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					JK Amorosa
Tuberculosis

 Primary –selflimiting    Postprimary-progressive
 Infection in patients  Reactivation and
  previously not exposed reinfection
  to M tuberculosis
  (under age 5 in the
  past, now common in
  adults also)
Chest X-ray is normal in TB
in

 50%
 75%
 15%
Manifestations of Primary
TB are:

   Parenchymal disease
   Lymphadenopathy
   Miliary disease
   Pleural Effusion
Manifestations of
Postprimary TB are:

   Upper lobe distribution
   Cavity
   Absence of adenopathy
   Airway involvement
Human disease causing
mycobacteria are more likely:



 Slow growing
 Fast growing
Mycobacteria – aerobic rods

 Categories by disease cause: 1.tuberculosis
  complex: causes human disease
  2.nontuberculous or atypical
 Categories by rate of growth: 1.rapid
  growing: < 7 days 2.slow growing:> 7 days
 Rapid: M.abscessus, M.fortiutum,
  M.chelonae
 Slow: MTB, MAC, M.Kansasii
Transmission

 Respiratory
 Desiccated bacilli remain airborne for long
  time – indoor close many months contact is
  necessary for transmission
 Laryngeal, transbronchial, cavitary disease
  produce most bacilli
 Ventillation reduces infectiousness
Lung Parenchymal involvement
Primary
57 yo f with chronic cough
Value of thin section
Tuberculous mediastinal
adenopathy
TB mediastinal adenopathy
 19 f
TB mediastinal adenopathy
is seen as part of

 Reactivation TB
 HIV
 Primary TB usually in children
TB mediastinal adenopathy
is seen as part of

 Reactivation TB
 HIV
 Primary TB usually in children
TB Lymphadenopathy


   Central low attenuation
   Active disease
   Necrosis
   R hilar is most common
Pathogenesis

 TB bacilli in the body elicit acute
  inflammatory response – no symptoms
 Macrophages ingest bacilli and transport
  them to regional lymph nodes
 If not contained in local LNs, hematogenous
  dissemination of bacilli occurs and usually is
  contained, if not, then: miliary, meningeal,
  GU, MSK
Miliary
60 f smoker Langerhans
Histiocytosis
Miliary
 Chickenpox pneumonia                Granulomatous,
  Tuberculosis, disseminated           Inflammatory Disorders
  Blastomycosis, disseminated          Bronchiocentric
  Coccidioidomycosis,
  disseminated Cryptococcosis
                                       granulomatosis/lung
  Histoplasmosis, disseminated         Granulomatous lung
  Melioidosis Blastomycosis            disease Sarcoidosis
  Coccidioidomycosis, pulmonary,       Sarcoidosis, pulmonary
  chronic Cryptococcosis,              Neoplastic Disorders
  pulmonary Filariasis Fungal lung
  infection Histoplasmosis
                                       Lymphomas Metastatic
  Histoplasmosis, pulmonary            lung lymphatics/carcinoma
  Parasitic lung infection             Alveolar cell carcinoma,
  Pulmonary larval                     lung Carcinoma, thyroid,
  infestation/nematodes                anaplastic
  Pulmonary larval migrans
  Schistosomiasis
Miliary cont
                               Anatomic, Foreign Body,
 Allergic, Collagen, Auto-     Structural Disorders
  Immune Disorders              Atelectasis, pulmonary
  Pulmonary                     Reference to Organ
  arteritis/vasculitis          System Respiratory
  Rheumatoid lung disease       distress (newborn)
  Metabolic, Storage            syndrome Pulmonary
  Disorders Histiocytosis,      fibrosis Pulmonary
  pulmonary Histiocytosis X     microlithiasis, alveolar
  Hereditary, Familial,         Poisoning (Specific Agent)
  Genetic Disorders             Silicosis Organ Poisoning
  Tuberous Sclerosis            (Intoxication)
                                Pneumoconiosis
Pleural Effusion TB
TB pleurisy

 Unilateral
 Exudative: high protein content, High WBC,
  low glucose
 Lymphocyte predominance
 Complications: B-P fistula, empyema
 1/3 negative TB skin test
Pleural Effusion exudative
   Malignancy
   Pneumonia
                                          Drug-induced pleural
   Tuberculosis
                                           disease
   Pulmonary embolism                    Asbestos pleural effusion
   Fungal infection                      Yellow nail syndrome
   Pancreatic pseudocyst
                                          Uremia
   Intra-abdominal abscess
   After coronary artery bypass graft
                                          Trapped lung
    surgery                               Chylothorax
   Postcardiac injury syndrome
                                          Pseudochylothorax
   Pericardial disease
   Meigs syndrome
                                          Acute respiratory distress
   Ovarian hyperstimulation syndrome
                                           syndrome
   Rheumatoid pleuritis                  Chronic pleural thickening
   Lupus erythematosus                   Malignant mesothelioma
Pleural Effusion transudate: <3 g
protein, low WBC, normal glucose
 Congestive heart          Glomerulonephritis
  failure (most common)     Superior vena cava
 Cirrhosis with hepatic     obstruction
  hydrothorax               Fontan procedure
 Nephrotic syndrome        Urinothorax
 Peritoneal                CSF leak to the pleural
  dialysis/continuous        space
  ambulatory peritoneal
  dialysis
 Hypoproteinemia
83 f
TB bacilli spread to meninges
via:
 Inhalation to lymphnodes to bloodstrean to
  meninges
 Inhalation to lymphnodes to meninges
 Ingestion to peritoneum to CSF
 Intravenous introduction to meninges
TB bacilli spread to meninges
via:


 Inhalation to lymphnodes to bloodstream
  to meninges
 Inhalation to lymphnodes to meninges
 Ingestion to peritoneum to CSF
 Intravenous introduction to meninges
Manifestations of
Postprimary TB are:

   Upper lobe distribution
   Cavity
   Absence of adenopathy
   Airway involvement
53 m
37 m
40 m with cough
Cavity vs cyst vs bulla

 Cavity: Gas-filled space in an area of lung
  consolidation or mass or nodule produced by
  the expulsion of a necrotic part of the lesion
  via the bronchial tree; wall thickness varies
 Cyst: wall thickness is 4 mm or less
 Bulla: wall thickness < 4 mm
 Often difficult to distinguish the 3

Clin Microbiol Rev. 2008 April; 21(2): 305–333
Cavity - causes
   Abscess
   TB
   Ischemic necrosis (infarct)
   PCP
   Fungal process
   Malignancy
   Wegener’s granulomatosis
   Sarcoidosis – rare
 COP (Cryptogenic Organizing Pneumonia -rare
38   51
Cavity

 T bacilli grow in       Tuberculosis
                           Volume 89, Issue 4 , Pages 243-
  cavities which           247, July 2009
  communicate with
  bronchi and spread
  infection
 MDR bacilli grow in
  cavities exclusively
 Hydrolytic enzymes
  break down lung
54 m
48 m
Cryptococcus
35 f
Aspergillus   AML
57 f
Primary lung ca with mets
67 f
43 m
34 m
43 m
Bronchopneumonia
 Invasive bronchiolar aspergillosis in a patient who 
underwent bone marrow transplantation
RadioGraphics, 

                                         Aspergillus
http://pubs.rsna.org/doi/abs/10.1148/rg.253045115
Five causes of tree-in-bud
are:
   Bronchopneumonia
   Fungal
   Viral
   ABPA
   TB
       Tree –in-bud pattern




Rossi, SE et al: May/June 2005
Radiographics 25,3
Cocaine 23 m
25 m
TB in HIV
TB    &     HIV

 Clinical features depend on the severity
  immunosuppression
 Relatively intact cellular immunity = non–HIV
  -infected individuals- TB remains localized to
  the lung.
 HIV (CD4 T-lymphocyte count: <200/mm3),
  pulmonary TB with extra-pulmonary
  involvement: lymphadenitis, miliary
46 m
76 m emphysematous pericarditis,
streptococcal
TB - healing



 Lung destruction: bronchiectasis
 Bronchial stenosis
LUL atelectasis,
bronchiectasis TB
77 m
Radical mastectomy & rad Rx
80 f
   The History of Tuberculosis
• The Hebrew word for phthisis or consumption (schachepheth)
  means to waste away occurs twice in the Bible:
• Leviticus 26:16
•     I, in turn, will do this to you: I will appoint over you a sudden
  terror, consumption and fever that will waste away the eyes and
  cause the soul to pine away; also you will sow your seed
  uselessly, for your enemies will eat it up.
• Deuteronomy 28:22
•     The Lord will smite you with consumption and with fever
  and with inflammation and with fiery heat and with the sword
  and with blight and with mildew and they will pursue you until
  you perish.
    The History of Tuberculosis

 By 1650 consumption was the leading cause of mortality
  and became a reference in some of Shakespeare's plays-
  one of the consumptive lovers, in "Much A Do About
  Nothing" , as well as scrofula in "Macbeth"
     The History of Tuberculosis
• Early attempts at treatment can be found throughout history
   Greeks believed cutting off cool air eventuated in a burning up of the
    tissues
   Romans put importance of diet
   Hebrews control disease from diet to the destruction of clothing
• Early "cures" from physicians
   Warm sea air
   Milk from pregnant women
   Seaweed placed under the pillow
   Cold baths
   Deep breathing


  The History of Tuberculosis

 The first breakthrough came when German
  bacteriologist named Robert Koch isolated the
  infectious agent known as tuberculosis bacteria or
  tubercle bacilli in 1882. He was later awarded the
  Nobel Prize for physiology or medicine in 1905
     The History of Tuberculosis
 The first sanatorium opened in 1854 in Gorbersdorf, Germany.
  Sick patients were given wholesome food and plenty of fresh air.
  This became the modern way to fight the disease. The
  sanatoriums provided medical care for almost 100 years and
  became one of the most remarkable and unique periods of
  medical care in history.

 By 1889 in the USA the National Tuberculosis Association fully
  realized that TB was distinctly preventable and not directly
  inherited

 No real progress was made until new antibiotics were used
  between 1945-1960
 It has taken almost three thousand years to understand the full
  nature of Tuberculosis
58 m
References
 Joshua Burrill, Christopher J. Williams, Gillian Bain,
  Gabriel Conder, Andrew L. Hine, Rakesh R. Misra
  RadioGraphics, 2007, Vol.27: 1255-1273,
  10.1148/rg.275065176
 Santiago Enrique Rossi, Tomas Franquet, Mariano
  Volpacchio, Ana Giménez, Gabriel Aguilar
  RadioGraphics, 2005, Vol.25: 789-801
 JR Cohen, JK Amorosa, PR Smith –The air-fluid level in
  cavitary pulmonary TB, Radiology, 1978 - radiology
 JK Amorosa, PR Smith, JR Cohen, C Ramsey… - …,
  Tuberculous mediastinal lymphadenitis in the adult
  1978 – radiology
 Medscape Tuberculosis (TB), a multisystemic disease
  ….JK Amorosa….

Famous people who had TB
 Gaius Valerius Catullus     Eugene O'Neill
  (ca. 84 BC – ca. 54 BC),    Molière
  Roman poet
                              Robert Louis Stevenson
 Bronte sisters              Dylan Thomas
 Elizabeth Barrett           Voltaire
  Browning                    Paul Gauguin
 Albert Camus                Amedeo Modigliani
 Anton Chekhov               Frédéric Chopin
 Maxim Gorky                 Niccolò Paganini

 Franz Kafka                 Igor Stravinsky
                              Cardinal Richelieu
 Eugene O'Neill
                              Simón Bolívar
Opera, Theatre, Novels - TB

 Puccini: La boheme     Johnny Nolan: A Tree
 Verdi: La Traviata      Grows in Brooklyn
 Thomas Mann: The       W.Somerset
  Magic Mountain          Maugham: Sanatorium
 Victor Hugo: Les       Frank McCourt:
  Miserables              Angela’s Ashes
 Upton Sinclair: The
  Jungle
END
jd
am 9-13-11
a.m. 3-19-12
jd.
jd
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posted:3/15/2014
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