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Chest Radiology Interpretation: Findings of Tuberculosis
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Case #1
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Plombage
Pneumonia
Cancer
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Reading the TB CXR
Be systematic!
Start centrally and work outwards
Normal or abnormal
If abnormal, consider technique as cause
Describe the finding(s)
Consider the significance of the finding(s)
Mediastinum
Hila
Lungs
Pleura
Bones
Mediastinum
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Lymphoma
AbnormalNormal
Metastatic disease (unknown primary)
Normal Abnormal
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Lung Cancer
Normal Abnormal
AO
PA
Heart
<55% thoracic diameter
Technique important
Larger in: AP film
Poor inspiration
Rotation
Children
True enlargement Chamber enlargement
Pericardial effusion
Mass
Artifactual cardiomegaly
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End stage rheumatic heart disease
Pericarditis
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Hila
Sarcoidosis
Normal Abnormal
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Pulmonary Hypertension
Normal Abnormal
Lungs
Pleura & Diaphragms
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Pleura & Diaphragms
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Lung Pleura
Lung Pleura
Lung Pleura
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Lung Pleura
TB Empyema
Don’t forget about the bones
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Case #1
Case #2
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Inspiration: (≥10 posterior ribs)
1st rib
2nd rib3rd rib
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2nd3rd
4th
5th
6th
7th
8th
9th
10th
1st
Poor inspiration
Good inspiration
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Rotation
Rotation
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PenetrationIntervertebralDisks
Over-penetrated
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Case #3
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)
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Nodule ≤ 3cm, Mass > 3 cm
2.7 cm3.4 cm
Consolidation
Confluent opacity
Fluffy around the periphery
Air bronchograms
ARDS
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Normal Nodular Reticular
Interstitial disease
Miliary TB
Idiopathic pulmonary fibrosis
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Airways disease
Circular
Tubular
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Tuberculosis
Case 3
Questions
Could this be TB?
Is TB the most likely diagnosis?
If so, what form of TB does the radiology suggest?
Is active disease likely or unlikely?
What are possible alternative diseases to produce the radiographic pattern?
(the answer is always yes!)
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Key points
TB patterns overlap with each other
TB patterns overlap with other diseases
If there is an abnormality, it could be due to TB
You must know the classic TB patterns
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
Case #3
Reactivaton TB- radiology
LocationApical/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
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Chest Radiology Interpretation: Findings of Tuberculosis (Part 2)
Is this likely TB?
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Lobar anatomy
Left Lung
LLL
LUL
Right Lung
RLLRML
RUL
Lobar anatomy
Right Lung
RLLRML
RUL
Lobar anatomy
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RUL Pneumonia
Right Lung
RLLRML
RUL
Lobar anatomy
Right Lung
RLLRML
RUL
Lobar anatomy
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Silhouette sign
A B A B
Silhouette sign
A B A B
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Right Lung
RLLRML
RUL
Lobar anatomy
Diaphragm
RLL
ObscuredDiaphragm
ClearHeartBorder
RLL pneumonia
? Which lobe is involved
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Right Lung
RLLRML
RUL
Lobar anatomy
RML
RML pneumonia
ClearDiaphragm
ObscuredHeartBorder
? pneumonia
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? pneumonia
Anterior Posterior
Superior
Inferior
Lateral Viewof the Chest
Heart
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Lateral Viewof the Chest
Spine
Lateral Viewof the Chest
Diaphragm
Lateral Viewof the Chest
Diaphragm
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Normal LLL Pneumonia
Normal Pleural effusion
Normal Nodule
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Normal Pott’s disease
Case #4
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Abnormal Normal
Prior reactivation tuberculosis
Upper lobe scarringVolume loss
Retraction of hila superiorly
Band-like (linear) opacities
Architectural distortion
Asymmetric > symmetric
Bronchiectasis
Cystic changes
Diff dx: fungal, sarcoid, pneumoconioses
Prior TB
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Warning signs
Consolidation outside areas of fibrosis
Consolidation with cavitation
Lower lobe abnormalities
Non-calcified nodules (ill-defined)
Change from prior CXR
Reactivation TB
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Case #5
Solitary nodule/mass- the top 5
Granuloma
Hamartoma
Solitary metastasis
Bronchogenic carcinoma
Lots of others
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So you see a nodule on CXR…
1. Look for old films
2. Is diffuse calcification present?
3. Get a CT scan
When to get a CT scan?
Questionable CXR findings
Further characterization of CXR findings
Concern for cancer
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Role of CT scan for nodules1. Attempt to prove they are definitively
benignBenign pattern of calcification (diffuse, central,
ring-like, popcorn)
Fat
≥2 years of stability
Features of benign nodules include:
PopcornRing-like
CentralDiffuse Initial CT
24 monthfollow-up
Benign patterns of calcification
Presenceof fat
Long term stability
Hamartoma
Hamartoma
.
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Irregular calcification: adenocarcinoma
Role of CT scan for nodules1. Attempt to prove they are definitively
benignBenign pattern of calcification (diffuse, central,
ring-like, popcorn)
Fat
≥2 years of stability
2. Determine likelihood of nodule being benign or malignantLow likelihood -> CT follow-up
High likelihood -> immediate action (e.g. biopsy)
Suspicious features of nodules include:
Initial CT
Follow-up
Large size Spiculatedborders
Growth
The size threshold above which malignancy is likely demonstrates geographic variability, depending upon the prevalence of endemic granulomatous infection.
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Size and likelihood of cancer
Swensen. Radiology 2005; 235: 259
0% 1%
15%
81%
Follow-up recommendationsNodule size Low-risk patient High-risk patients
≤4 mm No follow-up 12 months
>4-6 mm 12 months 6-12 months
18-24 months
6-8 mm 6-12 months
18-24 months
3-6 months
9-12 months
24 months
>8 mm 3 months
9 months
24 months
3 months
9 months
24 months
Fleischner Guidelines. Radiology 2005; 237: 395.
Old tuberculosis
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Bronchogenic carcinoma
Case #6
Case #6Ghonfocus
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Case #6Rankecomplex
Case #7
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Primary tuberculosis
Difficult radiologic diagnosis
Mimics other diseases
FindingsNonspecific consolidation
Nodule
Lymphadenopathy
Cavitation unusual
LAD more common than with 2° TB (particularly kids + HIV)
Primary tuberculosis
Primary tuberculosis
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Case #8
Miliary pattern CXR
Miliary tuberculosis
Fungal infection (histo, cocci, blasto)
Metastases
Sarcoidosis
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Miliary tuberculosis
Miliary TB
Sarcoidosis
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Metastases
Case #10
Pleural + pericardial disease
Primary or secondary
May be only manifestation in 1° TB
Empyema more common in secondary
Adults >> kids
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Suspected pleural effusion
Case #11
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Case #11
Lymphoma
Leukemia
Germ cell tumor
Bacterial mediastinitis
Fungal infection
Tuberculosis
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Lymphadenopathy with TB
Kids >> adults
Primary >> secondary
Asymmetric (right > left)
Most common locationsHilar
Right paratracheal
Necrosis very common
TB lymphadenitis
Case #12
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heart <65% thoracic diameter
thymus
Conclusions
Be systematic when reading CXR
Typical TB patterns
Mimics of TB
Get a CT scan when appropriate