Chest radiograph interpretation in tuberculosis

Tilman L. Koelsch, MD

Associate Professor

National Jewish Health

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GoalsUnderstand importance of adequate radiographic technique

Basics of CXR interpretation

Identify features of tuberculosisAdults

Children

HIV

Healed/inactive

Role of CT

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Technical adequacy of chest radiograph Exposure

Positioning

Inclusion

Inspiration

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Approach to chest radiograph

TechnicalExposure

Inclusion

Rotation

Inspiration

Initial “Gestalt”

Systematic survey

Soft tissues/abdomen

Lungs/ribs- symmetry

Mediastinum/heart

Miss/”Hidden” areas

Apices

Hila/suprahilar

Trachea/bronchi

Retrocardiac

Retrodiaphragmatic

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Approach to chest radiograph

Describe findingsAppropriate descriptors

Make inferences

Hansell DM, et al.

Fleischner Society: Glossary of terms for thoracic imaging.

Radiology. 2008;246:697-722.

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Common radiographic findings in tuberculosis Opacity

Nodule

Nodular pattern

Consolidation

Atelectasis

Pleural effusion

Lucency

Cavity

Bronchiectasis

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Nodule

Rounded

opacity, well or

poorly defined,

measuring up to

3 cm in

diameter.

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Nodular pattern

Innumerable

small rounded

opacities that

are discrete

and range in

diameter from

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Miliary pattern profuse, discrete, rounded pulmonary opacities

2-3 mm in diameter

generally uniform in size

diffusely distributed throughout the lungs- sometimes lower

lung predominant

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Consolidation Homogenous increase

in lung opacity

Often poorly defined

and confluent

Signs helpful

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Atelectasis Reduced volume of a lobe or

lung, with increased opacity

Displacement of

mediastinum, hila, bronchi,

or fissures

Not talking about mild

atelectasis

Signs helpful

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Case courtesy of Dr. Dipti NevrekarFlat Waist Sign

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Flat Waist Sign Left lower lobe collapse

Flattening of contours of left mediastinum

Aortic arch

Pulmonary artery

Leftward deviation and rotation of heart

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Pleural effusion

Fluid in the pleural

space

On erect chest

radiograph,

characterized by

blunting of

costophrenic angle

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Pleural thickening vs effusion

Blunted CP angle is

not curved

Thickening usually

extends up the chest

wall

Often associated

with rounded

atelectasis or linear

scarring

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Cavity

Gas-filled space

within consolidation,

mass, or nodule

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Bronchiectasis

Ring shadows

Train tracks

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Adenopathy

Challenging to see on radiography unless bulky

Luckily TB adenitis tends to be quite conspicuous

Hilar>mediastinal LANProp

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Hilar Adenopathy

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Hilar Adenopathy

Normal Lateral Hilum vs. Adenopathy

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Mediastinal Adenopathy

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Normal AP Stripe

•Formed by 2 layers of pleura

reflecting over left

anterolateral mediastinal fat

•Usually straight or minimally

convex

•Abnormal convexity:

•Prevascular/Anterior

Mediastinal lymph

nodes/mass.

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Normal AP Stripe

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Abnormal AP Stripe vs. Normal

Abnormal AP Stripe

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Normal Right Paratracheal Stripe

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Right Paratracheal Adenopathy

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AP Window•Left lung between aortic

arch and the left PA

•Seen almost always

•Usually concave or straight

•Abnormal convexity

•Lymph nodes

•Mediastinal mass

•Vascular abnormality

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Abnormal AP Window vs. Normal AP Window

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Hilar Adenopathy

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Hilar Adenopathy

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Hilar/mediastinal Adenopathy

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Primary vs Post-primary Tuberculosis

In adults, there is no significant difference in

radiographic features between recently and

remotely acquired TB, confirmed by RFLP

Therefore, “primary” and “post-primary” terms

inaccurate

Better to use terms “atypical” and “typical”

Geng E et al. JAMA. 2005 Jun 8;293(22):2740-5.

Jones BE, et al. AJRCCM 1997 Oct;156(4 Pt 1):1270-3.

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Typical tuberculosis

Upper lobe “infiltrate”

Upper lobe cavities

Geng E et al. JAMA. 2005 Jun 8;293(22):2740-5.

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Typical TuberculosisApical/Posterior Segment Involvement

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Typical TuberculosisConsolidation with Cavitation

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Typical Tuberculosis

Endobronchial spread

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Typical Tuberculosis

Endobronchial spread

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Atypical radiographs in tuberculosis

Lymphadenopathy

Lower or mid-lung opacity

Effusions without cavity or upper lung opacity

More common in children

Geng E et al. JAMA. 2005 Jun 8;293(22):2740-5.

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Atypical tuberculosis: RLL cavity/hilar adenopathy

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Atypical Tuberculosis

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Atypical TuberculosisHilar/Mediastinal Lymphadenopathy

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Atypical TuberculosisMiliary Pattern

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Finding

Any adenopathy 175 92%

Right hilar 83 43%

With mediastinal

nodes 43 23%

Left hilar 37 19%

With mediastinal

nodes 16 8%

Bilateral hilar 49 26%

With mediastinal

nodes 44 23%

Mediastinal only 6 3%

Lymphadenopathy in childhood tuberculosis (n=191)

Leung AN.

Radiology.

1992

Jan;182(1)

:87-91.

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Parenchymal abnormality in childhood tuberculosis

Finding

Parenchymal abnormality

with adenopathy 130 68%Parenchymal abnormality

without adenopathy 2 1%

Right lung consolidation 78 41%

Left lung consolidation 21 11%

Bilateral consolidation 33 17%

Lobar atelectasis 16 8%

Effusion 11 6%

Normal CXR 14 7%

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“Primary” tuberculosis in childhood: Pearls

Parenchymal abnormality is more common in >

3 years old

Lymphadenopathy more common in Native

American and Asian than in whites

Adolescents with recent infection usually have

typical features of tuberculosis with upper lobe

nodules or cavity

Leung AN, et al. Radiology. 1992 Jan;182(1):87-91.

Koh WJ, et al. Korean J Radiol. 2010 Nov-Dec;11(6):612-7.

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Childhood TuberculosisMid/lower lung Consolidation

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Childhood TuberculosisHilar/Mediastinal Lymphadenopathy

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Chest RadiographTB and HIV Chest radiograph often looks like “atypical” (“primary”)

disease

Adenopathy is common and highly predictive of tuberculosis

Radiograph may be normal in up to 10% of cases

Geng E et al. JAMA. 2005 Jun 8;293(22):2740-5.

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Chest radiograph: TB in HIV

With decreasing CD4 count

Lower likelihood of

Cavitary disease

Fibrosis

Upper lobe disease

Higher likelihood of

Normal CXR

Miliary abnormality

Adenopathy

Pleural effusion

Chamie G, et al. Int J

Tuberc Lung Dis. 2010

Oct;14(10):1295-302.

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Chest RadiographTB and HIV

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Chest RadiographTB and HIV

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Chest RadiographTB and HIV

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Pleural Tuberculosis Effusions common in adults (6-15%)

Less common in children

Very uncommon finding in infants

May be sole finding

Air fluid level may indicate bronchopleural or alveopleural

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Pleural Effusion

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Post-Primary TuberculosisEmpyema

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Tuberculosis and Airways

Atelectasis due to

1) Nodal enlargement - compressing airway

2) Endobronchial abnormality - obstructing airway

Medial segment of middle lobe

Anterior segment of upper lobe

Right side more common

Can mimic lung cancer

May never resolve

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Airway narrowing due to nodal enlargement

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Bronchostenosis

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The Chest RadiographBronchostenosis

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The Chest RadiographHealed Tuberculosis

Calcified granuloma - Ghon lesion

Calcified granuloma & hilar calcification - Ranke complex

Apical pleural thickening

Fibrosis and volume loss

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The Chest RadiographGhon Lesion

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The Chest RadiographRanke Complex

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The Chest RadiographApical Fibrosis

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Tuberculoma

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“Activity” of tuberculosis

Activity cannot be determined from single chest radiograph

Progressive disease indicates activity

Cavitation and bronchogenic spread suggest activity

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Stable tuberculosis

20062004

Old X-rays often helpful

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Role of CT in tuberculosis Not indicated in most cases

Occult miliary disease and cavities

Necrotizing adenopathy

Undiagnosed effusion

Roadmap for bronchoscopist

Presurgical stagingProp

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Adenitis

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Spinal involvement

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Summary Chest radiograph requires systematic approach

Typical (Post-primary) TB: Upper lung fibrocavitary disease, “endobronchial spread” nodules

Atypical (Primary) TB: Usually children, HIV, consolidation with adenopathy

Serial radiographic evaluation important to determine activity

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Acknowledgements David Lynch, MBBS

Jonathan Chung, MD

Charles Daley, MD

Gwen Huitt, MD

Shannon Kasperbauer, MD

Wendy Drummond, MDProp

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