PULMONARY TUBERCULOSIS
- RADIOLOGICAL IMAGES -
Dr. Miron Ramona
Conf Dr Antigona Trofor
TUBERCULOSIS RADIOLOGY
• Pulmonary tuberculosis, especially postprimary disease,
nearly always causes abnormalities on chest radiographs.
• Typically, the disease is parenchymal without nodal
enlargement, and it manifests as cavitary lesions.
• Upper-lobe involvement with cavitation and the absence of
lymphadenopathy are helpful in distinguishing postprimary
TB from primary TB.
• In addition to the usually involved pulmonary segments—
namely, the apical or posterior segments of the upper lobe
or the superior segment of a lower lobe—anterior or basal
segments may be involved in as many as 75% of cases.
http://emedicine.medscape.com/article/358735-imaging
PRIMARY TUBERCULOSIS RADIOLOGY
• Radiographic screening for active TB in high-risk
populations may demonstrate findings consistent
with prior and/or current infection.
• A Ghon focus refers to the initial site of
parenchymal involvement at the time of first
infection;
• A Ranke complex is the combination of a Ghon
focus and enlarged or calcified lymph nodes;
• Lymphadenopathy is the radiologic hallmark of
primary TB
• Simon focus are apical nodules that are often
calcified and result from hematogenous seeding
at the time of initial infection
PRIMARY PULMONARY TB
• Initial pulmonary lesions
GOHN-RANKE complex
• Focus Gohn
• Lymphangitis
Ranke Complex
• Lymphadenopathy
• Image in “halter”
Afect
Adenita
Limfangita
Complexul Ranke
Complexul primar Ranke:
1. GOHN focus
(alveolitis)=basal subpleural
nodular opacities (most often
on right), flou contour
2. Lymphangitis: radiological
expression, in some case
appear fibrosis; fine linear
opacities that connect the
Gohn focus with hilum
3. Homolateral adenopathy:
hilary, interbronchial or
paratracheal rounded shape,
massive polyciclic aspect,
3
2
1
Complex forms
• Excavation of caseous
alveolitis focus– primary
cavern (cavity) transparent
thin wall or anfractuous
circumscribed, usually
localized on the basal or
middle lung fields, is
accompanied by hilary
adenopathy.
• Voluminous adenophaties:
cause ventilation
modifications by
extrabronchial compression,
obstructive emphysema or
systematized atelectasis
Vouluminous right hilar
adenopathy
Segmental atelectasis in
upper right lobe
Complicated forms
Large cavitary tuberculosis with forms:
A. Pneumonia: triangular
opacity
- Can do to excavation
Is accompanied by
adenopathy
Pneumonie TB
lob superior
drept
B. Bronchopneumonia:
Macronodulare
alveolar opacities,
various sizes, unequal
distribution, with a
tendency to
confluence
Associated adenopathies!
Right paratracheal adenopathy
Miliary nodules
C. Miliary tuberculosis
-
Complication of Primary TB
Radiological: miliary
opacities with diameter < 3
mm, equal in size,
homogeneous distribution
Secondary tuberculosis
• Occurs due to reactivation of primary tuberculosis
• Reactivation of fibrotic lesions from apical territory
• Reinfection by exogenous contamination
Can occur after primary infection,
Radiology- polymorphic semiology!
Alveolar opacities systematized/nonsystematized;
Nodular images, cavitary lesions, fibrous lesions, associated
lesions
The affected territories predilection:
dorsal and apical segments of upper
lobes and apical segments of lower
lobes!
1. INFILTRATIVE TUBERCULOSIS
2. PLEURAL TB
3. CAVITARY CHRONIC TUBERCULOSIS
4. MYLIAR TUBERCULOSIS
5. FIBROTIC TUBERCULOSIS
6. TUBERCULOMA
1. INFILTRATIVE TUBERCULOSIS
- Lesions of exudative alveolitis
- Early infiltrates localize subclavicular
- RADIOLOGY:
NODULAR INFILTRATE
ROUND INFILTRATE(ASSMAN)
NEBULOUS INFILTRATE
SEGMENTAL INFILTRATE
Beginning of secondary TB can be: pneumonia, lobar or
segmental opacities , bronchopneumoni
Nodular infiltrate LUL
infiltrative TB RUL
Bilateral INFILTRATIVE LESIONS
Disseminated nodular
opacities in both lung
fields, most commonly
in middle and basal lung
fields, moderate
intensity, different size,
shape removed, the
tendency to confluence
TB
Bronchopneumonia
Triangular opacity
localized RUL
TB Pneumonia
Segmental infiltrate
occupying
almost the entire
RUL and central
tendency to
excavation
Massive left pneumonia – etiology TB
Opacity
nonhomogeneous RUL
Pneumonia
LUL
TB PLEURAL EFFUSION
In a patient with pleural exudate, TB is the first
etiology to be taken into consideration!
Radiological aspect of cavities(caverns) depends on
the stage in which there are:
Cavity grade 1
Cavity grade 2
Cavity grade 3
Cavity grade 1:
Lucency (darkened area) within the lung parenchyma, with or without
irregular margins
CAVITY GRADE 2 :wall has its own thin, elastic, net
contour
Cavern with
net wall
localized RUL
subclavicular
Cavity grade 2
Between cavern and
hilum- drainage
bronchia
Cavity grade 2
Cavity grade 3: old cavity, net shaped, wall fibrosis, cavitary sclerosis
may be due to irregular shape, around the cavity disabling injuries.
Calcification can exist around a cavity.
Cavity grade 3
Old cavity, net
contour, fibrosis
of wall, sclerosis
around cavity
Radiological aspects of cavitary TB
Multiple cavities
in different
stages of
evolution
Radiological aspects of cavitary TB
Radiological aspects of cavitary TB
Radiological aspects of cavitary TB
small,
multiple
aspects in
different
stages of
evolution
Complications of
cavitary
• SEROFIBRINOUS PLEURESY
• PACHIPLEURITIS(PLEURAL ADHESIONS)
(AFTER RESORBTION OF EXUDATE)
• PLEURAL EMPYEMA
(INFECTION OF EXUDATE)
• PARTIAL/TOTAL SPONTANEOUS
PNEUMOTHORAX
• BRONCHOGENIC DISEMINATIONS
Complications
of cavitary TB
TB infiltrative lesions
of RUL
Mixed image
horizontal line of the
air-fluid level
right hemithorax
PLEURAL
EMPYEMA
Complications
of cavitary TB
•TB left empyema
•Infiltrative lesions
of right lung
Complications of cavitary TB
Pulmonary
hiperlucency design
collapsed lung to
hilum (right lung
field), large infiltrative
lesions (left lung
field)
Complications of cavitary TB
•Bilateral
infiltrative lesions
•RIGHT
Pneumothorax
Complications of cavitary TB
•Bilateral
infiltrative lesions
• Right hydropneumothorax
Complications of cavitary TB – bronchogenic
dissemination
Micronodular opacities,
diffuse shape, vaguely
defined, tendency to
confluence to delimit
small areas excavated
”
Complications of cavitary TB – bronchogenic
dissemination
Bronchogenic
dissemination from
RUL to LIL
(disemination type
“Cardis”)
Complications of cavitary TB –
bronchogenic dissemination
Hiperlucency excluding
left lung, with attraction
of trachea to the left,
ascension compensatory
of the diaphragm,
hyperinflation of
contralateral lung, right
lung shows extensive
infiltrative lesions and a
cavity to the apex
Images - multi-drug
resistance TB
Miliary TB - miliary nodules distributed homogenous in both lung fields
POSTUBERCULOSIS FIBROSIS
• Retraction of
LUL with fibrous
lesions extended
to right lung
• Basal left
pachipleuritis
FIBROTHORAX
-The final process of sclerosis that
interested entirely the lung
• Sclerosis of right
lung
• Retraction of left
hemithorax
• Nodular lesions of
left lung
5. Tuberculoma
- Radiological: round, oval, encapsulated opacity,
homogeneous or heterogeneous structure, net shape,
can be solitary or multiple lesions
- Seriate radiographs show stability in time!