A 52-year old man with dyspnea, fatigue
and loss of weightM. TORFSB. CORTHOUTSB. OP DE BEECKSTAFF MEETING RADIOLOGY, 09-12-2014
Case presentation
Medical history:- HIV (stopped treatment 3 years before, lost to
follow-up by the ITM)- Depression
Current medical problems:- Dyspnoea- Extreme fatigue- Weight loss (15 kgs in 3-4 months)- Diarrhea- Right testis ‘problem’ (R/ ciprofloxacin)
Case presentation
Clinical examination:- Cachexia- Tachycardia- Bilateral crepitations on auscultation- Red, swollen right testis
Chest radiograph
Chest radiograph: imaging findings
Hilar lymphadenopathy
Chest radiograph: imaging findings
Miliary pattern
CT thorax
CT thorax
CT thorax
CT thorax
CT thorax
CT thorax
CT thorax
CT thorax
CT thorax
CT thorax
CT thorax
CT thorax
CT thorax
CT thorax
CT thorax
CT thorax
CT thorax
CT thorax
CT thorax
CT thorax
CT thorax
CT thorax
CT thorax
CT thorax: imaging findings
Hypodense mediastinal lymphadenopathy with rim
enhancement
Hypodense right hilar lymphadenopathy
CT thorax: imaging findings
Pericardial effusion
Splenomegaly with numerous hypodense splenic lesions
(miliary pattern)
CT thorax: imaging findings
Small right adrenal calcifications
CT thorax: imaging findings
Micronodules, tree-in-bud pattern
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen
CT abdomen: imaging findings
Splenomegaly with numerous hypodense splenic lesions
(miliary pattern)
Inflammation of the right seminal vesicles
CT abdomen
Hyperenhancement of the right spermatic cord
Intussusception
Diagnosis?
R/ Right orchidectomy
Pathology:- Abcedation and necrosis- Presence of numerous acid fast bacteria
Diagnosis: Disseminated tuberculosis
Tuberculosis: epidemiology Leading cause of death from infection worldwide
1/3 of world population infected 2010: 8.8 million incident cases worldwide, 1.4 million deaths 1.2 million cases among HIV-infected persons Largest number of incident cases: India, China, South Africa, Indonesia,
Pakistan Highest prevalence rates (> 300 cases/100,000 population) in African
region
Increased susceptibility in patients with impaired cellular immunity HIV infection, elderly, prisoners, congregate settings, indigent/homeless
Tuberculosis: pathology
M. tuberculosis: Aerobic, nonmotile bacillus Stains red with Ziehl-Neelsen stain Acid-fast: Resists discoloration with acid alcohol
Granulomatous infection/inflammation Macrophage aggregates transform into
epithelioid cells, epithelioid cells fuse to form multinucleated Langhans giant cells
Central necrosis, satellite granulomas May heal as fibrous scar or calcified lesion
ABDOMINAL MANIFESTATIONS IN
TUBERCULOSIS
Abdominal manifestations in tuberculosis Abdomen is the most common site of extrapulmonary TB (can be involved
without lung disease)
Abdominal lymphadenopathy is most common manifestation of abdominal TB
Any abdominal or pelvic organ or structure may be involved
Tuberculosis peritonitis
Gastrointestinal tuberculosis
Hepatosplenic tuberculosis
Renal tuberculosis
Abdominal lymphadenopathy Enlarged nodes with hypoattenuating centers and
hyperattenuating enhancing rims on CT (40-60%)
With healing, nodes calcify
Enteric TB probably most common cause of mesenteric nodal calcification
26-year old patient with disseminated TB
Tuberculous peritonitis
Wet type: Large amount of free or loculated ascites (higher than water density due to protein and cellular content)
Dry type: Mesenteric and omental thickening, fibrous adhesions, and caseous nodules
Difficult to distinguish from peritoneal carcinomatosis
Gastrointestinal tuberculosis
Ileocecal region most commonly affected Cecum & terminal ileum are usually contracted
with wall thickening; ileocecal valve is "gaping" Regional lymphadenopathy with central caseation
Colon tuberculosis less common
24-year old patient with intestinal TB and
enterocutaneous fistula
Gastrointestinal tuberculosis
42-year old patient with TB colitis
Hepatosplenic tuberculosis• Micronodular, miliary• Macronodular
CT Acute lesions are hypoattenuating nodules with ill-defined, enhancing
margins Chronic: Hepatic and splenic tuberculomas tend to calcify as they heal
MR T1WI: Hypotense, minimally enhancing, honeycomb lesions T2WI: Hyperintense with less intense rim relative to surrounding liver
Renal tuberculosis• 75% unilateral
• Most common CT finding is renal calcification (50%)
• IVP: "Moth-eaten" calix due to erosions and progression to papillary necrosis
• Caliectasis & hydronephrosis with irregular margins and filling defects due to caseous debris
• Irregular pools of contrast due to renal parenchymal cavitation
• Strictures of renal pelvis and infundibula www.statdx.com
Ureteric and bladder tuberculosis
• Ureteric tuberculosis:- Thickened ureteric wall with
strictures- Most common in distal 1/3 of
ureter- Hydronephrosis &
hydroureter can occur upstream
• Bladder tuberculosis:- Decreased bladder volume
with wall thickening, ulceration, and filling defects
http://www.isradiology.org/tropical_deseases/tmcr/chapter5/lymphadenopathy2.htm
Genital tuberculosis
Male genital tuberculosis- Affects seminal vesicles or prostate
gland, rarely testes- Occasional calcification
Female genital tuberculosis- Involves fallopian tubes in 94% of
cases- Bilateral salpingitis with strictures ±
occlusion
Differential diagnosis• Abdominal lymphadenopathy:
- Metastases or lymphoma- Whipple disease- MAI infection
• Tuberculosis peritonitis:- Nontuberculous peritonitis- Peritoneal metastases and lymphoma- Mesothelioma
• Ileocecal lesions:- Amebiasis- Crohn disease- Primary cecal malignancy
• Miliary hepatic lesions:- Hepatic metastases and
lymphoma- Hepatic opportunistic infection- Sarcoidosis
• Renal Lesions:- Renal papillary necrosis- Renal transitional cell
carcinoma- Other infections
DD: abdominal lymphadenopathy
41-year old man with Hodgkin lymphoma
DD: abdominal lymphadenopathy
68-year old man with Whipple diseaseCourtesy of Dr. Tom Seerden (Amphia Ziekenhuis Breda) and Dr. Bart Op De Beeck
DD: ileocecal lesions
55-year old female with M. Crohn
Take home messages
Tuberculosis is leading cause of death from infection worldwide
TB lymphadenitis is characterised by enlarged nodes with hypoattenuating centers and hyperattenuating enhancing rims on CT (tend to calcify with healing)
Disseminated TB: look at the whole picture!
Remember this patient?
References
Statdx.com
Radiopaedia.org
http://www.isradiology.org/tropical_deseases/tmcr/chapter5/lymphadenopathy2.htm