Pulmonary Tuberculosis: Up-to-Date Imaging and Management
Yeon Joo Jeong1 and
Kyung Soo Lee2
1 Department of Diagnostic Radiology, Pusan National University Hospital, Pusan
National University School of Medicine and Medical Research Institute, Pusan,
Korea.
2 Department of Radiology and Center for Imaging Science, Samsung Medical
Center, Sungkyunkwan University School of Medicine, 50, Ilwon-Dong,
Kangnam-Ku, Seoul 135-710, Korea.
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Fig. 1A —Primary tuberculosis manifesting primarily as lymphadenopathy
in 26-year-old woman. Posteroanterior chest radiograph shows right hilar mass
(arrow). Note smaller nodule (arrowhead) in right upper lung
zone.
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Fig. 1B —Primary tuberculosis manifesting primarily as lymphadenopathy
in 26-year-old woman. Contrast-enhanced transverse CT scan (5.0-mm section
thickness) obtained at level of basal trunk using mediastinal window setting
shows enlarged right hilar and subcarinal lymph nodes (arrows),
central necrotic low attenuation, and peripheral rim enhancement.
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Fig. 2B —Primary tuberculosis presenting with consolidation and
lymphadenopathy in 21-year-old woman. Contrast-enhanced transverse CT scan
(5.0-mm section thickness) obtained at level of right middle lobar bronchus
using mediastinal window setting shows airspace consolidation in right middle
lobe. Note enlarged right hilar and subcarinal lymph nodes (arrows).
Hilar node has necrotic low attenuation.
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Fig. 3 —Tuberculous granulomas in 58-year-old man. 18F-FDG
PET/CT scan shows increased FDG uptake in nodules—well-defined
predominant nodule (arrow) and surrounding smaller satellite nodules
(arrowheads)—in right upper lobe with maximum standard uptake
value of 6.1.
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Fig. 4B —Reactivation tuberculosis in 55-year-old man. High-resolution
CT scans (1.0-mm section thickness) obtained at levels of aortic arch
(B) and proximal ascending aorta (C) show consolidation and
acinus-sized nodules containing several cavities in both upper lobes. Note
branching nodular and linear opacities (tree-in-bud signs) (arrows)
and centrilobular small nodules (arrowheads, C) in both
lungs.
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Fig. 4C —Reactivation tuberculosis in 55-year-old man. High-resolution
CT scans (1.0-mm section thickness) obtained at levels of aortic arch
(B) and proximal ascending aorta (C) show consolidation and
acinus-sized nodules containing several cavities in both upper lobes. Note
branching nodular and linear opacities (tree-in-bud signs) (arrows)
and centrilobular small nodules (arrowheads, C) in both
lungs.
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Fig. 4D —Reactivation tuberculosis in 55-year-old man. Photograph of
gross specimen obtained at lobectomy from different patient shows multiple
foci of nodules and consolidation that are distinctly white, consistent with
caseous necrosis. Most have nodular appearance and some appear to be branching
(arrows), suggestive of airway-centered nature of lesions.
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Fig. 4E —Reactivation tuberculosis in 55-year-old man. Photomicrograph
of surgical specimen discloses multiple granulomas, each related to small
membranous bronchiole (arrows). Some granulomas show central caseous
necrosis (arrowhead). (H and E, x40)
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Fig. 5B —Miliary tuberculosis in 70-year-old man. High-resolution CT
image (1.0-mm section thickness) at level of right upper lobar bronchus shows
uniform-sized small nodules randomly distributed throughout both lungs. Note
subpleural and subfissural nodules (arrows).
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Fig. 6A —Miliary tuberculosis presenting as acute respiratory distress
syndrome in 47-year-old man. Posteroanterior chest radiograph shows
innumerable millet-sized nodular opacities and ground-glass opacities in both
lungs.
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Fig. 6B —Miliary tuberculosis presenting as acute respiratory distress
syndrome in 47-year-old man. High-resolution CT image (1.0-mm section
thickness) obtained at ventricular level shows randomly distributed small
nodules and extensive bilateral ground-glass opacity. Note interlobular septal
(arrows) and intralobular interstitial thickenings in both lungs.
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Fig. 6C —Miliary tuberculosis presenting as acute respiratory distress
syndrome in 47-year-old man. Photomicrograph of pathologic specimen obtained
with transbronchial lung biopsy discloses granuloma (arrows) in
alveolar wall. Diffuse alveolar wall thickening and intraalveolar fibrin
deposition (not shown) suggesting early stage of diffuse alveolar damage were
also observed. (H and E, x400)
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Fig. 7A —Actively caseating bronchial tuberculosis in 42-year-old
woman. Contrast-enhanced transverse CT scans (5.0-mm section thickness) using
mediastinal window setting obtained at levels of thoracic inlet (A) and
main bronchi (B) show luminal narrowing of trachea and proximal left
main bronchus and irregular wall thickening. Note lymph nodes
(arrows, A) in mediastinum.
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Fig. 7B —Actively caseating bronchial tuberculosis in 42-year-old
woman. Contrast-enhanced transverse CT scans (5.0-mm section thickness) using
mediastinal window setting obtained at levels of thoracic inlet (A) and
main bronchi (B) show luminal narrowing of trachea and proximal left
main bronchus and irregular wall thickening. Note lymph nodes
(arrows, A) in mediastinum.
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Fig. 7C —Actively caseating bronchial tuberculosis in 42-year-old
woman. Bronchoscopy shows narrowed left main bronchial lumen with its mucosa
swollen and covered diffusely with whitish cheeselike substance
(arrow).
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Fig. 8A —Paradoxical worsening of tuberculous lymphadenitis associated
with immune reconstitution inflammatory syndrome in 40-year-old woman with
AIDS. Contrast-enhanced transverse CT scan (5.0-mm section thickness) using
mediastinal window setting obtained at level of aortic arch just before highly
active antiretroviral therapy, shows multiple enlarged lymph nodes
(arrows) with central necrotic low attenuation in prevascular and
right paratracheal areas. Patient's HIV RNA viral load and CD4 counts were
more than 1 million copies/mL and 35 cells/µL, respectively.
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Fig. 8B —Paradoxical worsening of tuberculous lymphadenitis associated
with immune reconstitution inflammatory syndrome in 40-year-old woman with
AIDS. Follow-up CT image obtained 3 months after A shows increased
extent of necrotic lymph nodes (arrows). Patient's HIV RNA viral load
and CD4 counts at this time were 433 copies/mL and 142 cells/µL,
respectively.
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Fig. 9A —Pulmonary tuberculosis with lymphadenopathy and
extrapulmonary involvement in 42-year-old man with AIDS. His CD4 count was 64
cells/µL. Posteroanterior chest radiograph shows multiple small nodular
opacities in both lungs, especially in upper lung zones.
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Fig. 9B —Pulmonary tuberculosis with lymphadenopathy and
extrapulmonary involvement in 42-year-old man with AIDS. His CD4 count was 64
cells/µL. High-resolution CT scan (1.0-mm section thickness) obtained at
level of aortic arch shows randomly distributed small nodules and interlobular
septal thickenings in both lungs.
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Fig. 9C —Pulmonary tuberculosis with lymphadenopathy and
extrapulmonary involvement in 42-year-old man with AIDS. His CD4 count was 64
cells/µL. Contrast-enhanced transverse CT scans (5.0-mm section thickness)
using mediastinal window setting obtained at levels of mandible (C) and
thoracic inlet (D) show enlarged lymph nodes (arrows), central
necrotic low attenuation, and peripheral rim enhancement in right neck and
left axilla.
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Fig. 9D —Pulmonary tuberculosis with lymphadenopathy and
extrapulmonary involvement in 42-year-old man with AIDS. His CD4 count was 64
cells/µL. Contrast-enhanced transverse CT scans (5.0-mm section thickness)
using mediastinal window setting obtained at levels of mandible (C) and
thoracic inlet (D) show enlarged lymph nodes (arrows), central
necrotic low attenuation, and peripheral rim enhancement in right neck and
left axilla.
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Fig. 10A —Pulmonary tuberculosis in 51-year-old man with AIDS. His CD4
count was 4 cells/µL. Posteroanterior chest radiograph shows multifocal
masslike airspace consolidation in bilateral upper lung zones.
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Fig. 10B —Pulmonary tuberculosis in 51-year-old man with AIDS. His CD4
count was 4 cells/µL. High-resolution CT scans (1.0-mm section thickness)
obtained at levels of left innominate vein (B) and azygos arch
(C) show masslike airspace consolidation with air bronchograms,
centrilobular small nodules (arrows, C), and ground-glass
opacity in both upper lobes.
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Fig. 10C —Pulmonary tuberculosis in 51-year-old man with AIDS. His CD4
count was 4 cells/µL. High-resolution CT scans (1.0-mm section thickness)
obtained at levels of left innominate vein (B) and azygos arch
(C) show masslike airspace consolidation with air bronchograms,
centrilobular small nodules (arrows, C), and ground-glass
opacity in both upper lobes.
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Fig. 11A —Multidrug-resistant tuberculosis in 36-yearold man.
Posteroanterior chest radiograph shows multiple small nodules, patchy
consolidation containing several cavities, and linear opacities in both lungs.
Note decreased volume in right lung and apical pleural thickening.
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Fig. 11B —Multidrug-resistant tuberculosis in 36-yearold man.
High-resolution CT scan (1.0-mm section thickness) obtained at level of left
basal trunk shows consolidation containing several cavities in right middle
lobe and right lower lobe. Note small cavitary nodule and centrilobular
nodules in left upper lobe.
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Fig. 12A —Rasmussen aneurysm in chronic destructive pulmonary
tuberculosis in 62-year-old man. Contrast-enhanced transverse CT scan (2.5-mm
section thickness) obtained at level of main bronchi using mediastinal window
setting shows cavitary consolidation with air-crescent sign (low-attenuation
lesion and surrounding air) (arrow) in left upper lobe.
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Fig. 12B —Rasmussen aneurysm in chronic destructive pulmonary
tuberculosis in 62-year-old man. CT scan obtained 15 mm inferior to A
shows contrast-enhancing round vascular structure (arrow) in
consolidative lesion.
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Fig. 13A —Pleural and chest wall tuberculosis in 74-year-old man.
Posteroanterior chest radiograph shows loculated pleural fluid and pleural
calcification in right hemithorax. Soft-tissue bulging opacity is also
observed in right lower lateral chest wall (arrowheads). Note right
upper lobe volume loss, calcifications, and cavity.
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Fig. 13B —Pleural and chest wall tuberculosis in 74-year-old man.
Contrast-enhanced transverse CT scan (5.0-mm section thickness) obtained at
level of porta hepatis using mediastinal window setting shows pleural fluid
collection and visceral pleural calcification (arrow) in right
hemithorax, suggesting chronic tuberculous empyema. Lentiform chest wall
lesion (arrowhead) showing central low attenuation, consistent with
focal tuberculous chest wall abscess, is also seen.
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