Slide 1. Chest Radiology Interpretation: Findings of Tuberculosis. Slide 2 Case #1. Slide 3. Reading the TB CXR

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1 Slide 1 Chest Radiology Interpretation: Findings of Tuberculosis Slide 2 Case #1 Slide 3 Reading the TB CXR Be systematic! Start centrally and work outwards Normal or abnormal Describe the finding(s) Consider the significance of the finding(s)

2 Slide 4 Mediastinum Slide 5 Hila Slide 6 Lungs

3 Slide 7 Pleura & Diaphragms Slide 8 Pleura & Diaphragms Slide 9 Pleura & Diaphragms

4 Slide 10 Soft tissue & bones Slide 11 Slide 12 Mediastinum

5 Slide 13 Normal Lymphoma Abnormal Slide 14 Normal Abnormal Metastatic disease (unknown primary) Slide 15 AO PA Normal Lung Cancer Abnormal

6 Slide 16 Heart <55% thoracic diameter Technique important Larger in: AP film Poor inspiration Rotation Children True enlargement Chamber enlargement Pericardial effusion Mass Slide 17 Artifactual cardiomegaly Slide 18

7 Slide 19 End stage rheumatic heart disease Slide 20 Pericarditis Slide 21 Hila

8 Slide 22 Slide 23 Q1. Pathology in this patient is most likely to show? A. Caseating granulomas B. Non-caseating granulomas C. Atypical cells with high nuclear/cytoplasmic ratio D. Fibrosis Slide 24 Normal Sarcoidosis Abnormal

9 Slide 25 Normal Abnormal Pulmonary Hypertension Slide 26 Lungs Slide 27 Pleura & Diaphragms

10 Slide 28 Pleura & Diaphragms Slide 29 Slide 30

11 Slide 31 Slide 32 Q2. Where is this lesion located? A. Lung B. Mediastinum C. Pleura D. Chest wall Slide 33

12 Slide 34 Lung Pleura Slide 35 Lung Pleura Slide 36 Lung Pleura

13 Slide 37 Lung Pleura Slide 38 TB Empyema Slide 39 Don t forget about the bones

14 Slide 40 Case #1 Slide 41 Case #2 Slide 42 Q3. What is the primary abnormality? A. Mediastinal widening B. Diffuse lung opacities C. Pleural effusion D. Normal

15 Slide 43 Inspiration: ( 10 posterior ribs) Slide 44 Slide 45 1st rib 3rd rib 2nd rib

16 Slide 46 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th Slide 47 Poor inspiration Slide 48 Good inspiration

17 Slide 49 Rotation Slide 50 Slide 51

18 Slide 52 Intervertebral Disks Penetration Slide 53 Over-penetrated Slide 54 Case #3

19 Slide 55 Q4. What is the most likely diagnosis? A. Tuberculosis B. Aspergillosis C. Malignancy D. Mycoplasma Slide 56 Categories of lung opacities 1. Nodule(s) or mass(es) 2. Alveolar, airspace, consolidation 3. Interstitial (diffuse lines or nodules) 4. Airways (circular or tubular) Slide 57 Nodule 3cm, Mass > 3 cm 3.4 cm 2.7 cm

20 Slide 58 Consolidation Confluent opacity Fluffy around the periphery Air bronchograms Slide 59 ARDS Slide 60 Interstitial disease Normal Nodular Reticular

21 Slide 61 Miliary TB Slide 62 Idiopathic pulmonary fibrosis Slide 63

22 Slide 64 Airways disease Circular Tubular Slide 65 Slide 66 Tuberculosis

23 Slide 67 Case 3 Slide 68 Questions Could this be TB? (the answer is always Is TB the most likely yes!) diagnosis? If so, what form of TB does the radiology suggest? Is active disease likely or unlikely? Is TB an unlikely diagnosis? What are possible alternative diseases to produce the radiographic pattern? Slide 69 Key points You must know the classic TB patterns TB patterns overlap with each other TB patterns overlap with other diseases If there is an abnormality, it could be due to TB But, if it doesn t fit into a typical TB pattern, it is unlikely to be TB It s all about likelihood! Clinical-radiographic correlation

24 Slide 70 Case #3 Slide 71 Reactivaton TB- radiology Location Apical/posterior segments upper lobes Superior segment lower lobes Isolated anterior disease very unusual Presence of cavities Pleural disease Volume loss/scarring early in disease Diff dx: fungal, bacterial infections Slide 72 Chest Radiology Interpretation: Findings of Tuberculosis (Part 2)

25 Slide 73 Is this likely TB? Slide 74 Q5. What lobe is involved? A. Right upper lobe B. Azygous lobe C. Right middle lobe D. Right lower lobe Slide 75 Lobar anatomy LUL Left Lung LLL

26 Slide 76 Lobar anatomy RUL RML Right Lung RLL Slide 77 Lobar anatomy RUL RML Right Lung RLL Slide 78 RUL Pneumonia

27 Slide 79 Lobar anatomy RUL RML Right Lung RLL Slide 80 Lobar anatomy RUL RML Right Lung RLL Slide 81

28 Slide 82 Silhouette sign A B A B Slide 83 Silhouette sign A B AB Slide 84 Lobar anatomy RUL RML RLL Right Lung Diaphragm

29 Slide 85 RLL pneumonia RLL Obscured Diaphragm Clear Heart Border Slide 86? Which lobe is involved Slide 87 Lobar anatomy RUL RML Right Lung RLL

30 Slide 88 RML pneumonia RML Clear Diaphragm Obscured Heart Border Slide 89? pneumonia Slide 90? pneumonia

31 Slide 91 Superior Anterior Posterior Inferior Slide 92 Lateral View of the Chest Heart Slide 93 Lateral View of the Chest Spine

32 Slide 94 Lateral View of the Chest Diaphragm Slide 95 Lateral View of the Chest Diaphragm Slide 96 Normal LLL Pneumonia

33 Slide 97 Normal Pleural effusion Slide 98 Normal Nodule Slide 99 Normal Pott s disease

34 Slide 100 Case #4 Slide 101 Q6. What is the primary abnormality? 1. Consolidation 2. Emphysema 3. Airway enlargement 4. Fibrosis Slide 102 Abnormal Normal

35 Slide 103 Prior reactivation tuberculosis Upper lobe scarring Volume loss Retraction of hila superiorly Band-like (linear) opacities Architectural distortion Asymmetric > symmetric Bronchiectasis Cystic changes Diff dx: fungal, sarcoid, pneumoconioses Slide 104 Prior TB Slide 105

36 Slide 106 Warning signs Consolidation outside areas of fibrosis Consolidation with cavitation Lower lobe abnormalities Non-calcified nodules (ill-defined) Change from prior CXR Slide 107 Reactivation TB Slide 108 Case #5

37 Slide 109 Q7. What is the likelihood of malignancy? A. <5% B. 5-10% C % D. >20% Slide 110 Solitary nodule/mass- the top 5 Granuloma Hamartoma Solitary metastasis Bronchogenic carcinoma Lots of others Slide 111 So you see a nodule on CXR 1. Look for old films 2. Is diffuse calcification present? 3. Get a CT scan

38 Slide 112 Slide 113 When to get a CT scan? Questionable CXR findings Further characterization of CXR findings Concern for cancer Slide 114 Role of CT scan for nodules 1. Attempt to prove they are definitively benign Benign pattern of calcification (diffuse, central, ring-like, popcorn) Fat 2 years of stability

39 Slide 115 Features of benign nodules include: Benign patterns of calcification Diffuse Central Presence of fat Hamartoma Long term stability Initial CT Ring-like Popcorn 24 month follow-up Slide 116 Hamartoma. Slide 117 Irregular calcification: adenocarcinoma

40 Slide 118 Role of CT scan for nodules 1. Attempt to prove they are definitively benign Benign pattern of calcification (diffuse, central, ring-like, popcorn) Fat 2 years of stability 2. Determine likelihood of nodule being benign or malignant Low likelihood -> CT follow-up High likelihood -> immediate action (e.g. biopsy) Slide 119 Suspicious features of nodules include: Large size Spiculated borders Growth Initial CT The size threshold above which malignancy is likely demonstrates geographic variability, depending upon the prevalence of endemic granulomatous infection. Follow-up Slide 120 Size and likelihood of cancer 81% 0% 1% 15% Swensen. Radiology 2005; 235: 259

41 Slide 121 Follow-up recommendations Nodule size Low-risk patient High-risk patients 4 mm No follow-up 12 months >4-6 mm 12 months 6-12 months months 6-8 mm 6-12 months months >8 mm 3 months 9 months 24 months 3-6 months 9-12 months 24 months 3 months 9 months 24 months Fleischner Guidelines. Radiology 2005; 237: 395. Slide 122 Old tuberculosis Slide 123 Bronchogenic carcinoma

42 Slide 124 Case #6 Slide 125 Ghon Case #6 focus Slide 126 Ranke Case #6 complex

43 Slide 127 Prior tuberculosis Mid to lower lung predominance Can be anywhere Nodule: Ghon focus Nodule + lymph node: Ranke complex Calcification indicative of inactivity Slide 128 Case #7 Slide 129 Q8. What is the most likely diagnosis? A. Tuberculosis B. Bacteria C. Adenovirus D. Mycoplasma

44 Slide 130 Primary tuberculosis Difficult radiologic diagnosis Mimics other diseases Findings Nonspecific consolidation Nodule Lymphadenopathy Cavitation unusual LAD more common than with 2 TB (particularly kids + HIV) Slide 131 Primary tuberculosis Slide 132 Primary tuberculosis

45 Slide 133 Case #8 Slide 134 Q9. What is the LEAST likely diagnosis? A. Tuberculosis B. Hypersensitivity pneumonitis C. Fungal infection D. Sarcoidosis Slide 135 Miliary pattern CXR Miliary tuberculosis Fungal infection (histo, cocci, blasto) Metastases Sarcoidosis

46 Slide 136 Miliary tuberculosis Slide 137 Miliary TB Slide 138 Sarcoidosis

47 Slide 139 Metastases Slide 140 Case #10 Slide 141 Pleural + pericardial disease Primary or secondary May be only manifestation in 1 TB Empyema more common in secondary Adults >> kids

48 Slide 142 Suspected pleural effusion Slide 143 Slide 144 Case #11

49 Slide 145 Q10. What is the primary abnormality? A. Lymphadenopathy B. Pericardial effusion C. Lytic bony lesion D. Normal Slide 146 Case #11 Slide 147 Lymphoma Leukemia Germ cell tumor Bacterial mediastinitis Fungal infection Tuberculosis

50 Slide 148 Lymphadenopathy with TB Kids >> adults Primary >> secondary Asymmetric (right > left) Most common locations Hilar Right paratracheal Necrosis very common Slide 149 TB lymphadenitis Slide 150 Case #12

51 Slide 151 thymus heart <65% thoracic diameter Slide 152 Conclusions Be systematic when reading CXR Typical TB patterns Mimics of TB Get a CT scan when appropriate Slide 153

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