AJR 2001; 176:441-445
© American Roentgen Ray Society
CT Manifestations of Late Sequelae in Patients with Tuberculous Pleuritis
Jung-Ah Choi1,
Ki Taek Hong1,
Yu-Whan Oh1,
Myung Hee Chung2,
Hae Young Seol1 and
Eun-Young Kang1
1
Department of Diagnostic Radiology, College of Medicine, Korea University,
Korea University Guro Hospital, 80 Guro-dong, Guro-ku, Seoul 152-050,
Korea.
2
Department of Radiology, Holy Family Hospital, Catholic University,
Sosa-2-dong, Wonmi-gu, Pucheon city, Kyunggi-do 420-717, Korea.
Received April 19, 2000;
accepted after revision July 24, 2000.
Address correspondence to E.-Y. Kang.
Introduction
Tuberculous pleuritis remains one of the major causes of pleural effusion
with an incidence ranging from as high as 86% in a population with a high
number of HIV-positive patients to 25% in a population with high incidence of
pulmonary tuberculosis [1].
Tuberculous pleuritis occurs when a subpleural focus of Mycobacterium
tuberculosis ruptures into the pleural space initiating a delayed
hypersensitivity reaction, by hematogeneous dissemination of mycobacteria, or
by direct extension of the primary disease
[2].
Tuberculous pleuritis usually resolves completely even in the absence of
treatment [1]. However, in some
patients, chronic complications occur during the healing of tuberculous
lesions or as late sequelae. The complications of tuberculous pleuritis are as
varied as its pulmonary manifestations. CT scans can be valuable in the
diagnosis of the chronic complications or the late sequelae of tuberculous
pleuritis, which manifest as pleural thickening, calcifications, fibrothorax,
chronic persistent effusion, including pseudochylothorax, empyema
necessitatis, bronchopleural fistula, and malignancy.
Pleural Thickening and Fibrothorax
Tuberculous pleuritis often leaves sequelae ranging from minimal pleural
thickening, seen as obliteration of the costophrenic sulcus, to severe
thickening, seen as fibrous tissue and calcification encompassing and
restricting the lung and referred to as fibrothorax. Fibrothorax may be
associated with extensive volume loss of the ipsilateral lung and even with
ventilatory impairment [3].
On CT, pleural thickening is depicted as a layer of soft-tissue density at
the chest wall-lung interface (Figs.
1 and
2). CT can easily show pleural
calcification, which is a frequent associated finding of pleural thickening
caused by tuberculosis. Fibrous obliteration of the pleural space, or
fibrothorax, may develop as a result of organized hemorrhagic effusions,
tuberculous effusions, other empyemas, and benign asbestos-related pleurisy
[3]. Several radiologic
features allow differentiation among these various causes of fibrothorax. On
radiography and CT, evidence of underlying parenchymal disease, extensive
calcification of the fibrothorax, and unilateral involvement are strongly
suggestive of previous tuberculosis
[3]
(Fig. 3).
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Fig. 1. —Pleural thickening in 64-year-old man diagnosed with
tuberculous pleuritis 3 years earlier. CT scan shows diffuse pleural
thickening with areas of calcifications (arrows) in right
hemithorax.
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Fig. 2. —Fibrothorax in 25-year-old woman. Radiographs of chest (not
shown) obtained 6 months earlier revealed incidental abnormalities. CT scan
shows extensive pleural thickening encompassing right hemithorax, which is
decreased in volume.
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Fig. 3. —Fibrothorax in 74-year-old man. CT scan shows extensive
pleural thickening with calcifications in left hemithorax. Note loss of
volume. Also, note adjacent rib hypertrophy and prominent epipleural fat pads
(arrows), suggesting chronic benign pleural disease.
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Chronic Persistent Pleural Effusion
Tuberculous pleuritis may progress to chronic persistent pleural effusion
or tuberculous empyema, which may be defined as persistent grossly purulent
pleural fluid containing numerous tubercle bacilli
[4]. Chronic persistent
effusion is often asymptomatic and sometimes does not become apparent until
many years after the episode of acute pleurisy. Chronic persistent effusion
should be suspected if pleural thickening is in excess of 2 cm or if more than
one linear shadow is visible running parallel to the inner chest wall on chest
radiographs [5]. CT shows a
loculated pleural fluid collection in association with pleural thickening and
calcifications (Figs. 4 and
5). Chronic tuberculous empyema
may either decompress through the chest wall, in which case it is called
empyema necessitatis, or communicate with the bronchial tree, in which case a
bronchopleural fistula results
[5].
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Fig. 4. —Chronic tuberculous empyema in 66-year-old man diagnosed with
tuberculous pleuritis 23 years earlier. CT scan obtained at level of lower
thorax shows large loculated pleural fluid collection in right lower lateral
hemithorax. Note surrounding pleural thickening and calcifications.
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Fig. 5. —Chronic persistent pleural effusion in 40-year-old man. CT
scan shows lenticular-shaped chronic loculated pleural effusion enclosed by
calcified pleural layers in left lateral hemithorax. Note loculated fluid is
near soft-tissue density (arrow), indicating chronicity of loculated
content.
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Empyema Necessitatis
Empyema necessitatis, another well-known complication of tuberculous
pleuritis, is formed by breakage of the tuberculous empyema through the
parietal pleura for spontaneous discharge of its contents. The most common
site of empyema necessitatis is subcutaneous tissue of the chest wall, but
other sites include the esophagus, breast, retroperitoneum, flank, groin,
pericardium, and vertebral column
[6].
CT can lead to a diagnosis of empyema necessitatis by allowing simultaneous
visualization of intrathoracic and extrathoracic lesions. CT findings include
well-demarcated, thickwalled fluid collections in intrathoracic and
extrathoracic locations [6]
(Figs.
6A,6B
and 7). A fistulous track
between a pleural fluid collection and an extrathoracic fluid collection is
often revealed on CT. Findings of empyema necessitatis differ from those
associated with musculoskeletal tuberculous infection involving rib, costal
cartilage, sternum, and vertebra by the absence of bony or costal cartilage
destruction and by the main location of the lesion.
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Fig. 6A. —Empyema necessitatis in 23-year-old man. CT scans reveal
thick-walled, bilobed fluid collection involving both pleural cavity
(A) and adjacent chest wall (B) without adjacent rib
destruction. Direct communication between pleural (arrows, A)
and chest wall fluid collection (arrows, B) is not shown on
this CT scan. Patient had history of tuberculous pleuritis 5 years ago and
presented with chest pain of 1-2 months' duration. He underwent surgery and no
rib destruction was found, consistent with findings on CT.
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Fig. 6B. —Empyema necessitatis in 23-year-old man. CT scans reveal
thick-walled, bilobed fluid collection involving both pleural cavity
(A) and adjacent chest wall (B) without adjacent rib
destruction. Direct communication between pleural (arrows, A)
and chest wall fluid collection (arrows, B) is not shown on
this CT scan. Patient had history of tuberculous pleuritis 5 years ago and
presented with chest pain of 1-2 months' duration. He underwent surgery and no
rib destruction was found, consistent with findings on CT.
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Fig. 7. —Empyema necessitatis in 25-year-old man. CT scan shows
bilobed fluid collection along pleura and another unilocular fluid collection
along adjacent outer chest wall (arrows) in right hemithorax. Center
of fluid collections is located in intercostal space, and no definite evidence
of rib destruction is present. At surgery, no evidence of rib destruction was
found, consistent with CT findings.
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Bronchopleural Fistula
A bronchopleural fistula is a direct communication between the pleural
cavity and the bronchial tree or the lung parenchyma and may develop either
during the active stage of the tuberculous infection or during a quiescent
phase many years later [7] as
another chronic complication of tuberculous pleuritis.
Chest radiographs are valuable not only for suggesting the possibility of a
bronchopleural fistula, but also for monitoring the efficacy of therapy. The
fistula is almost never directly seen but is suggested on chest radiographs
[8]. CT is known to be the
imaging technique of choice for visualization and characterization of
bronchopleural fistulas [8]. CT
findings include air and fluid collections in the pleural space with or
without evidence of a communication or tract from an airway or the lung
parenchyma to the pleural space
[8] (Figs.
8A,8B,9A,9B,10A,10B,10C,10D).
Fistulas may be shown as focal areas of low-attenuation lung consolidation
that appear to communicate directly with an empyema or an obvious disruption
of the visceral pleura (Fig.
8A,8B).
In one study, a fistula was directly visualized on CT in 10 of 20 patients
with possible bronchopleural fistulas
[8]. Peripheral bronchopleural
fistulas have been described as most evident in the presence of chronic
inflammatory changes that lead to bronchiectasis or bronchiolectasis, which
are depicted better on thin-section CT
[8]. Identification of a
fistula helps in planning treatment
[9].
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Fig. 8A. —Bronchopleural fistula in 57-year-old man diagnosed with
tuberculous pleuritis 3 years earlier. CT scans obtained at lung window
setting reveal extensive nodular pleural thickening (arrows,
A) extending for more than two thirds of circumference of right
hemithorax (A) and allow direct visualization of fistula between
bronchus and pleural cavity (arrow, B). Active cavitary
pulmonary tuberculosis is noted in left lung, which suggests cause of
bronchopleural fistula is reactivated tuberculosis.
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Fig. 8B. —Bronchopleural fistula in 57-year-old man diagnosed with
tuberculous pleuritis 3 years earlier. CT scans obtained at lung window
setting reveal extensive nodular pleural thickening (arrows,
A) extending for more than two thirds of circumference of right
hemithorax (A) and allow direct visualization of fistula between
bronchus and pleural cavity (arrow, B). Active cavitary
pulmonary tuberculosis is noted in left lung, which suggests cause of
bronchopleural fistula is reactivated tuberculosis.
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Fig. 9A. —Bronchopleural fistula in 68-year-old man diagnosed with
tuberculous pleuritis 20 years earlier. At presentation, patient had known
about his tuberculous empyema for 6 years but had refused treatment. CT scans
obtained at lung (A) and soft-tissue (B) window settings at
level of mid chest reveal extensive parietal and visceral pleural thickening
and calcification with loculated pneumothorax in right hemithorax. Also note
loss of volume of hemithorax.
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Fig. 9B. —Bronchopleural fistula in 68-year-old man diagnosed with
tuberculous pleuritis 20 years earlier. At presentation, patient had known
about his tuberculous empyema for 6 years but had refused treatment. CT scans
obtained at lung (A) and soft-tissue (B) window settings at
level of mid chest reveal extensive parietal and visceral pleural thickening
and calcification with loculated pneumothorax in right hemithorax. Also note
loss of volume of hemithorax.
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Fig. 10A. —Bronchopleural fistula in 56-year-old man with history of
multidrug-resistant tuberculosis. Initial CT scans obtained at mediastinal
(A) and lung (B) window settings show extensive pleural
thickening, calcifications in visceral and parietal pleurae, air—fluid
level (arrowheads, B) within pleural space, and minimal
peripheral lung opacity, and findings suggestive of bronchiectasis
(arrow, B) and atelectasis in adjacent lung.
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Fig. 10B. —Bronchopleural fistula in 56-year-old man with history of
multidrug-resistant tuberculosis. Initial CT scans obtained at mediastinal
(A) and lung (B) window settings show extensive pleural
thickening, calcifications in visceral and parietal pleurae, air—fluid
level (arrowheads, B) within pleural space, and minimal
peripheral lung opacity, and findings suggestive of bronchiectasis
(arrow, B) and atelectasis in adjacent lung.
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Fig. 10C. —Bronchopleural fistula in 56-year-old man with history of
multidrug-resistant tuberculosis. Follow-up CT scans obtained at mediastinal
(C) and lung (D) window settings after 13 months show more
extensive pleural thickening, calcifications, increased lung opacity, and
atelectasis with bronchiectasis in adjacent lung parenchyma.
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Fig. 10D. —Bronchopleural fistula in 56-year-old man with history of
multidrug-resistant tuberculosis. Follow-up CT scans obtained at mediastinal
(C) and lung (D) window settings after 13 months show more
extensive pleural thickening, calcifications, increased lung opacity, and
atelectasis with bronchiectasis in adjacent lung parenchyma.
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Malignancy of the Pleura
The occurrence of malignant neoplasm is a relatively rare but critical
complication of chronic tuberculous empyema. Although the pathogenesis of this
entity remains undetermined, chronic inflammation is considered the most
important factor. Pathologic cell types of malignancy associated with
long-standing empyema are variable and include malignant lymphoma, squamous
cell carcinoma, mesothelioma, malignant fibrous histiocytoma, sarcoma, and
hemangioendothelioma [10]. In
a study by Minami et al. [10],
who reviewed radiologic findings of six cases of malignancy associated with
chronic empyema, the following retrospective findings on conventional chest
radiographs were suggestive of malignancy: increased opacity in the thoracic
cavity; soft-tissue bulging, unsharpness of fat planes in chest walls, or
both; destruction of bone near empyema; extensive medial deviation of the
calcified pleurae; and new occurrence of an air-fluid level in the empyema
cavity. CT can reveal an abnormal mass with soft-tissue attenuation around the
empyema and usually contrast enhancement in the mass
[10] (Fig.
11A,11B).
In a patient with chronic empyema, a baseline CT scan is recommended to
understand abnormal findings on chest radiographs and follow-up studies.
Chronic complications should be watched for, and in patients with suspected
malignancy, further radiologic evaluation with CT and MR imaging is
recommended.
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Fig. 11A. —Adenocarcinoma associated with chronic tuberculous empyema of
30 years' duration in 69-year-old man. CT scans of right lower hemithorax show
soft-tissue mass lesion (arrows, A), which extends to
posterior chest wall with adjacent rib destruction and is enhanced
heterogeneously (B). Note adjacent extensive pleural thickening and
calcifications.
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Fig. 11B. —Adenocarcinoma associated with chronic tuberculous empyema of
30 years' duration in 69-year-old man. CT scans of right lower hemithorax show
soft-tissue mass lesion (arrows, A), which extends to
posterior chest wall with adjacent rib destruction and is enhanced
heterogeneously (B). Note adjacent extensive pleural thickening and
calcifications.
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Introduction
Pleural Thickening and...
