RADIOLOGY

POSTING
CASE
PRESENTATION
PRESENTER :
KAARTHIGAN
RAMAIAH
ID NO.
: 06201204-00011
LECTURER :
DR.AZMAN

CONTENT
1.
2.
3.
4.
5.
6.
7.
8.

History taking
Physical examination
Provisional diagnosis
Diff erential diagnosis
Investigation
Management plan
Discussion and learning outcomes
References

HISTORY TAKING
Patients details

Name
: Wa n D a y a n g M e m i
Age : 40 years old
Ra c e
: Malay
G e n d e r: Fe m a l e
Ad d re s s : Ta n j u n g G a d i n g , M u a r
Occupation: Housewife
D a t e o f a d m i s s i o n : 2 6 /0 4 / 2 01 6
D a t e o f c l e r k i n g : 2 8 / 04 / 2 0 1 6

Chief complaint
S h o r t n e s s o f B re a t h f o r 3 w e e k s

History of presenting
illness:
Patient is a known case of
hypertension and pleural
tuberculosis. Patient started to
have shortness of breath 3 weeks
ago. She claimed that it is
worsening on sitting and waking
but not at rest. Patient also
presented with orthopnoea and
paroxysmal nocturnal dyspnoea
since 3 weeks ago. She needs to
sleep using 3 pillows. Patient also
added that she also had decreased
eff ort tolerance since 3 weeks ago.
She said it started to worsen 2
weeks ago in which patient claimed
that she started feeling lethargy
after walking around 30 metres.
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Past medical history

Patient also presented with
on and off giddiness.
Patient said that she starts
to vomit and feels
nauseated only after taking
anti-TB drugs. Patient said
that she lose 80kg to 40kg
in this 3 years time.
Otherwise, patient denied
blurring of vision, fever,
cough, chest pain, and
palpitation.

Tu b e rc u l o s i s
Diagnosed 6 months ago
Patient is having recurrent pleural
eff usion.
She has done pleural tapping for 16
times due to this.
Patient
was
placed
under
a
treatment
regimen
for
6
months(D.O.T.S) and completed the
treatment.
She feels better now due to the
treatment.
Hypertension
Diagnosed 3 years back
Latest blood pressure reading is
176/90 mmHg
Taking medications for it
Compliant
So
far
no
complication
from
hypertension
like
headache,
palpitation, or blurring of vision
No Known Medical Illness
4

Past surgical history

Lo w e r s e g m e n t c a e s a re a n
section
Done in 2008 and 2013 to
p re v e n t c o m p l i c a t i o n s a s p a t i e n t
h a d p re v i o u s h i s t o r y 5
m i s c a r i a g e h i s t o r y.
Other than that no other
s u rg e r i e s w e re d o n e .

Drug history and allergy

T. C a l c i u m c a r b o n a t e 5 0 0m g T D S
T. P y r a z i n a m i d e 5 0 0m g E O D
T. A m l o d i p i n e 5 m g O D
T. Fe rro u s Fu m a r a t e 2 0 0 m g O D
Fo l i c a c i d 5 m g O D
Vi t a m i n B 1 / 1 O D
T. I s o n i a z i d 3 0 0 m g O D
T. R i f a m p i c i n 3 0 0 m g O D
T. P y r i d ox i n e 5 0 m g O D
T. E t h a m b u t o l H C l 4 0 0m g E O D

Family history
Fa t h e r p a s s e d a w a y a t t h e a g e o f 6 3
d u e t o m y o c a r d i a l i n f a rc t i o n .
Mother is still alive and is 62 years
old with history of diabetes mellitus
and hypertension.
8 siblings, 5 males and 3 females
with No Known Medical Illness.

Social history
Pa t i e n t l i v e s i n v i l l a g e a re a .
Pa t i e n t c l a i m e d t h a t o p e n b u r n i n g
h a p p e n s c o n s t a n t l y.
Pa t i e n t g e t s a c l e a n w a t e r s u p p l y.
Pa t i e n t h a s n o f o o d a l l e r g y a n d
observes a normal balanced diet.
Pa t i e n t h u s b a n d i s a s m o ke r b u t
d o e s n t s m o ke i n f ro n t o f p a t i e n t .
Pa t i e n t i s n o t a n a l c o h o l i c .
Pa t i e n t a l s o c l a i m e d t h a t t h e re i s n o
pets in her house
Pa t i e n t c l a i m e d t h a t n o o n e i n h e r
family has TB and also her friends. 5

PHYSICAL EXAMINATION
Patient was alert, pink and thin and weak, there was a
cannula inserted on the left hand.
Vital signs :
Temperature: afebrile
Blood pressure: 176/90
Pulse rate: 85 bpm, regular rhythm with normal character and
volume.
Respiratory rate: 16 bpm

Inspection
No peripheral cyanosis, no Osler's node, no jane ways lesion.
The periphery was cold. No conjunctival pallor and scleral
jaundice, oral hygiene acceptable, no central cyanosis.
JV not distended. No any visible pulsation of neck.
Chest: no any chest deformities, no any surgical scars and no
visible pulsation
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Palpation
Trachea is not deviated
The cricosternal distance is 3 fi nger breadths
Apex beat is felt at 5th intercostal space along midclavicular line
Chest expansion was good
Tactile vocal fremitus- increased on the right area

Percussion
Anterior
Dull sound heard on right lower zone

Posterior
Dull sound heard on right lower zone

Auscultation

Bronchial breathing was heard

Decreased air entry on the right compartment
No rhonchi or basal crepitation
Tactile vocal fremitus- increased on the right area
End with PEFR, urine dipstick

PROVISIONAL DIAGNOSIS

Pleural Tuberculosis
Positive fi ndings
Previous history of pleural eff usions
shortness of breath,
decreased eff ort tolerance
lethargy,
loss of weight
Percussion revealed dull sound heard on right lower zone on
both anterior and posterior chest wall
Auscultation revealed bronchial breathing, decreased air entry
on the left compartment and tactile vocal fremitus- increased
on the right area

DIFFERENTIAL DIAGNOSIS
1. Pneumonia
Signs of lobar or atypical pneumonia such as dyspnoea.
Generally, shorter duration of symptoms compared with TB.

2. Sarcoidosis
Other features of sarcoidosis, such as intrathoracic
lymphadenopathy and arthralgias, may be present.

3. Fungal infection
Potential fungi include histoplasmosis, coccidioidomycosis,
and blastomycosis. Travel history may help narrow the
diff erential diagnosis

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INVESTIGATION
Blood investigations
FULL BLOOD

RESULT

REFERENCE RANGE

COUNT
Hb

10.3g/dL

11.5-15.5

TRBC

3.6 x 10 /uL

3.8-5.8

PCV

31.8 %

37-47

MCV

88.8 fL

76-96

MCH

28.6 pg

27-32

MCHC

32.2 g/dL

30-35

PLT

284 x103/uL

150-400

TWBC

8.1 x 103/uL

4-11

Neutrophil

63.6 %

5.15%

2-7.5

Lymphocyte

24.2 %

1.96%

1.5-4

Monocyte

5.5 %

0.45%

2-10

Eosinophil

5.7 %

0.46%

1-6

Basophil

1.0%

0.08%

0.02-0.1

Normal FBC finding.

Patient is slightly
anemic.

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LIVER FUNCTION

RESULT

TEST
TOTAL PROTEIN
ALBUMIN
GLOBULIN
A/G RATIO
TOTAL BILIRUBIN
ALKALINE

REFERENCE
RANGE

73 g/L
39 g/L
34 g/L
1.1 g/L
7 umol/l
84 U/L

65-85
35-50
20-35
1.0-2.2
UP TO 22.2
30-120

15 U/L

UP TO 32

Normal results of
Liver Function Test.

PHOSPHATASE
ALANINE
TRANSAMINASE
RENAL

RESULT

REFERENCE

PROFILE
SERUM

70 umol/l

RANGE
53-100

CREATININE
UREA
SODIUM

8 mmol/l
134

2.5-8.3
135-145

POTASSIUM

mmol/l
4.0

3.5-5.0

CHLORIDE

mmol/l
95 mmol/l

98-108

Normal results of
Renal Profile.

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CARDIAC ENZYMES

RESULT

REFERENCE

CREATINE KINASE
LACTATE

53 U/L
254 U/L

RANGE
25-200
110-248

DEHYDROGENASE
ASPARTATE

13 U/L

UP TO 40

TRANSAMINASE
CALCIUM
INORGANIC

2.16 mmol/l
1.0 mmol/l

2.1-2.6
0.87-1.45

RESULT

REFERENCE

LDH is slightly high.

Other than that, normal
Cardiac Enzymes
values.

PHOSPHATE

COAGULATION

RANGE
PT
INR
APTT

11.70
1.14
36.20

9.56 11.05

29.5 40.9

Normal results of
Coagulation Profile

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Pleural fl uid sample for examination (Microscopic

Examination)

Gross appearance
Microscopic fi ndings
WBC

: Blood stained
: Packed with RBC, unable to count

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IMAGING (CHEST X-RAY)

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Ta ke n o n 26 / 4 / 2 0 16
Fin d i n g s
PA v ie w C h es t X- r a y.
Ta ke n i n ere ct p o s it io n w i t h n o ro t a t i o n a n d t h e fi l m i s a d e q u a t e l y
p e n e t r a t ed .
T h e fi l m is a d eq u a t ely i n s p ire d a n d t h e l u n g fi e l d i s cl e a r.
T h e ca rd ia c th o r a c ic r a t i o i s < 5 0 % .
B il a t e r a l lu n g h ila r v is ib l e w i t h b l u n t e d r i g h t c o s t o p h re n ic a n g le w it h
r a d i o - o p a c it y lo w er z o n e o f r ig h t lu n g .
Lu n g i s h y p er in fl a t ed a n d t h e t r a c h e a i s ce n t r a ll y lo ca t e d a n d n o
d e v i a t i o n . N o c o n s o lid a t io n a n d n o s i g n o f a i r u n d e r d i a p h r a g m .
T h e re i s n o Ao r t ic A n eu r y s m , n o d i l a t e d p u l m o n a r y t r u n k , n o rm a l
h e a r t o r ien t a t io n , n o d ext ro - c a rd ia a n d t h e a p ex i s l o c a t e d i n t h e l e ft .
I m p re s s i o n
Due to blunted costophrenic angle and radioopacity, there might be a fl uid
collection (pleural eff usion) up to the medial border at the right lung.
No cardiomegaly.

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Ta ke n o n 27 / 4 / 2 0 16
Fin d i n g s
PA v ie w C h es t X- r a y.
Ta ke n i n ere ct p o s it io n w i t h n o ro t a t i o n a n d t h e fi l m i s a d e q u a t e l y
p e n e t r a t ed .
T h e fi l m is a d eq u a t ely i n s p ire d a n d t h e l u n g fi e l d i s cl e a r.
T h e ca rd ia c th o r a c ic r a t i o i s < 5 0 % .
B il a t e r a l lu n g h ila r v is ib l e w i t h b l u n t e d r i g h t c o s t o p h re n ic a n g le w it h
r a d i o o p a c it y lo w er z o n e o f r ig h t lu n g .
Lu n g i s h y p er in fl a t ed a n d t h e t r a c h e a i s ce n t r a ll y lo ca t e d a n d n o
d e v i a t i o n . N o c o n s o lid a t io n a n d n o s i g n o f a i r u n d e r d i a p h r a g m .
T h e re i s n o Ao r t ic A n eu r y s m , n o d i l a t e d p u l m o n a r y t r u n k , n o rm a l
h e a r t o r ien t a t io n , n o d ext ro - c a rd ia a n d t h e a p ex i s l o c a t e d i n t h e l e ft .
I m p re s s i o n
Due to blunted costophrenic angle and radioopacity, there might be a fl uid
collection (pleural eff usion) at the lower zone of the right lung.
No cardiomegaly.

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COMPARISON
26/4/2016

27/4/2016

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IMAGING (CECT)

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Taken on 16/2/2016
Findings
Image quality is degraded by breathing artefact.
There is moderate amount of pleural eff usion noted in the
right
hemithorax.
The fl uid is homogenous in density, which measures <20HU.
No pockets of air or soft tissue mass within the eff usion.
The pleural lining is homogenously thin and non-enhancing.
There is a collapse consolidation of the medial segment of the right
middle lobe and basal segment of the right lower lobe with air
bronchograms.

No lung mass seen in the right lung.

No lung nodule or cavitating lesion seen in the right upper
lobe or the rest of the middle and lower lobe.

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 No focal lesion in the left lung.

Heart is enlarged. No pericardial eff usion.
The visualised liver is enlarged. No focal liver lesion
No signifi cant enlarged lymph node in the upper
abdomen.
The pancreas, gallbladder and adrenal glands are
normal.
Impression
Collapse consolidation right middle lobe and basal
segment of the right lower lobe with moderate pleural
eff usion. No lung mass or cavitating lesion.
Cardiomegaly.
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MANAGEMENT PLAN
PHARMACOLOGICAL:

Recommendation on duration of EPTB treatment by WHO

are: regimen should contain 6 months of rifampicin: 2HRZE/4HR

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Others:1. Strict I/O chart

2. Fluid restriction
3. Weigh daily
4. Regular U&E
5. Strict bedrest

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LEARNING OUTCOME AND

DISCUSSION
Summary
It is a 40 years o ld Ma lay female who is a known case of
hypertension and also pleura l tuberculosis who was admitted
due to shortness of breath fo r 3 weeks which was asso ciated
with
ortho pnea,
decreased
eff ort
tolerance,
paroxysmal
nocturnal dyspnea, lethargy, giddiness and lo ss of weight.
Patient is an non-smoker a nd non- alcoholic.
On physical examinatio n, her pulse rate was in regular rhythm
with normal character and vo lume. On palpation, tactile vocal
fremitus- increased o n the right area. On percussion, dull sound
was heard on right lower zone. On auscultation, bronchial
breathing was heard, decrea sed air entry on the right
compartment, tactile vocal fremitus- increased on the right area.
X r a y fi n d i n g : r i g h t l ow e r zo n e e ff u s i on

DEFINITIVE DIAGNOSIS: PLEURAL TUBERCULOSIS

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IMAGING IN EPTB
Pleural TB
I n c l i n i c a l p r a c t i c e , u l t r a s o n o g r a p h y ( U S ) ca n b e u s e d t o d e m o n s t r a t e
p l e u r a l c o l l e c t i o n a n d g u i d e d i a g n o s t i c o r t h e r a p e u t i c p ro c e d u re s s u c h a s
p l e u ro s c o p y.
M u s c u l o s ke l e t a l T B
T h e i m a g i n g m o d a l i t i e s u s e d i n d i a g n o s i s a re p l a i n r a d i o g r a p h y , C T a n d
MRI.
C T a n d M R I i m a g i n g a re o f g re a t v a l u e i n d e m o n s t r a t i n g a s m a l l f o c u s o f
b o n e i n f e c t i o n a n d a l s o t h e ex t e n t o f t h e d i s e a s e p ro c e s s .
M R I i s t h e p re f e rre d i m a g i n g m o d a l i t y i n t h e a s s e s s m e n t o f t u b e rc u l o u s
s p o n d y l i t i s b e c a u s e o f i t s s u p e r i o r a b i l i t y t o d e m o n s t r a t e s o ft t i s s u e
a b n o rm a l i t i e s .
Central Nervous System TB
T h e m o d a l i t i e s t h a t a re u s e d t o i m a g e t h e b r a i n a n d s p i n e a re C T a n d M R I .
C T b e t t e r d e m o n s t r a t e s h y d ro ce p h a l u s w h i c h i s a c o m m o n c o m p l i ca t i o n
o f T B m e n i n g i t i s . I t m a y a l s o s h o w a b n o rm a l m e n i n g e a l e n h a n c e m e n t a n d
p a re n c h y m a l c h a n g e s .
In addition to the above, MRI better demonstrates the involvement of the
31
s p i n a l c o rd a n d c r a n i a l n e r v e s .

Abdominal TB
T h e i m a g i n g m o d a l i t i e s m o s t l y u s e d i n t h e i n v e s t i g a t i o n a re U S , C T a n d
barium studies.
T h e d i a g n o s t i c y i e l d s f o r t h e d i ff e re n t m o d a l i t i e s a re 8 3 % f o r b a r i u m
m e a l f o l l o w t h ro u g h , 80 % f o r C T a n d 7 7 % f o r U S .
Fe a t u re s s u g g e s t i v e o f a b d o m i n a l T B a re a s c i t e s ( 7 9 % ) , e n l a rg e d L N
( 3 5 % ) o m e n t a l t h i c ke n i n g ( 2 9 % ) a n d b o w e l w a l l t h i c ke n i n g ( 2 5% ) .
Genitourinary TB
I n v e s t i g a t i o n i n c l u d e s i n t r a v e n o u s u ro g r a p h y ( I V U ) , U S , C T a n d M R I .
IVU can demonstrate the moth-eaten calyx which may be the earliest
e v i d e n c e o f re n a l T B . I t c a n a l s o d e m o n s t r a t e u re t e r a l a b n o rm a l i t i e s .
U S , C T o r M R I c a n d e m o n s t r a t e t h e re n a l p a re n c h y m a a n d u r i n a r y
bladder better than IVU.
U S a n d C T a re u s e d i n g e n i t a l T B t o e v a l u a t e t h e u t e r u s a n d a d n ex a i n
f e m a l e s a n d t h e p ro s t a t e i n m a l e s b u t t h e i m a g i n g f e a t u re s a re n o n s p e c i fi c .
Head and Neck TB
CT and MRI can be used to evaluate head and neck TB.
C a s e a t i o n a n d c a l c i fi c a t i o n o f c e r v i c a l l y m p h a d e n o p a t h y m a y b e h i g h l y 32
suggestive but is not pathognomonic of TB

THANK YOU

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