5 курс / Пульмонология и фтизиатрия / Clinical_Tuberculosis_Friedman_Lloyd_N_,_Dedicoat
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140 Radiology of Mycobacterial Disease
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Figure 8.23 (a–c) Tuberculoma formation in a 40-year-old male. A 1981 radiograph shows a poorly marginated opacity in the left upper lobe and some scarring (stable over several years) in the right upper lobe (a). Sputum was positive for M. tuberculosis. Films in 1986 (b) and 1989 (c) demonstrate contraction of the left upper lobe nodular opacity with increasing density to form a smooth lobulated mass, typical of a tuberculoma. At autopsy, tuberculomas may contain viable organisms.
Figure 8.24 Biapical cavities as well as nodules in a 39-year- old alcoholic male. Complete resolution occurred after 1 year of therapy.
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Figure 8.25 (a, b) Healing with cavity closure. A large cavity in the right upper lobe in October has an air fluid level (a). Note the calcified nodule in the left perihilar region. Twelve months following treatment the cavity has closed with right upper lobe volume loss and residual apical nodular opacities (b). In cavitary tuberculosis, air fluid levels are slightly unusual, but do occur. Cavities may or may not close completely. Radiographic stability for 6 months must be documented to describe “inactive” tuberculosis.
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Healing 141
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Figure 8.26 (a, b) Incomplete cavity closure. Right upper lobe consolidation, volume loss and multiple lucencies representing cavities are present in association with a pleural effusion (a). Considerable resolution is present after 6 months of treatment with clearing of the pleural effusion. Volume loss persists as well as a cystic space (b). Repeated cultures were negative. Preexisting cystic spaces may simulate cavitary disease where infection occurs with community acquired pneumonia (see Figure 8.27).
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Figure 8.27 (a–c) A 55-year-old male alcoholic with cavitary tuberculosis diagnosed in October 1982 (a) that healed with contraction and residual cystic spaces by April 1983 (b). He presented in December 1992 with weakness, seizures, and vomiting. There is an air-fluid level in the right upper lobe at presentation (c). Although tuberculosis was suspected, it was not found at bronchoscopy and the cavitary opacity healed with nontuberculous antibiotic therapy. This demonstrates that air fluid levels may occur in preexisting spaces and do not necessarily reflect necrosis with cavitation, as would be seen in active tuberculosis.
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Figure 8.28 (a–c) A 32-year-old male with active tuberculosis and a positive sputum smear. Over a 2-year period, healing occurs with progressive destruction of the parenchyma and extensive bullous formation in the right lung. Minimal nodular changes are seen on the left.
142 Radiology of Mycobacterial Disease
TUBERCULOSIS OR CANCER?
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Figure 8.29 (a, b) A 60-year-old male with a 50 pack/year smoking history and an apical density at the right apex. The skin test was negative and old films were not available. The irregular margins of this lesion are highly suspicious for a neoplasm, but at resection the lesion proved to be tuberculous.
Figure 8.30 CT of a 54-year-old male nonsmoker performed to evaluate the pulmonary hilum, which was normal. Nodular opacities are noted peripherally at both bases. At surgery, multiple subpleural nodules were found that were non-necrotizing granulomas. A lymph node resected at the same time was culture positive for
M. tuberculosis.
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Figure 8.31 (a, b) A 50-year-old male with cough and weight loss whose sputum was positive on culture for M. tuberculosis (a). A mass in the right upper lobe continued to enlarge despite response to therapy in the left upper lobe (b), and adenocarcinoma was demonstrated by biopsy.
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Tuberculosis and non-HIV-related immunosuppression 143
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Figure 8.32 (a–c) A 44-year-old white female with a history of incomplete treatment for tuberculosis. The patient was followed for several years, and a growing mass was resected and proved to be an adenocarcinoma. Multiple granulomas were noted in the specimen as well. The patient had a 40 pack/year smoking history, but stopped 6 years before entry into the clinic. Adenocarcinoma is the most frequently associated “scar” carcinoma, but other cell types have been reported as well. It is important when evaluating serial films to compare films widely separated in time (e.g., 2 years) if they are available. Subtle progressive changes over repeated short intervals (e.g., 3−6 months) may be overlooked, as had happened to this patient over a 6-year period.
TUBERCULOSIS AND NON-HIV-
RELATED IMMUNOSUPPRESSION
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Figure 8.33 (a–c) A 67-year-old male with fever and chronic myelogenous leukemia. Over 3 days, aggressive opacification of the left upper lobe was noted. Sputum smear and culture were positive for M. tuberculosis. Rapid progression may be related to immunosuppression.
144 Radiology of Mycobacterial Disease
Figure 8.34 A 50-year-old male presenting with fever and nasal stuffiness completed 1 year of treatment with cyclophosphamide for granulomatosis with polyangiitis. Recurrence of granulomatosis with polyangiitis has not been reported once complete remission has occurred in a patient who continues on full doses of chemotherapy. In this case, with a new infiltrate, there was no evidence of relapse, and another cause of cavitary disease was sought. Although tuberculosis is very unusual in patients with granulomatosis with polyangiitis, M. tuberculosis was found at bronchoscopy.
HIV-RELATED TUBERCULOSIS
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Figure 8.35 (a, b) An HIV-positive intravenous drug abuser with a 3-month history of fever and a mass in the neck. Mediastinal widening extending into the neck with deviation of the trachea to the right is seen on a chest radiograph (a). Computed tomography demonstrates multiple enlarged lymph nodes with low-density centers (arrows) (b). M. tuberculosis was obtained at mediastinoscopy. Thoracic adenopathy is not a feature of AIDS-related complex, and an infectious or neoplastic cause should be sought to explain the adenopathy.
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HIV-related tuberculosis 145
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Figure 8.36 (a–c) A 27-year-old HIV-negative intravenous drug abuser, on peritoneal dialysis for 1 year, presented with fevers. Initial chest radiograph (a) shows free intraperitoneal air as well as azygos (curved arrow) and aortopulmonary adenopathy with a convex margin at the main pulmonary outflow tract (straight arrows). Empiric therapy for M. tuberculosis was given for 6 weeks. Treatment was discontinued when cultures were negative. The chest radiograph after 6 weeks of treatment shows regression of the aortopulmonary and azygos adenopathy (arrows) (b). A routine chest radiograph 7 months later demonstrates a mediastinal mass, and the patient was noted to have become HIV positive (c). Thoracotomy demonstrated M. tuberculosis in the mediastinal nodes. Adenopathy is far more common in patients with tuberculosis who are HIV positive than those who are HIV negative. Careful comparison with a baseline radiograph, if available, is mandatory as the adenopathy may be subtle. Tuberculosis may be the first manifestation of AIDS. (Photo courtesy of Ernest Moritz, MD.)
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Figure 8.37 (a–c) A 37-year-old HIV-positive male intravenous drug user with fever and cough. Six months before admission, he had been diagnosed with tuberculosis, but discontinued therapy after 4 months. There is consolidation of the right upper lobe with bulging of the fissure, as well as right paratracheal adenopathy (a). A pleural effusion developed 5 days later (b). Computed tomography demonstrates dense consolidation with a bulging fissure, a pleural effusion, and spread to the right lower lobe (c). The sputum was positive for M. tuberculosis. Tuberculosis can be very aggressive in immunocompromised patients, particularly those with low CD4 counts. The consolidation in the right upper lobe with a bulging fissure is more typical of staphylococcal and Gram-negative organisms reflecting aggressive infection.
146 Radiology of Mycobacterial Disease
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Figure 8.38 (a–d) A 29-year-old intravenous drug abuser with AIDS and a CD4 count of 53 presented with fever and cough. Initial exam demonstrates some hilar adenopathy (a). An exam 1 month later demonstrates progression to right paratracheal adenopathy (b). Two weeks following, there is marked increase in the mediastinal and hilar adenopathy with narrowing of the bronchus intermedius as well as the left main stem bronchus (arrows) (c). Diffuse parenchymal consolidation developed rapidly as well (d). After 12 days, the admission sputum culture was positive for M. tuberculosis. The sputum became positive on smear when the parenchymal opacities appeared. Rapid clearing resulted after 2 weeks of therapy. This is an example of extremely rapid progression of both lymphadenopathy and parenchymal consolidation in an immunocompromised patient. This patient typifies what once was called “galloping consumption.”
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Figure 8.39 (a–c) A 28-year-old HIV-positive female, presenting with cough, fever, abdominal pain, and back pain. Blood cultures were positive for M. tuberculosis, and miliary dissemination occurred, followed by acute respiratory distress syndrome (ARDS), shown here with three consecutive daily chest radiographs (a–c). Bronchoscopy following intubation demonstrated AFB on smear. Although unusual, tuberculosis is a well-known cause of ARDS.
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Atypical mycobacteriosis: HIVand non-HIV-related 147
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Figure 8.40 (a–c) A 32-year-old HIV-positive male with a history of intravenous drug abuse presented with abdominal pain and was found to have a perforated duodenal ulcer. Computed tomography demonstrates destruction of a vertebral body (curved arrow), with a paraspinal fluid collection (arrow) (a). Similar fluid collections were noted elsewhere in the abdomen. Drainage of the paraspinal collection demonstrated M. tuberculosis. Mediastinal computed tomography shows a paravertebral mass extending superiorly from the abdomen, representing a tuberculous abscess (arrow) (b). Chest computed tomography shows parenchymal involvement as well (c).
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Figure 8.41 (a–c) A 27-year-old HIV-positive female intravenous drug abuser presented with a 1-month history of cough and fever followed by the sudden onset of right-sided chest pain. A hydropneumothorax is demonstrated (arrows) (a). A sharply marginated mass with multiple air fluid levels is seen in the right upper lobe (a). Extensive cavitation ensued (b), and multiple smaller cavitary lesions were noted on computed tomography (c). Resection of the abscess showed Pneumocystis carinii on silver stain, and cultures grew M. tuberculosis, M. avium complex (MAC), Klebsiella, and Enterobacter. A portion of a resected rib showed necrotizing granulomas in the marrow. This patient responded well to therapy, but died 3 months later with a severe electrolyte disturbance. The chest radiograph during that admission showed no new abnormalities and she was negative for M. tuberculosis.
ATYPICAL MYCOBACTERIOSIS: HIV-
AND NON-HIV-RELATED
HIV-related
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Figure 8.42 (a–d) A 36-year-old HIV-positive male with left hilar adenopathy seen on chest radiography (a) and computed tomography (b), followed by lingular consolidation (c, d). At bronchoscopy, an endobronchial mass was found which occluded the lingular bronchus. This was AFB positive on smear and only MAC was cultured.
148 Radiology of Mycobacterial Disease
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Figure 8.43 (a–e) A 33-year-old HIV-positive male with progressive middle lobe consolidation (a–c) that resulted in complete collapse of the middle lobe (d, e). Adenopathy can be appreciated (arrows) (a, b). Bronchoscopy yielded M. kansasii. This is much less frequent than MAC. Consolidation with atelectasis should suggest endobronchial disease and, in the HIV population, mycobacterial disease should be considered strongly.
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Figure 8.44 (a, b) A 37-year-old male with AIDS and a CD4 count of 16 who presented with fever and neck swelling. A digitized radiograph shows massive swelling in the right neck (a) and computed tomography shows large nodes with low-density central areas typical of tuberculous lymphadenitis (arrow) (b). Culture of the biopsied node was positive for MAC.
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Atypical mycobacteriosis: HIVand non-HIV-related 149
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Figure 8.45 (a, b) HIV with reconstituted immunity. A 35-year-old African-American woman diagnosed 2 months previously with AIDS. After 6 weeks of antiviral treatment, she developed a cough and hemoptysis. The CD4 count had risen from 34 to 490, and the PPD had become positive as had the chest radiograph. The open lung biopsy demonstrated MAC. The chest radiograph (a) shows multiple pleural-based poorly marginated apical opacities bilaterally (large arrow) as well as a cavitating parenchymal nodule (small arrow). Computed tomography of the chest shows the poorly marginated pleural-based parenchymal masses (b). Subsequent computed tomography of the abdomen showed necrotic lymph nodes compatible with MAC.
Non-HIV-Related
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Figure 8.46 (a–c) A 71-year-old female with a history of whooping cough as a child followed by multiple episodes of pneumonia. Bronchiectasis was diagnosed on bronchography in 1977 and, when required, intermittent antibiotics were administered for infection. MAC was seen in increasing concentration in the sputum with the onset of hemoptysis in 1986. A chest radiograph shows cavitary lesions of various sizes in the right and left lungs (a). Over 2 years, the largest cavity on the left has contracted and a new cavity is noted below this (arrow) (b). After 4 years of chemotherapy, the sputum finally became negative and the chest radiograph stabilized (c). Bronchiectasis may be a predisposing factor for infections with atypical mycobacteria.
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Figure 8.47 (a, b) A 54-year-old female with a history of recurrent pneumonias following an episode of whooping cough as a child. She presented with mild hemoptysis and a positive purified protein derivative (PPD). In 1992 her sputum was positive for AFB, which initially were identified by probe as M. tuberculosis, then biochemically as M. xenopi, and finally as M. celatum. Computed tomography demonstrates an area of cystic bronchiectasis in the right middle lobe (arrow) (a). Elsewhere are cavities of varying sizes, some irregularly shaped (b). Smaller cavitary lesions were present on a computed tomographic examination 7 years previously.