Original subtitles

hello everyone and welcome to indian

radiologist my name is dr sanjeev mani

and today's tutorial is on x-ray

findings in pulmonary tuberculosis

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now before we begin with the lecture a

quick statistic we know that the year

2020 has been one of covert 19

and as of today more than 1.48 million

people have died with covet out of a

total

64 million cases that have been detected

worldwide

but if we put this statistic across the

one of tuberculosis

of 2019 from who 1.4 million people have

died of tuberculosis in 2019

out of an estimated 10 million people

who fell ill with tuberculosis

so we should understand that this is a

serious disease it is a disease

of the developing countries developed

countries also see it but not to that

much of an extent as

we do in countries like india and

southeast asia

india in fact leads the cases with tb

globally

now we know that tuberculosis is caused

by the bacteria mycobacterium

tuberculosis

and more often than not affects the

lungs there are other bacteria involved

like the atypical

mycobacteria as well besides the

pulmonary manifestation there are extra

pulmonary tuberculosis

lesions that can occur these occur

usually because of hematogenous spread

or sometimes direct extension from

adjacent organs

now what are the organs that are

affected almost every organ of the human

body so it could be lymph nodes between

the pleura

the gi tract the geo tract the central

nervous system

bones as well as the larynx now we

should know that most extra pulmonary

diseases

are not contagious with the exception of

laryngeal tuberculosis

now what are the typical symptoms of

active tuberculosis these

include cough hemoptysis

a low grade fever usually that comes up

in the evenings or nights

there may be night sweats and typically

the patient will have fatigue malaise

and sometimes even weight loss now

imaging plays

a very vital role in the diagnosis and

management of tuberculosis and in this

tutorial our plan is to understand

the radiological features and the value

it has

in management of tuberculosis now

traditionally

primary tuberculosis was considered a

disease of childhood

and post-primary tuberculosis is

believed to represent

a reactivation of this latent infection

in adults

so the first common lesion that we see

is a gons complex now what exactly is

gone's complex

it is made up of a a lesion that is seen

in the lung that is caused by

tuberculosis and

b an adjacent enlarged mediastinal node

these two the pulmonary lesion as well

as the lymph node

together form the gons complex this

lesion usually heals

and once it heals it can undergo

calcification either the pulmonary

lesion

or the mediastinal node and that is

known as a ranked complex

a ranked complex is not specific for

tuberculosis

and it can also be seen as a sequelae in

other granumatis infections

now let's come down to the parenchymal

findings of tuberculosis

now commonly it is seen as a

consolidation or an area of opacity

which may have a segmental or lobar

distribution

now these consolidations are usually

inhomogeneous

so we see on this frontal radiograph an

inhomogeneous consolidation

involving the right upper zone as well

as the mid zone

you can see areas of breakdown also

within this lesion

now this is classic tuberculosis why

because it is affecting

the upper lobe usually it affects the

upper lobe as well

as the superior segment of the lower

lobes and once you have a lesion

which is in homogeneous which shows

areas of breakdown like we see here

your diagnosis is more likely to be

tuberculosis than a bacterial infection

let's have a look at another radiograph

here we see much more subtle lesions in

fact we

call these classically infiltrates we

can see them here

in the left upper and mid zone again

it is upper lobe and superior segment of

the lower lobe

so this is more often than not likely to

be tuberculosis

we see another view here again a much

more denser consolidation

and you can see almost an air

bronchogram seen within this lesion

but once again upper lobe lesion more

likely than not to be tuberculosis

you look for other subtle signs of

tuberculosis also and you will find them

you see a little small nodule here

which could very well represent a

tuberculoma next case

much tensor consolidation again in the

upper lobe here as well as the midzone

this patient also had a small plural

effusion as we can see here

and uh histopath examination of the

pleural fluid revealed tuberculosis

so let's have a look at this ct scan

here what we can see are inhomogeneous

consolidates seen

in the apico posterior segment of the

left upper lobe as we see here

and we can see the fissure over here

so we know the structure behind happens

to be the superior segment of the left

lower lobe

so you see inhomogeneous consolidates as

well over here

you see areas of breakdown and small

cavity formation

these findings are the hallmark of

pulmonary tuberculosis

now tree in bird appearance is another

sign that has been attributed to

pulmonary tuberculosis

and it is the appearance of areas of

centrilobunner nodules with

a linear branching pattern it was

earlier believed to occur only in

endobronical

tuberculosis but not anymore and

bronchos filled with pus

in bronchopneumonia or tumor emboli can

also give rise to this

dream bird appearance this finding of

course is not visible on x-ray and is

seen only on

hrct once the consolidation is

larger it starts breaking down so we get

areas of breakdown and

if those breakdowns get larger and

coalesce together

what we get is a cavity so you can see

here again

a lesion which is inhomogeneous in

nature a consolidation initially to

begin with

in the right upper zone and midzone but

what you can see also is a very thick

walled cavity

which is formed as a result of the

breakdown this again is tuberculosis

remember when you're reading x-ray chess

you can diagnose a cavity when you can

very clearly see 75 percent of the walls

of that cavity

it is only then that you will call it a

lung cavity

as tuberculosis starts healing you get

fibrosis

so this is a patient who is undergoing

treatment currently on treatment

and has come up for follow-up and what

we see are areas of fibrosis seen

in the upper lobe over here we can see

formation of bullae right here

we can see a plural effusion which

appears to have

organized and we can see some

retrocardiac bronchitic

lesions as well and here's another x-ray

we see a patient with heal tuberculosis

and what we

get here are fibrotic lesions in the mid

zone there is tenting off the dome of

diaphragm as we can see here

there's a bit of pleural thickening

organized pleural effusion

you see cardiomedia still shifts so you

can see the trachea deviated to the

right

and the heart also coming across to the

right side pulled by the fibrotic

lesions

so fibrotic changes fiber bronchitic

changes

pleural thickening ending of dope off

diaphragm

and lung volume loss are classic signs

of sequelae of pulmonary tuberculosis

now once there is a cavity of course the

treatment protocols differ

but once this cavity has healed there is

always a danger

there is a danger of this region

persisting after treatment

and that persistence can predispose to

bacterial super infection

fungal ball formation or even erosion of

adjacent vasculature which could result

in hemoptysis we see here in this case

we can see

a thin walled cavity with the soft

tissue lesion

well within it this mag view here shows

the cavity wall right there

and a soft tissue mass lesion well seen

within this cavity this is nothing but a

fungal ball

now one more thing in pulmonary

manifestations before we move to the

pleura

is military mottling amiliary motoring

occurs because of hematogenous spread

and what you see are discrete nodules

seen across the entire lung this is

commonly seen in children

teenagers as well as in

immunocompromised patients

we must also remember that the dd is

fungal

sometimes metastasis and even

sarcoidosis so you will end up doing a

ct scan to try to differentiate

these as well so these are the more

common parathyroid manifestations of

tuberculosis from parent type we move on

to pleura

and what we commonly get is pleural

effusion so what you got to watch out

of all the costophrenic angles right

here you can see this one is clear

but over here you can see that the right

dome of diaphragm is elevated

you can see blunting of the costophrenic

angle as well as a little bit of fluid

that is moving up

almost towards the axilla this is a

plural effusion with

a subpulmonic component one more case

here

you see this plural effusion on the left

blending out the costophrenic angle you

see the right side over here very

clearly

and we see the left side which is

blunted and you see the soft tissue

density lesion moving up towards the

axilla

with a nice concave contour this is

nothing but a plural effusion

also as radiologists we must react to

this plural effusion it's not a buyer

area always

to get an ultrasound down of this

patient establish the amount of plural

fluid that's there

speak to the clinician and complete a

plural tap that can aid in quick

diagnosis of tuberculosis

sometimes patients present later with

pleural effusion and the picture may be

different

you may get multiple septa in that

plural fluid

once we do the ultrasound and this is

not very amenable to

therapeutic tapping lymph nodes are

another manifestation of tuberculosis so

what we can see here

are enlarged paratracheal nodes on the

right side

as well as enlarged higher nodes once we

see this picture and if you are

suspecting tuberculosis

the next best thing of course is to do a

ct scan test

with contrast where you will see typical

tuberculosis enhancement

so how do you see this enhancement you

can see classical rim enhancement with

central keysighting necrosis that is a

hallmark

of tuberculosis you can see this picture

this is an enlarged subcarnal node

almost conglomerate with central areas

of necrosis that represent

case issue necrosis so there are two

questions a clinician asks us one

does this patient have pulmonary

tuberculosis and once the patient is on

treatment they ask us

whether it is still active or is it

healing so that's a tricky question but

let's answer the first question so when

a patient comes to you

and comes with symptoms and if you get

any of these findings like consolidation

or cavitation miliary mottling or

lymphadenopathy

plural effusion you know that you're

dealing with a patient who has

currently active pulmonary tuberculosis

the treatment for these patients is

usually medical

and they are put on akt for their

prescribed period of 6

to 12 months and intermittent x-rays are

taken to see that the lesions

are in check and are not increasing now

coming to the second question

whether this lesion is still active or

is it healing or not

so if you see a regression of the

lesions that you have seen on the

previous radiograph

if you start seeing fibronodular

scarring if you see the pleural effusion

organizing you know that these are signs

that this is

healing this information for the

physician is very important because

then he or she knows that they can

continue the

prescribed schedule as has been decided

from the very beginning

so we end this tutorial with this x-ray

this x-ray was seen a lot in the past

we don't see it now anymore and what is

it exactly

so this is surgical procedure known as

thoracoplasty

that was designed to permanently

collapse cavities of pulmonary

tuberculosis by removing ribs from the

chest wall

by doing this the resection would allow

the acquisition of parietal to the

visceral or mediastinal pleura

and make the cavities collapse this

procedure has been replaced by

lobectomy or pneumonectomy if the

situation so demands

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you