Introduction

*The increasing prevalence

tuberculosis in both immunocompetent
of
and immunocompromised individuals
in recent years makes this disease a
topic of universal concern.
 Introduction

*Because tuberculosis demonstrates

a variety of clinical and radiologic
findings and has a known propensity
for dissemination from its primary
site, it can mimic numerous other
disease entities..
 Epidemiology

*The World Health Organization (WHO)

estimates that each year more than 8
million new cases of tuberculosis occur
and approximately 3 million persons die
from the disease.
*Ninety-five percent of tuberculosis cases
occur in developing countries.
*It is estimated that between 19 and 43% of
the world's populationis infectedwith
Mycobacterium the
bacterium
tuberculosis,that causes
tuberculosis infection and disease
 Epidemiology
 Most cases in the US are due to
reactivation, especially amongst immigrants
 Highest risk of progression to active TB is
within 2 years of seroconversion
 Increase in incidence in late 1980s-early
90s largely due to HIV
 Needs to be reported to the health department
Microbiology
 Aerobic
 Bacillus (rod-shaped)
 Non-spore forming
 Non-motile
 Cell wall – mycolic acid – retains acid fast
stain
 Growth - doubling time of 15-20 hrs.
 3-8 weeks for growth on solid media
TB Skin
Testing
 PPD – purified protein derivative
of tuberculin (antigenic)
 Delayed type hypersensitivity
reaction
 PPD may not become “positive” until
3 months after exposure
 Boosting effect
Skin Test Interpretation
 PPD >/= 5 mm:
– HIV patients
– Recent contacts of someone with TB
– Fibrotic changes on CXR c/w prior TB
– Organ transplant recipients
– Immunosuppressed (includes patients
receiving the equivalent of 15 mg/day or
more of prednisone for one month or
more)
Skin Test Interpretation
 PPD >/= 10 mm:
– Recent immigrants (< 5 years) from high
prevalence areas (Eastern Europe, Latin
America, Asia, Africa)
– IV drug users
– Residents and employees of high risk facilities
(hospitals, nursing homes, homeless
shelters, prisons)
– Children < 4 years of age
– Mycobacteriology lab personnel
Skin Test Interpretation

 PPD >/= 10 mm:

– People with medical conditions that place
them at high risk for active TB
 Chronic renal failure
 Diabetes mellitus

 Silicosis

 Leukemias/lymphomas

 Carcinoma of the head/neck or lung

 Weight loss > 10% of ideal body weight

 Gastrectomy/jejunoileal bypass
Skin Test Interpretation

 PPD >/= 15 mm:

– Low risk people
– Routine tuberculin testing not
recommended for low risk populations
Skin Test Intrepretation
 False positives:
– Non-tuberculous mycobacterial infection
– BCG vaccination
 False negatives:
– HIV
– Malnutrition
– Steroid therapy
– Recent infection
BCG

 Bacille Calmette-Guerin vaccination:

 Live attenuated mycobacterial strain
derived from M. bovis
 Can yield false positives to PPD – less likely
as time from vaccination increases
 Reactions > 20 mm likely are true

 CDC advises that the PPD be interpreted by

the same guidelines (ignore the BCG history)
 Bacteriology
Causative organism;
 M y c o b a c t e r i u m tuberculosis COMPLEX

 S t a i n e d with:
-Modified gram stain: gram positive.
-Carbolfuchsin stain: *Cold method(Kynon)
*Hot(Zeil-Neelson)
- Fluorescent dyes: rhodamine and
auramine stains.
Diagnosis of Active
TB
 Acid fast stain of sputum
 Sputum AFB culture (culture
needed for drug susceptibility)
 Radiographic imaging (CXR, CT)
 PCR/NAT
 Fluid Aspiration
 Tissue biopsy – higher yield than
fluid
Transmission
 Transmitted by airborne particles 1-5
microns in size
 Ease of transmission depends on duration
and proximity of contact as well as the
number of bacteria excreted
 Infection can result from only 1-5 bacteria
entering a terminal alveolus
 Only those with active pulmonary TB are
infectious
*M tuberculosis is transmitted via
airborne droplet nuclei that are
produced when persons with
pulmonary or laryngeal TB cough,
sneeze,nuclei
* Droplet speak,may
or sing .
be produced by aerosol
treatments, sputum induction,aerosolization
during bronchoscopy, and through
manipulation of lesions or processing of
tissue or secretions in the hospital or
laboratory.
Pathogenesis
– Inhalation -> phagocytosis by alveolar
macrophages
– Bacterial multiplication occurs
intracellularly
– Lymphatic spread to regional lymph nodes
or hematogenous dissemination
– Immune response results in granuloma formation
(containment of infection)
– Cell death in the granuloma results in caseous
necrosis
– Bacteria can remain dormant in the
granuloma
Pathogenesis
– Medical conditions that increase risk for
active TB:
 Chronic renal failure
 Diabetes mellitus

 Silicosis

 Leukemias/lymphomas

 Carcinoma of the head/neck or lung

 Weight loss > 10% of ideal body weight

 Gastrectomy/jejunoileal bypass
Primary pulmonary tuberculosis

*The first infection with tubercle bacillus.

Includes the involvement of the draining
lymph nodes in addition to the initial
lesion(Ghon).
Clinical features:
Majority: symptomless.(specially
in young adults)
Brief febrile
illness. Loss of
appetite.
Failure to gain
weight in children.
Cough is not unusual and may mimic
paroxysm of whooping cough.
Physical signs:
•May be normal,
•Crepitation may be heard.
•Primary lesion could
be heard.
•Segmental or lobar collapse
may occur.
Radiological features:
•Lymphadenoathy: hilar lymph nodes
are most commonly involved rarely
paratracheal.Calciflcation of the nodes
may occur.
•Pulmonary componant: ( mainly in
adults) segmental or lobar
consolidation or
obstructive emphysema.
•Resolution of radiological shadow 6m-
2ys.
Diagnosis:
*Vague ill health with history of contact.
* X-ray.
*Tubercli test: is usually strongly
n
positive. and gastric lavage for
smear
*Sputum direct and culturehelpfulin 20-
25% of cases.
* DNA amplification: PCR.
Primary pulmonary tuberculosis

Primary pulmonary TB typically

manifests radiologically as parenchymal
disease, lymphadenopathy, pleural
effusion, miliary disease, or lobar or
segmental atelectasis.
Post primary pulmonary tuberculosis
The most important type of tuberculosis
because it is the most frequent and
smear positive sputum is the main
source of infection responsible for the
persistence of the disease in the
community.
Source;
1.Direct progression of the
primary lesion.
2.Reactivation of the quiescent primary
or post primary.
3. Exogenous infection.
Predisposing factors for reactivation:
1. Malnutrition.
2. Poor housing and overcrowding.
3. Steroid and other immunosuppressive
drugs.
4. Alcoholism.
5. Other diseases: HIV
malignancy, lymphomas ,
Leukaemia,Diabetes.
Clinical features:
Mainly in middle aged and
A-Symptoms: elderly.
1. May be no symptoms, or just mild
debility.
Gradual onset of symptoms over weeks or months.
2. General malaise.
3. Loss of appetite, loss of weight.
4. Febrile course.
5. Night sweating.
6. Cough with or without sputum.
7. Sputum could be mucoid, purulent or blood stained.
8. Could be presented with frank haemoptysis.
9. Tuberculous pneunonia.
B-Signs:
1. May be no signs.
2. Pallor, cachexia.
3. Fever.
4. Post tussive crepitations on the apices.
5. Signs of Consolidation.
6. Signs of fibrosis.
7. Signs of cavitary lesion.
8.Localised wheezes in
endobronchial tuberculosis
 Postprimary Tuberculosis
Postprimary disease results from reactivation of a
previously dormant primary infection in 90% of cases;
in a minority of cases, it represents continuation of the
primary disease . Postprimary tuberculosis is almost
exclusively a disease of adolescence and adulthood.
Radiology:
1.Bilateral upper zone fibrotic shadows: with
shift of trachea, mediastinum, distortion of
fissures and diaphragm, and elevation of the
pulmonary hila.
2.Soft confluent shadows of exudative lesion
(D.D pneumonia)
3 Calcification.
4. Cavitation.
5. Tuberculoma.
6.Hilar and paratracheal lymph node
enlargement may be present.
Diasnosis:
1) Clinical
2) Plain X-ray.
3) Sputum Examination: direct smear and culture
(very
important).
4)Other samples: Gastric aspirate, laryngeal swab, fiberoptic
specimens (wash,brush,biopsy),transtracheal spirate.
5 Polymerase chain reaction.)
6) Tuberclin test: mainly strongly positive
7) Others
White blood cells if normal favour the
Normocytic
diagnosis ESR may be normochromic
elevated. anaemia.
CT may be useful in detecting
small cavities
or calcification. ,
 Miliary Tuberculosis
Produced by acute dissemination of tubercle
bacilli via the blood stream.The term miliary
derives from the radiological picture of
diffuse, discrete nodular shadows about the
size of millet seed (2mm).
A- Classical
Clinical
form: features:
Most common in infants and young children with acute
or subacute febrile illness.
In adults: the onset is insidious, gradual vague ill health.
Malaise, Cough (usually dry), dyspnea. Night sweat
is
less common.
Headache suggest associated tuberculous meningitis

Chest examination is free, crepitations may be found.

Hepatomegaly, splenomegaly,
lymphadenopathy,
neck rigidity may be found in rare cases.
Diasnosis
1)
: Clinical.
2) Xray.
3) Choroidal tubercles in fundus
examination
4) Tuberclin test not conclusive
5)Direct smear and culture of sputum if
present.
6)Other samples as transtracheal aspirate,
fiberoptic specimens may be obtained.
7)If failed to prove therapeutic trial for 2
weeks
 Cardiac Tuberculosis

Although tuberculosis rarely involves the heart

pericardial involvement may occasionally be
seen with and pulmonary
mediastinal
tuberculosis and is cause of calcific
a pericarditis
(
 Skeletal Tuberculosis
Tuberculous Spondylitis (Pott Disease)

The spine is the most frequent site of osseous

involvement in tuberculosis , with the upper lumbar
and lower thoracic spine being involved most
frequently. More than one vertebra is typically
affected, and the vertebral body is more commonly
involved than the posterior elements. An anterior
predilection is seen in the vertebral body
Tuberculous spondylitis. Lateral radiograph demonstrates obliteration of the disk
space (straight arrow) with destruction of the adjacent end plates (curved arrow)
and anterior wedging. Subligamentous spread of spinal tuberculosis. Lateral
radiograph demonstrates erosion of the anterior margin of the vertebral body
(arrow) caused by an adjacent soft-tissue abscess.
 Extraspinal Tuberculous
Osteomyelitis

Tuberculous osteomyelitis is usually hematogenous

in origin and is most commonly seen in bones
of the extremities, including the smallbones
of the hands and feet. In long, tubular bones,
tuberculosis often involves the
epiphyses.In children, metaphyseal foci can
involve the growth plate. This feature
differentiates tuberculosis from pyogenic
infection
Tuberculous osteomyelitis involving the skull. Axial contrast-
enhanced CT scan demonstrates a bilobed, peripherally
enhancing cold abscess centered along the right frontal bone
(arrow, arrowhead). Note the significant edema and the mass
effect on the underlying brain parenchyma. Axial CT scan
obtained with bone windowing demonstrates an ill-defined
lytic area of bone destruction (arrow).
 Gastrointestinal Tuberculosis

Although abdominal tuberculosis is usually

secondary to pulmonary tuberculosis,
radiologic evaluation often shows no evidence
of lung disease
Ileocecum and Colon
The ileocecal region is the most common area
of involvement in the gastrointestinal tract due
to the abundance of lymphoid tissue. The
natural course of gastrointestinal tuberculosis
may be ulcerative, hypertrophic, or
Ileocecal tuberculosis.
Radiograph obtained
with peroral
pneumocolon technique
demonstrates a conical
and shrunken cecum
(straight arrow)
retracted out of the iliac
fossa by contraction of
the mesocolon. Note also
the narrowing of the
terminal ileum (curved
arrow).
 Peritoneum
Peritoneal involvement in tuberculosis is rare and is
usually associated with widespread abdominal
disease involving lymph nodes or bowel .Three
principal types of tuberculous peritoneal
involvement are recognized. The wet type is the
most common and is associated with large amounts
of viscous ascitic fluid that may be either diffusely
distributed or loculated .The fluid demonstrates high
attenuation at CT due to its high protein and cellular
content .The dry or plastic type is uncommon and is
characterized by caseous nodules, fibrous peritoneal
reaction, and dense adhesions
The fibrotic fixed type (consists of large omental
masses, matted loops of bowel and mesentery,and,
on occasion, loculated ascites .CT may also
demonstrate tethering of bowel loops. Infiltration
of the mesentery, when associated with a large
amount of ascites, may have a stellate appearance
at CT.
Peritoneal tuberculosis (dry type). Axial CT scan
demonstrates thickening and infiltration of the
peritoneum (white arrows) along with thickening
of bowel loops. Note the small amount of
loculated fluid (black arrow).
Abdominal tuberculous lymphadenitis.
Axial contrast-enhanced CT scan demonstrates multiple
enlarged mesenteric lymph nodes with central areas
of low attenuation (arrow).
 Hepatic tuberculosis.
Axial contrast-enhanced
CT scan demonstrates multiple nonuniform,
low-attenuation lesions within the liver (straight arrows).
An enlarged gastrohepatic lymph node is also
seen (curved arrow).
Renal tuberculosis.
Chest radiograph that includes
the upper abdomen
demonstrates lobar
calcification in the right
kidney (black arrow). Note
also the bilateral fibrocalcific
changes in the upper lobes
(white arrows).
 Endometrial tuberculosis.
Hysterosalpingogram demonstrates an obliterated
and deformed endometrial cavity (arrow)
due to tuberculous endometritis.
 Cranial tuberculous
Axial gadolinium-enhanced T1-weighted MR image demonstrates leptomeningeal
meningitis.
enhancement along the left sylvian fissure (straight arrow). There is an
accompanying ring-enhancing granuloma in the left parieto-occipital region
(curved arrow).
 Cranial tuberculomas
Axial contrastenhanced CT scan demonstrates multiple
ring-enhancing lesions (straight arrows) along with
diffuse meningeal enhancement (curved arrow).
 Conclusions
Tuberculosis can affect virtually any organ system in
the
body and can be devastating if left untreated. The
increasing prevalence of this disease both
in
immunocompetent and immunocompromised individuals
makes tuberculosis a topic of universal concern.
Tuberculosis has a variety of radiologic appearances and
can mimic numerous other disease entities. A high degree
of clinical suspicion and familiarity with the various
radiologic manifestations of tuberculosis allow early
diagnosis and timely initiation of appropriate therapy,
thereby reducing patient morbidity.