indirect Signs  Mediastinal

shift: more common upper lobe collapse (Trachea); more common lower lobe collapse (heart)

Radiology of the chest. Regional roentgen pathology. pp. 365-367 Thoracic Imaging: Pulmonary and Cardiology. pp. 47-65



Indirect signs  

Compensatory overinflation of normal lung on the same side; increased volume with decreased density of lung Hilar displacement: Hilum ELEVATED with ULA; Hilum DEPRESSED with LLA Thoracic Imaging: Pulmonary and Cardiology. Pp 47-65



Indirect signs  Reorientation

of hilum or bronchi  ULA: hilum rotates outward and descending pulmonary artery is less vertical and easily seen  LLA: hila are depressed and bronchi appear more vertical Radiology of the chest. Regional roentgen pathology. pp. 365-367 Thoracic Imaging: Pulmonary and Cardiology. pp. 47-65



Indirect Signs  Approximation of the ribs: ipsilateral ribs appear closer together  Flat waist sign: flattening of the left heart border due to rotation of heart and great vessels Radiology of the chest. Regional roentgen pathology. pp. 365-367 Thoracic Imaging: Pulmonary and Cardiology. pp. 47-65



Indirect Signs  Increased

lung opacity: reflects replacement of alveolar air with fluid or compressed airless tissue  Absence of air bronchograms Radiology of the chest. Regional roentgen pathology. pp. 365-367 Thoracic Imaging: Pulmonary and Cardiology. pp. 47-65



Indirect signs  Absence of air bronchograms suggests central bronchial obstruction  Mucus bronchograms  Shifting granuloma sign: parenchymal lesions of prior film shifts in location Radiology of the chest. Regional roentgen pathology. pp. 365-367 Thoracic Imaging: Pulmonary and Cardiology. pp. 47-65

OUTLINE  

Pathophysiology of Tuberculosis Radiographic Signs of PTB    

   

Tuberculoma Bronchiectasis Cavitation Atelectasis

Primary vs. Re-infection PTB Active vs. Healed PTB Role of Chest X-Ray in Follow-up Role of CT Scan

Primary Tuberculosis  

Pulmonary imaging findings in individuals with primary tuberculosis are nonspecific Note that chest radiographic findings may be normal in as many as 15% of patients with primary pulmonary tuberculosis

Primary Tuberculosis 

Parenchymal consolidation  Predilection

for the lower lobes, middle lobe and lingula, and anterior segments of the upper lobes  Homogeneous, with ill-defined margins  Caseous necrosis occurs centrally within the lung parenchymal opacity, decreasing its size  Become rounded with healing, continues to shrink until only a small nodule remains → calcified or ossified → calcified granuloma



PTB with bronchogenic spread in 34 y/o woman   

CXR: Nodules, right lower lobe HRCT: Peribronchial (arrows) and large acinar (arrowheads) nodules CT: Lobular consolidations (arrows) and acinar nodules (arrowheads) (Lee KS et al, 1003)



Tuberculoma may be a manifestation of either primary or postprimary tuberculosis (Lee KS et al, 1003)

Primary Tuberculosis 

Lymphadenopathy  Distinguishing

feature of primary TB vs.

recurrent TB  More common with immune incompetent hosts  Most common in the ipsilateral hilar region  May involve the airways  Indistinguishable from that of sarcoid or lymphoma



Tuberculosis, lymphadenopathy in a 19 y/o male  

CXR: Bilateral widening of superior mediastinum and enlargement of right hilum CT: Extensive mediastinal adenopathy with central low density and peripheral rim enhancement

Primary Tuberculosis 

Airway involvement  Airway

compression with resultant atelectasis  Mucosal infection  Broncholithiasis  Endobronchial spread of infection  Bronchiectasis



Traction bronchiectasis in a 52 y/o male  HRCT: Dilatation of right upper lobe bronchi and granuloma in left upper lobe (Hyae Young Kim,



Tracheobronchial stenosis in a 40 y/o female  Contrast-enhanced CT: narrowing of left main bronchus

(Hyae Young Kim, 2001)



Broncholithiasis in a 58 y/o male   

Contrast-enhanced CT: broncholith within lateral segmental bronchus of right middle lobe Distal obstructive atelectasis and calcified lymph nodes Right pleural effusion (Hyae Young Kim,

Re-infection Tuberculosis Often on the apical and posterior segments of the upper lobes or superior segments of the lower lobes  Associated with progressive disease 

Re-infection Tuberculosis



Most common clinical finding is poorly defined areas of consolidation in involved segments

Re-infection Tuberculosis



There may be cavitation, with visible endobronchial spread

Re-infection Tuberculosis



In 20-45% of patients with active post-primary TB, cavitation is visible on chest radiographs, with numerous small nodules

Re-infection Tuberculosis 

Pleural involvement  Uncommon

in children, seen more frequently

in adults  More frequently identified in post-primary tuberculosis



Tuberculosis with pleural effusion in a 38 y/o female  

CT: Pleural effusion in anterior and lateral pleural spaces and right major fissure Parenchymal tuberculous focus in right middle lobe (Lee KS et al, 1003)

Re-infection Tuberculosis





Miliary TB is a disseminated systemic infection from a pulmonary nidus spread hematogenously May also be seen in primary TB

OUTLINE  

Pathophysiology of Tuberculosis Radiographic Signs of PTB    

   

Tuberculoma Bronchiectasis Cavitation Atelectasis

Primary vs. Re-infection PTB Active vs. Healed PTB Role of Chest X-Ray in Follow-up Role of CT Scan

Active PTB       

Infiltrate or consolidation Cavitary lesion Nodule with poorly defined margins Pleural effusion Hilar or mediastinal lymphadenopathy Linear, interstitial disease (in children only) Miliary findings

Healed PTB   





Discrete fibrotic scar or linear opacity Discrete nodule(s) without calcification Discrete fibrotic scar with volume loss or retraction Discrete nodule(s) with volume loss or retraction Upper lobe bronchiectasis

OUTLINE  

Pathophysiology of Tuberculosis Radiographic Signs of PTB    

   

Tuberculoma Bronchiectasis Cavitation Atelectasis

Primary vs. Re-infection PTB Active vs. Healed PTB Role of Chest X-Ray in Follow-up Role of CT Scan

ROLE OF FOLLOW-UP CHEST X-RAY 

To determine presence of late complications at completion of therapy  Relapse  Aspergilloma  Bronchiectasis  Broncholithiasis  Fibrothorax  Carcinoma eMedicine: Tuberculosis by Thomas Herchline, MD

OUTLINE  

Pathophysiology of Tuberculosis Radiographic Signs of PTB    

   

Tuberculoma Bronchiectasis Cavitation Atelectasis

Primary vs. Re-infection PTB Active vs. Healed PTB Role of Chest X-Ray in Follow-up Role of CT Scan

ROLE OF CT SCAN  

Better define abnormalities in patients with vague findings on chest radiography More sensitive in the detection of: Cavitation  Hilar and mediastinal lymphadenopathies  Endobronchial spread  Malignancy  Complications in the course of the disease 

eMedicine: Tuberculosis by Thomas Herchline, MD; Eisenhuber E, et al. Radiologic Diagnosis of Lung Tuberculosis (abstract), Der Radiologe Vol.37 No.5 May 2007

ROLE OF CT SCAN 

Valuable technique in the assessment of tuberculosis activity, especially in patients where M. tuberculosis has not been detected in the sputum or in patients with multi drug-resistant tuberculosis

eMedicine: Tuberculosis by Thomas Herchline, MD; Eisenhuber E, et al. Radiologic Diagnosis of Lung Tuberculosis (abstract), Der Radiologe Vol.37 No.5 May 2007

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