Imaging of Tuberculosis - Rizki Yuda Purnomo

Imaging in
Tuberculosis
Rizki Yuda Purnomo
21904101028
Adviser : dr. P. Tigor Yeheskiel, Sp. Rad
• Tuberculosis (TB) remains a global emergency despite substantial investment in
health services over the past two decades.
• Patients with sputum-negative pulmonary TB (PTB) and extrapulmonary TB (EPTB)
are difficult to diagnose.
• Diagnostic imaging is challenging because signs of TB may mimic those of other
diseases. Clinical signs and symptoms in affected adults can be non-specific and a
history is fundamental in the diagnostic work-up.
• Early diagnosis promotes effective treatment and leads to a reduced onward
transmission of TB
Background
Skoura, Evangelia, Alimuddin Z., Jamshed Bomanji. 2015. Imaging in Tuberculosis.
International Journal of Infectious Disease.
Epidemiology
World Health Organization (WHO)
global tuberculosis report 2018
10 million people developed TB
1.5 million died from the disease
TB is the top 10 causes of death
5.7 million men, 3.2 million woman
and 1.1 million child
Kemenkes RI, 2020
TB estimate case : 845.000
Died : 11.993 (WHO, 2018)
(KEMENKES, 2020)
Etiopathology Mycobacterium Tuberculosis
Zuniga, Joaquin, Diana T.G., Teresa Santos-M., Tatiana S.R.,

Julio G. and Edmond J.Y., 2015. Cellular and Humoral
Mechanisms Involved in the Control of Tuberculosis. Clinical
and Developmental Immunology. doi:10.1155/2012/193923
Classification
TB
Pulmonary TB Extra-pulmonary TB
• Musculoskeletal TB
• Central Nervous System TB
• Primary • Abdominal TB
• Post-Primary • Lymph node TB
• Pleural TB
• Upper airway TB
• Genitourinary TB
• Miliary TB
• Pericardial TB
Yadav, K. and Satyam Prakash. 2017. Tuberculosis: Airbone Disease. Global Journal
Clinical Features
1. Chronic cough
2. Hemomptoe
3. Weight loss
4. Low-grade fever
5. Night sweats
6. History of contact
7. HIV Status
Adigun, Rotimi and Rahulkumar Singh. 2020. Tuberculosis.
National Centre for Biotechnology Information. Available at:
https://www.ncbi.nlm.nih.gov/books/NBK441916/
Imaging Diagnosis
● Chest x-ray
● CT-Scan
● MRI
● PET-Scan ● Anamnesis
● Physical Examiation
●Laboratories
● Acid Fast Staining Ziehl-Neelsen
● Culture
● Nuclear Amplification and Gene-
Based Test
●Histopathology
Adigun, Rotimi and Rahulkumar Singh. 2020. Tuberculosis. National Centre for
Biotechnology Information. Available at: https://www.ncbi.nlm.nih.gov/books/NBK441916/
Chest X-ray
• Conventional radiography remains the
initial modality for suspected PTB and
for mass screening purposes.
• Consolidation, infiltration, pleural
effusions may appear, coin lession
TB Milier
CT-Scan and MRI
• CT and MRI are the
modalities of choice for
the evaluation TB and
specific body parts
• There are, infiltration,
consolidation,calsification,
enlarged bilateral hilar
PET-Scan
• Positron emission tomography is a non-invasive imaging
method that has been used widely for the differentiation of
malignant from benign lesions.
• showing hilar and mediastinal lymph nodes
• showing multiple lymph nodes (porta hepatis, portacaval,
para-aortic, retroperitoneal, bilateral internal iliac, left
external iliac, and left and enlarged and in bones

● Pneumonia
● Malignancy
Differential ● Non-tuberculous
mycobacterium
Diagnose
● Fungal Infection
● Histoplasmosis
● Sarcoidosis
Prognosis
Majority of patients with a diagnosis of TB have a
good outcome. This is mainly because of effective
treatment. Without treatment mortality rate for
tuberculosis is more than 50%.
The following group of patients is more

susceptible to worse outcomes or death following
TB infection:
1. Extreme of age, elderly, infants and young

children
2. Delay in receiving treatment
3. Radiologic evidence of extensive spread
Adigun, Rotimi and Rahulkumar Singh. 2020. Tuberculosis.
4. Severe respiratory compromise requiring
National Centre for Biotechnology Information. Available at: mechanical ventilation
https://www.ncbi.nlm.nih.gov/books/NBK441916/
5. Immunosuppression
CASES
Pulmonary TB
● a 5-year-old girl with
primary tuberculous
disease. a, b
Anteroposterior (a) and
lateral (b) views show a
middle lobe opacity
(asterisk) with right hilar
lymphadenopathy (arrow)
Concepcion, Nathan D.P., Bernard F. L., Savvas A., Pedro A.N.D., Marion O.S., Jacqueline Austine U.U., Timothy R.U. 2017.
Standardized radiographic interpretation of thoracic tuberculosis in children. National Centre for Biotechnology Information. 47(10) p:
1237-1248. Available at : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5574960/
CASES
Pulmonary TB
● Chest radiographs in a 1-year-
old boy with primary
tuberculous disease and
lymphadenopathy. a, b
Anteroposterior (a) and lateral
(b) views show hilar
lymphadenopathy (arrows) on
the right without ipsilateral
lung abnormality. A left
retrocardiac opacity (asterisk)
is noted
CASES
Pulmonary TB
● Ghon focus in a 7-year-old
boy. a Anteroposterior
chest radiograph shows a
Ghon focus (arrow) in the
right lower lobe. b Non-
enhanced axial chest CT
demonstrates the focus,
which is calcified (arrow)
CASES
Pulmonary TB
● Primary progressive tuberculous
disease in a 15-month-old boy. Axial
contrast-enhanced CT image shows
progressive Ghon focus (asterisk) in
the right middle lobe and progressive
hilar lymphadenopathy (arrow). The
enlarged lymph node demonstrates
the characteristic central necrosis with
peripheral enhancement (rim sign)
CASES
Miliary TB Concepcion, Nathan D.P., Bernard F. L., Savvas A., Pedro
A.N.D., Marion O.S., Jacqueline Austine U.U., Timothy R.U.
● Miliary tuberculosis in a 14-year-old boy. a, b Focused 2017. Standardized radiographic interpretation of thoracic
tuberculosis in children. National Centre for Biotechnology
anteroposterior chest radiograph (a) and axial contrast- Information. 47(10) p: 1237-1248. Available at :
enhanced CT (b) of the upper lobes show innumerable https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5574960/
2-mm or smaller discrete nodules

CASES
Lymphobronchial TB
● Primary progressive
lymphobronchial tuberculous
disease in a 6-year-old boy. a
Anteroposterior chest
radiograph shows left lung
collapse. b Volume-rendered
CT shows occlusion of the left
mainstem bronchus caused by
lymphobronchial disease
CASES
Pleural effusion
● Pleural effusion and cardiac
involvement in a 10-year-old girl with
primary progressive tuberculous
disease. a Posteroanterior chest
radiograph shows an enlarged cardiac
shadow (arrowheads) with pleural
effusion (asterisk) on the left. b Follow-
up axial contrast-enhanced CT image
demonstrates bilateral pleural effusions
(asterisks) and pericardial effusion
(arrows)
CASES
Pericarditis TB
● Tuberculous pericarditis
in a 6-year-old boy.
Anteroposterior
radiograph of the chest
shows globular
enlargement (arrows) of
the cardiac silhouette
(water bottle sign)
CASES
Post TB
● Post-primary tuberculosis in
a 14-year-old girl. a, b
Posteroanterior chest
radiograph (a) and volume-
rendered CT (b) show
cavitations, traction and
cystic bronchiectasis in the
right lung
CASES
Post TB
● Post-primary tuberculous disease
with bronchogenic spread in a 15-
year-old girl. a Posteroanterior chest
radiograph of shows ill-defined
infiltrates in the left upper lobe
(encircled). b Coronal reconstruction
CT image demonstrates multiple
centrilobular nodules (arrows) with
linear branching opacities (tree-in-bud
sign)
Conclusion
Radiologic interpretation of pulmonary tuberculosis remains challenging.

Classically, tuberculosis is classified as primary and post-primary tuberculosis, but
the typical radiologic patterns are now complicated by overlapping imaging
characteristics as well as occurrence of atypical features seen in
immunocompromised children. It is important to differentiate infection and disease
because treatments are different. The proposed standardized clinical and
radiographic classification presented in this paper aims to provide helpful guides in
the proper nomenclature of suspected tuberculosis patients. The pitfalls and
limitations of imaging likewise caution both clinicians and radiologists to avoid
erroneous interpretations and over-diagnosis of childhood tuberculosis.
THANK
S!
Do you have any questions?
Riz.yud30@gmail.com
+62 813 5987 8173
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Imaging in

Zuniga, Joaquin, Diana T.G., Teresa Santos-M., Tatiana S.R.,

Skoura, Evangelia, Alimuddin Z., Jamshed Bomanji. 2015. Imaging in Tuberculosis.

The following group of patients is more

1. Extreme of age, elderly, infants and young

2-mm or smaller discrete nodules

Radiologic interpretation of pulmonary tuberculosis remains challenging.

CREDITS: This presentation template was created by

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