Response of pulmonary tuberculomas to anti-tuberculous treatment

Pulmonary tuberculomas are well-circumscribed masses caused by Mycobacterium tuberculosis. However, the response of tuberculomas to anti-tuberculous (TB) treatment has not been well defined as yet. The response of pulmonary tuberculomas to anti-TB treatment was retrospectively reviewed in 45 patients diagnosed between January 1997 and December 2001. The areas of pulmonary tuberculomas were estimated by calculating products of the longest and their perpendicular short diameters on chest radiographs. The response to anti-TB treatment was categorised as "decreased" (> 25% reduction in area versus its initial area), "increased" (> 251% increase) and "no change" (the remainder). The mean of treatment duration was 11.5 +/- 3.6 months. Three months after treatment, 18 patients (40.0%) were categorised as decreased, 25 (55.6%) as no change and two (4.4%) as increased. Twelve months after treatment, out of 42 patients available for chest radiographs, 32 patients (76.2%) were categorised as decreased, nine (21.4%) as no change and one patient (2.4%) as increased. At the last follow-up (mean follow-up 27.0 +/- 10.2 months), 37 patients (82.2%) were categorised as decreased. The majority of pulmonary tuberculomas were decreased by anti-tuberculosis treatment during and even after treatment, although a transient enlargement during the early period of treatment was observed infrequently.

Diagnostic value of 99mTc-HMDP bone scan in atypical osseous tuberculosis mimicking multiple secondary metastases

STUDY DESIGN

A case of atypical osseous tuberculosis (TB) mimicking multiple secondary metastases on radiologic and nuclear imaging is presented.

OBJECTIVES

To emphasize the contribution of nuclear bone scanning for the assessment of osseous tuberculosis in typical and atypical presentations.

SUMMARY AND BACKGROUND DATA

Skeletal locations of TB mostly involve the dorsolumbar spine and diagnosis is often delayed. The presence of multiple TB sites can mimic secondary metastases and biopsy remains the mainstay for final diagnosis.

METHODS

Clinical symptoms, lab tests, and imaging data are presented. Possible diagnoses are discussed. A review of imaging characteristics in cases of typical and atypical presentations of osseous TB is proposed.

RESULTS

A dorsal spine spondylitis was first diagnosed on a 56-year-old patient presenting neurologic deficit of the left arm. Fine needle aspiration identified bacterial infection but was negative for Mycobacterium tuberculosis. Whole-body bone scan allowed the identification of an asymptomatic sacroiliac lesion, which was accessible to biopsy and gave a final diagnosis.

CONCLUSION

Nuclear bone scanning should be kept in mind when assessing spinal pain in patients at high risk of TB infection or reactivation.

[Fistulisation of a tubercular adenopathy in the oesophagus. About a paucisymptomatic form]

The authors present the case of a cervico-mediastinal mass which disappeared spontaneously. The clinical presentation and the image of a fistula during the oesophagoscopy are in favour of the fistulisation of a tubercular adenopathy in the oesophagus. This pathology is rare. This observation is original by the delay of diagnosis due to a dysphagie summarizing the clinical signs and the spontaneously favorable evolution of the fistula.

Tuberculomas of the hypophysis cerebri: report of five cases

Tuberculomas involving the hypophysis cerebri are extremely rare lesions, and these may occur even in the absence of systemic tuberculosis. This report presents the clinical data of 5 patients harbouring tuberculomas of the pituitary gland. Sellar tuberculomas commonly mimic pituitary adenoma. Histological diagnosis of a sellar lesion is mandatory irrespective of the clinical presentation and radiological findings. A history of extracranial tuberculosis in the past associated with radiological findings like leptomeningeal enhancement, parenchymatous brain tuberculomas or a thickened pituitary stalk on contrast MRI, are indicative of the possibility of a sellar tuberculoma. The aim of surgery is tissue diagnosis and tumour debulking. The response to long-term antituberculous chemotherapy is excellent. There is often a complete resolution of the granuloma and a satisfactory recovery of visual and endocrinological function.

Imaging of pulmonary tuberculosis

Tuberculosis, more than any other infectious disease, has always been a challenge, since it has been responsible for a great amount of morbidity and mortality in humans. After a steady decline in the number of new cases during the twentieth century, due to improved social and environmental conditions, early diagnosis, and the development of antituberculous medication, a stagnation and even an increase in the number of new cases was noted in the mid-1980s. The epidemiological alteration is multifactorial: global increase in developing countries; minority groups (HIV and other immunocompromised patients); and elderly patients due to an altered immune status. Other factors that may be responsible are a delayed diagnosis, especially in elderly patients, incomplete or inadequate therapy, and the emergence of multidrug-resistant tuberculosis. The course of the disease and its corresponding clinicoradiological pattern depends on the interaction between the organism and the host response. Classically, pulmonary tuberculosis has been classified in primary tuberculosis, which occurred previously in children, and postprimary tuberculosis, occurring in adult patients. In industrialized countries, however, there seems to be a shift of primary tuberculosis towards adults. Furthermore, due to an altered immunological response in certain groups, such as immunocompromised and elderly patients, an atypical radioclinical pattern may occur. The changing landscape, in which tuberculosis occurs, as well as the global resurgence, and the changed spectrum of the clinical and radiological presentation, justify a renewed interest of radiologists for the imaging features of pulmonary tuberculosis. This article deals with the usual imaging features of pulmonary tuberculosis as well as the atypical patterns encountered in immunodepressed and elderly patients.

Pancreatic pseudotumor due to peripancreatic tuberculous lymphadenitis

Peripancreatic tuberculous lymphadenitis is a very rare and difficult diagnosis. We report herein a patient with a clinically solitary abdominal tuberculoma. A 68-year-old woman was admitted to our hospital with moderate-level obstructive jaundice due to a mass located between pylorus and head of the pancreas. There were no clinical signs or symptoms of tuberculosis in lungs or abdomen. After the diagnosis of a neoplasm of the pancreas was made, exploratory laparotomy was performed which revealed a conglomerated mass penetrating into the pancreas. Since an exact diagnosis could not be reached on the basis of frozen sections prepared during the operation, a standard Whipple procedure was performed. After the histopathological examination of the resected specimen revealed tuberculous lympadenitis, the patient was given antituberculous medication. The patient recovered well. An abdominal tuberculoma is often mistaken for a malignant neoplasm, and nonsurgical diagnosis and treatment of this entity continues to be a challenge.

Tuberculous meningitis with tuberculomata presenting as postpartum pyrexia of unknown origin

A35-year-old Chinese woman had primary infertility as a result of bilateral fallopian tube blockage. She had had uterine fibroids resected 3 years previously. Her precious pregnancy via in-vitro fertilization was complicated by premature rupture of amniotic membrane at 18 weeks' gestation. Two doses of betamethasone 12 mg were given at 29 weeks' gestation, and fetal bradycardia was noted on the next day. A baby girl was delivered by emergency caesarean section. The patient had a high swinging fever following the delivery. Extensive investigations for postpartum pyrexia were normal or negative. She was given courses of broad-spectrum antibiotics for 4 weeks before she developed mental dullness and right partial ptosis. On the next day, she became disorientated with left hemiplegia. Examination also revealed left-sided neglect, dysphasia, conjugate gaze deviation to the right, and left homonymous hemianopia. Computed tomography (CT) of the brain revealed a left temporal hypodense area (Figure 1a). Lumbar puncture revealed the following CSF findings: opening pressure of 34 cmH2O, protein level of 3.8 g/litre, glucose level of 2.1 mM (serum 6.4 mM), cell count of 30 × 106/litre (56% lymphocytes, 40% neutrophils, 4% monocytes), and red cell count of 11 × 106/litre. Other CSF tests were negative.

Tuberculoma en plaque: a case report

A 14 year old girl presented with a 6-month history of headaches and visual blurring. CT showed a right tentorial enhancing lesion. Angiogram showed no enhancement. Histopathological examination of the excised material was consistent with tuberculoma. The presentation of such unusual intracranial tuberculoma is reported and the literature reviewed on the subject.

[Diagnostic accuracy of semiquantitative analysis of positron emission tomography in radiologically indeterminate lung lesions]

OBJECTIVE

The objective of this work was to assess the Standardized Uptake Value (SUV) in the differential diagnosis of radiologically indeterminate lung lesions by means of ROC curves.

MATERIAL AND METHOD

Forty seven patients were studied by Positron Emission Tomography with 18-fluorine-2-desoxy-D-glucose (FDG PET) analyzing the value of maximum SUV. The patients were classified into three groups. Group 1 = patients without previous neoplasia (WPN) + patients with previous neoplasia (PN). Group 2 = WPN. Group 3 = PN.

RESULTS

The ROC curves showed a high diagnostic accuracy in the three groups, with area under the curve (AUC) values of 0.96, 0.98 and 0.91 respectively. The typical error was 0.03, 0.02 and 0.08. The maximum SUV cutoffs with the best diagnostic accuracy for the three groups were: 2.6; 3 and 2.4, with an accuracy (A) of 93.6%, 97% and 92.3%, respectively. Analyzing all the patients globally (group 1), we obtained one false positive result in a patient with hamartoma (max SUV = 2.8) and two false negative results in one patient with lung metastases from malignant fibrohistiocytoma (max SUV = 0.7) and in another patient with lung metastases from unknown origin adenocarcinoma (max SUV = 1.9).

CONCLUSIONS

FDG PET permits differentiation with a very high diagnostic accuracy of benign and malignant lung lesions using the maximum SUV. The differences observed between the different groups are due to the different disease prevalence, obtaining a lower negative predictive value of max SUV in patients with previous neoplasia.

Role of contrast-enhanced dynamic CT in the diagnosis of active tuberculoma

STUDY OBJECTIVES

To assess the role of contrast-enhanced dynamic CT in the diagnosis of active tuberculoma.

SETTING

Hospitals with an isolated ward for tuberculosis.

METHODS

Fifty-five subjects with newly diagnosed active tuberculoma and 24 subjects with inactive tuberculoma were examined and evaluated retrospectively. Six subjects with active tuberculomas and seven subjects with inactive tuberculomas were confirmed by histologic and microbiologic evaluation of resected specimens, whereas the remainder of the subjects with tuberculoma were confirmed clinically. The subjects were receiving iopamidol, 370 mg/mL IV, at a rate of 3.0 mL/s on contrast-enhanced dynamic CT. The time-attenuation curve was obtained and adapted to a gamma function. The peak height (PH), maximum attenuation subtracted by the background attenuation, relative flow (RF), and mean regional flow were used for comparison.

MEASUREMENTS AND RESULTS

In the surgically confirmed group, the PH and RF values of six subjects with active tuberculomas were significantly higher than those of the seven subjects with inactive tuberculoma (p < 0.05). Similarly, in the subjects with noninvasive diagnoses, the PH and RF values of 49 subjects with active tuberculoma were significantly higher than those of the subjects with inactive tuberculoma (mean +/- SD PH, 43.4 +/- 4.1 Hounsfield units [HU] vs 11.6 +/- 2.7 HU, p < 0.0001; RF, 0.012 +/- 0.001/s vs 0.006 +/- 0.001/s, p < 0.05). When the cutoff value was defined as mean +/- 2 SD, the sensitivity and specificity of the diagnosis for active tuberculoma were 77.1% and 96.4% in PH, and 68.5% and 88.8% in RF, respectively.

CONCLUSION

Contrast-enhanced dynamic CT is a potentially valuable tool for the diagnosis of active tuberculoma.

Intramedullary tuberculoma of the spinal cord: a series of 10 cases

OBJECTIVE

Involvement of vertebral column is common in tuberculosis but intramedullary tuberculomas are rare. We report a series of ten cases of intramedullary tuberculomas, which, to the best of our knowledge, is the largest series of biopsy proven intramedullary tuberculomas in English literature.

METHODS

During a period of 16 years (1985-2000), ten cases of intramedullary tuberculomas were diagnosed in our department. Of these, eight cases were histologically proven intramedullary tuberculomas. The clinical profile, radiological data and histological slides were reviewed.

RESULTS

Age ranged from 18 to 45 years (mean 29.7 years) and there was slight male preponderance (six men, four women). Duration of symptom varied from 3 to 20 months (mean 11.5 months). All of them presented with motor weakness and sensory impairment. Most common site of involvement was dorsal cord followed by cervical, cervicodorsal and dorsolumbar regions. Three patients had associated involvement of lungs, cervical lymphnodes, and brain, and one patient had past history of tuberculous meningitis. Two patients were treated conservatively but surgical excision was done in eight cases followed by medical treatment.

CONCLUSION

Radiologically, intramedullary tuberculomas should be differentiated from other space occupying lesions (SOL) to avoid unnecessary surgery especially in those patients with tuberculosis of the other organs. The incidence of intramedullary tuberculomas is likely to increase with a rise in the incidence of AIDS.

[Experience in using a Renex-Fluoro digital fluorograph in tuberculosis control service in Novomoskovsk]

The paper outlines the design of a Russian Renex-Fluoro small-dose digital fluorograph and its operating principle. The capacities of digital fluorography in the diagnosis of different forms of pulmonary tuberculosis are considered. The data of a comparative statistical analysis of the diagnostic informative value of digital and film fluorography are given.

Single enhancing computerized tomography-detected lesion in immunocompetent patients

Single enhancing computerized tomography (CT)-documented lesions may occur in several infectious and neoplastic diseases of the central nervous system and are the most common radiological abnormality seen in patients with acute-onset seizures in India and many other developing countries. Similar CT-documented lesions have also been reported in the developed world where these lesions are often considered to be caused by neoplasms or tuberculoma. Histopathological studies in India and even in some developed countries revealed that neurocysticercosis (NCC) is the most likely cause of these lesions provided they fulfill a rigid set of clinical and radiological criteria. Single cysticercus granuloma measures less than 20 mm in diameter, may be associated with cerebral edema not severe enough to produce midline shift, and occur in patients with seizures, normal neurological status, and no evidence of active systemic disease. When these lesions resolve spontaneously, either disappearing or changing into a calcified nodule, the diagnosis of NCC is very likely. The second most common cause of these CT-detected lesions is tuberculoma; in patients with these lesions similar clinical and neuroimaging features are also present. Few authors believe that in poor and developing countries, where both tuberculosis and NCC are common, it is difficult to differentiate between tuberculoma and a single cysticercal granuloma. The most interesting feature of these solitary enhancing lesions is their spontaneous disappearance within weeks or months. Some lesions "heal" by becoming calcified. These patients require only antiepileptic therapy, and this medication may be withdrawn safely after the lesion has resolved on CT scanning. In several studies provision of anticysticercal drugs has been attempted, but because of conflicting results, their role in the management of these single lesions is uncertain. Neurosurgeons have a very limited role to play. In very rare situations, if the lesion increases in size and if focal neurological deficits manifest or seizures are uncontrolled, a brain biopsy sample may be required and histopathological evaluation performed to establish the correct diagnosis.

[Comparison of enhanced thin CT sections with pathologic findings in pulmonary carcinoma, inflammatory, pseudo-tumor and pulmonary tuberculoma]

OBJECTIVE

To compare quantitatively the enhanced thin CT section with pathologic findings in pulmonary carcinoma, pulmonary inflammatory pseudotumor (IPT) and pulmonary tuberculoma so as to demonstrate the relation of degree of enhancement and the vascular structure within the lesion with special emphasis on pulmonary carcinoma.

METHODS

Enhanced thin CT sections were obtained in 35 cases with nodular or patchy lesions in the peripheral lung field which are difficult to differentiate clinically. There were pulmonary carcinoma 21, inflammatory pseudotumor 7 and tuberculoma 7. The number of small vessels (inner diameter 0.02 approximately 0.1 mm), relatively large vessels (inner diameter > 0.1 mm) and their vascular bed areas were analyzed by computed image analyzing system. The relation between CT average attenuation and the number of vessels or the vascular bed areas were statistically evaluated.

RESULTS

1. The differences of average attenuation in carcinoma, inflammatory pseudotumor and tuberculoma were statistically significant (P < 0.05). 2. The differences in number of small vessels, relatively large vessels and vascular bed areas among these three types of lesion were also significant (P < 0.05). 3. A positive correlation was found in the average CT affenuation of lung carcinoma and its number of small vessels and relatively large vessels and 4. A positive correlation was found between the average CT attenuation in these three lesions and the relatively large vessels, total vascular amount and vascular bed areas.

CONCLUSIONS

1. The average degree of attenuation, being divided into four degrees, is of practical value in the differentiation of lung carcinoma, inflammatory pseudotumor and tuberculoma. 2. The average CT attenuation of lung carcinoma, inflammatory pseudotumor and tuberculoma is in direct proportion to the number of vessels and vessel bed areas and 3. The characteristic CT enhancement in lung carcinoma reflexes the condition of vessels and blood supply within the tumor.

CT of tuberculosis and nontuberculous mycobacterial infections

Radiologic manifestations of pulmonary tuberculosis (TB) can vary according to several host factors, including prior exposure to TB, age, and underlying immune status. Although chest radiography is the mainstay in the evaluation of pulmonary TB, CT generally is required to detect fine lesions overlooked on chest radiographs, to define equivocal lesions, or to evaluate complications. High-resolution CT is useful in understanding the pathologic process of the disease and in determining disease activity in selected cases. This article describes the characteristic CT findings of various forms of pulmonary TB and nontuberculous mycobacterial infection according to immune status of the patients, and assesses the role of CT in the diagnosis and management of pulmonary TB.

CT and MR findings in a calcified myocardial tuberculoma of the left ventricle

Tuberculosis can involve a multitude of organ tissues but generally affects the respiratory tract. Heart tuberculosis is rare, and the pericardium is the most common location reported in the literature, accounting for 0.5% of extrapulmonary tuberculosis. Isolated myocardial tuberculosis is a very unusual occurrence, with only a few case reports in the literature, usually diagnosed at necropsy. Findings of myocardial tuberculoma on cross-sectional images previously have not been reported. We present computed tomography and magnetic resonance imaging findings of an isolated calcified myocardial tuberculoma.

Tuberculous granulomas in childhood tuberculous meningitis: radiological features and course

The clinical course and serial cranial computerized tomographic (CT) findings of 202 children with tuberculous meningitis (TBM) admitted to Tygerberg Hospital between 1985 and 1994 were reviewed with regard to the incidence, CT appearance and clinical course of associated intracranial tuberculous granulomas. Thirty-four patients (16.85 per cent) had associated intracranial granulomas. Thirty-eight individual lesions were analysed and classified as meningeal, parenchymal or ependymal according to their central nervous system (CNS) location. Twenty-five patients had round to irregular, brain iso-, hypo- or hyperdense meningeal granulomas with variable degrees of enhancement and peri-lesional hypodensities. Four patients had diffusely enhancing, brain isodense, enplaque-like ependymal granulomas associated with the ventricular ependymal lining. Four patients with miliary tuberculosis and TBM showed multiple small diffusely enhancing, brain iso- or hyperdense parenchymal lesions and associated hypodensities on initial CT. Although granulomas in the meningeal and ependymal group had the propensity to paradoxically enlarge or appear on standard four-drug antituberculosis therapy, the majority resolved uneventfully. Rapid resolution of small parenchymal granulomas associated with miliary tuberculosis occurred in all cases. Most granulomas in this series were co-incidental, asymptomatic CT findings. In rare cases, the development or enlargement of a strategically located granuloma may result in complications.

Supraorbital burr hole via a glabellar incision: a simple approach to anterior skull base

A left subfrontopolar lesion with marked edema was totally resected utilizing a minimally invasive approach. It was possible to expose and resect the lesion, which turned out to be a tuberculoma, through a burr hole placed supraorbitally through a glabellar incision. The development and significance of minimalization techniques for surgery in the skull base region are discussed.

Pulmonary tuberculosis: CT and pathologic correlation

Typical CT findings of active postprimary pulmonary tuberculosis include centrilobular nodules and branching linear structures (tree-in-bud appearance), lobular consolidation, cavitation, and bronchial wall thickening. The CT findings of inactive pulmonary tuberculosis include calcified nodules or consolidation, irregular linear opacity, parenchymal bands, and pericicatricial emphysema. The typical appearance of primary tuberculosis on CT scans is homogeneous, dense, well-defined segmental or lobar consolidation with enlargement of lymph nodes in the hilum or the mediastinum. Miliary nodules may be seen in primary and postprimary tuberculosis. On CT, tuberculomas appear as a nodule with surrounding satellite nodules and internal cavitation on CT. Atypical radiologic manifestations of tuberculosis, encountered in as many as one third of the cases of adult-onset tuberculosis, are single or multiple nodules or masses, basilar infiltrates, miliary tuberculosis with diffuse bilateral areas of ground-glass opacity, and reversible multiple cysts. Underlying histopathologic findings of typical and atypical CT findings of tuberculosis are caseating granulomas or pneumonia in the active phase and fibrosis and dystrophic calcification in the inactive phase.

Pulmonary tuberculoma evaluated by means of FDG PET: findings in 10 cases

PURPOSE

To describe findings of pulmonary tuberculoma at 2-[fluorine 18]fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET).

MATERIALS AND METHODS

Ten consecutive patients who underwent PET and subsequently were proved to have pulmonary tuberculoma were analyzed. Tuberculosis was proved histopathologically in eight by means of wedge resection or lobectomy (n = 7) or needle biopsy (n = 1) and in two by means of clinical follow-up for more than 2 years. PET scans were evaluated by using peak standardized uptake values. Computed tomographic (CT) and histopathologic findings also were reviewed.

RESULTS

Nine of 10 tuberculomas showed FDG uptake at PET, and the mean peak standardized uptake value was 4.2 +/- 2.2 (SD). FDG uptake (range, 1. 9-3.7) in lesions adjacent to main abnormalities was demonstrated in four patients. On CT scans, the mean of the longest nodule diameters was 21 mm +/- 8, and there were some areas of branching linear opacities or satellite nodules that suggested pulmonary tuberculosis in seven patients. Histopathologic findings were chronic granulomatous inflammation with caseation necrosis (n = 7) and healed tuberculosis with aspergilloma (n = 1).

CONCLUSION

Pulmonary tuberculoma commonly causes an increase in FDG uptake. These results suggest that in geographic regions with a high prevalence of granulomatous lesions, positive FDG PET results should be interpreted with caution in differentiating benign from malignant pulmonary abnormalities.

Intradural extramedullary tuberculoma of the spinal cord: a case report

Intradural extramedullary (IDEM) tuberculoma of the spinal cord is uncommon entity and moreover, few reports have been documented on concurrent IDEM and intracranial tuberculomas. Authors report a case of IDEM spinal tuberculoma having intracranial lesion simultaneously. A 49-year-old woman suffered from paraparesis and urinary incontinence while being given medical treatment for tuberculous meningitis. Magnetic resonance imaging (MRI) revealed an IDEM mass lesion between the T1 and T2 spinal levels, and multiple intracranial tuberculous granulomas. Surgical resection of the IDEM tuberculoma followed by anti-tuberculous medication resulted in good outcome.

Small solitary pulmonary nodules: assessment of enhancement and enhancement patterns in benign and malignant tumours by high resolution computed tomography

Our aim was to determine the accuracy of quantitative and qualitative findings of contrast-enhanced computed tomography (CT) by means of differential analysis of small uncalcified solitary pulmonary nodules and to compare the CT diagnosis with the results of transthoracic needle biopsies (TTNB). We assessed a consecutive series of 109 patients with 66 malignant or 45 benign pulmonary nodules before TTNB and surgery with contrast and high resolution computed tomography (HRCT). Pulmonary nodules were classified as small when equal to or smaller than 15 mm and large when larger than 15 mm. Diagnostic accuracy of CT qualitative evaluation was 95% for large nodules and 92% for small nodules. Specificity was 92% for small nodules, 80% for large nodules. Enhancing regular septa were observed in 28 hamartomas (80%) while except for two cases (3%), inner septa were absent or irregular in malignant tumours. TTNB accuracy was 70% for small nodules and 94% for large ones. Low-enhancing hamartomas are more frequent in Italy than in the US where the prevalence of high-enhancing granulomas in benign nodules reduces the specificity of quantitative CT analysis. We propose that certain geographic areas would benefit from enhanced-CT in place of TTNB in managing lung nodules equal to or less than 1.5 cm.

MR image and CT scan of a tuberculous abscess in the gluteus maximus muscle

A 77-year-old man had rapidly increased intramuscular tuberculous abscess in his left buttock. Radiographs showed a bone defect in the left ischium. Postcontrast CT scanning revealed marginal enhancement. MR imaging showed low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. T1-weighted MR images with Gd-DTPA enhancement showed enhancement of the wall. Bone defect and marginal enhancement on postcontrast MR images and on postcontrast CT images are image character of the intramuscular tuberculous abscess.

Evolution of brain tuberculomas under standard antituberculous treatment

The treatment of brain tuberculomas is primarily medical. Surgery, excision or biopsy, is generally performed when the diagnosis is in doubt or there is no response to medical therapy. The aim of this study was to determine the radiological evolution of intracranial tuberculomas under standard anti-tuberculous drug therapy and to establish guidelines for better management of these patients. Eighteen patients were studied retrospectively. None of them had surgical intervention and all were treated by standard antituberculous drugs and had serial computed tomography (CT) scans until disappearance or stabilization of brain lesions. The regression of lesions' size and number was slow in the first month (mean -7.3%) then became rapid after this (-15% to -20% per month). A paradoxical increase in size was noted in three patients in the first month. All three had associated meningitis. All tuberculomas disappeared on CT scan after 12 months of therapy. Most of the edema images disappeared by 6 months. This study would suggest that a long treatment regimen of 15-18 months may not be necessary in most intracranial tuberculomas occurring in non-immunocompromised patients. It also demonstrates that medical trial in well tolerated suspected cases should last for at least 2 months before considering other etiologies or surgical exploration.

Macronodular multi-organs tuberculoma: CT and MR appearances

The case of a 21-year-old woman presenting with macronodular multi-organs tuberculoma is reported. She was examined for pulmonary tuberculosis on a chest X-ray film in January, 1995, and admitted with a cough, anorexia, and abdominal pain in July, 1996. Computed tomography revealed multiple calcified nodules with peripheral hypodense areas in the brain, and calcified hypodense masses in the liver and spleen. Magnetic resonance (MR) imaging showed hypointense masses in the liver and spleen on T1-weighted spin echo images and a hypointense mass with a hyperintense area on T2-weighted spin echo images. On contrast-enhanced dynamic MR images, the liver and spleen masses were unenhanced and hypointense with slight rim enhancement. T2-weighted spin echo images showed a round hypointense nodule in the right kidney and hydronephrosis and enlargement in the left kidney. Antituberculous treatment was started with a gradual improvement in her signs and symptoms. Her temperature became normal. However, she was systemically treated with antituberculous chemotherapy 10 months later, her condition worsened again. She died from increased intracranial pressure in August, 1997.

[Solitary pulmonary nodule: application of Bayes theorem in prediction of malignancy]

Most radiological signs are of low specificity for predicting malignancy in patients with a solitary pulmonary nodule (SPN), making clinical management difficult. Only certain calcification patterns in SPN or the absence of growth over a period two years assures that the nodule is benign. The clinical and radiological characteristics of 31 patients with SPN were studied. Twenty-two were cases bronchopulmonary carcinoma and 9 were pulmonary tuberculoma. Accuracy in the prediction of malignancy was assessed using Bayes' theorem, which is based on degrees of likelihood of various radiological and clinical characteristics. Patients with carcinoma (mean age 65 +/- 9 years) were significantly older than those with tuberculoma (38 +/- 19 years) (p < 0.05). The proportion of smokers was significantly higher among patients with carcinoma (91%) than those with tuberculoma (44%) (p < 0.05). In 50% of the patients with SPN due to bronchopulmonary carcinoma (11 patients), the nodule was in the upper right lobe; in 55% of those with tuberculomas (5 patients) the nodule was found in the upper left lobe. There were no significant differences in the characteristics of the computerized tomography images for the two groups. Mean likelihood of malignancy for patients with carcinoma, by Bayes' theorem, was 83.7%, a rate that was significantly higher than that of tuberculoma patients (46%) (p < 0.05). The application of Bayes' probability theorem for a set of clinical and radiological characteristics can orient the physician as to whether an SPN is likely to be malignant or not, thereby providing guidance on the advisability of performing invasive diagnostic procedures to determine etiology.

Tuberculoma of the liver presenting as a hyperechoic mass on ultrasound

An unusual case of hepatic macronodular tuberculoma is presented. As demonstrated by CT, the tuberculoma replaced the entire lateral segment of the left lobe of liver and resembled an infiltrative tumour. On ultrasound, the tuberculoma presented as a hyperechoic lesion, in contrast to a round hypoechoic mass which is usually seen in this condition. Hepatic macronodular tuberculomas are not uncommonly misdiagnosed as primary or secondary liver tumours by imaging studies, and the definite diagnosis is usually established by liver biopsy. The prognosis of hepatic macronodular tuberculoma is usually very good with effective treatment.

Pleural signs of small peripheral pulmonary masses: pathologic correlation with chest radiographs and diagnostic value

OBJECTIVE

The current interest in 'cost-effectiveness' of medical imagings means that chest radiography is the primary radiological examination of lung diseases. We attempted to investigate the pathological basis of different pleural signs, and determine their usefulness in differentiating small bronchogenic carcinomas from tuberculomas by using chest radiographs.

MATERIALS AND METHODS

We prospectively studied 30 small solitary pulmonary masses, including 24 carcinomas and 6 tuberculomas. All 30 resected lobe specimens were investigated with preoperative radiographs, postoperative specimen radiographs, 10-15 microns thick whole-mount sections, and 5 microns thick slices for conventional histological examination. To evaluate the clinical usefulness of these pleural signs, we also retrospectively reviewed 100 chest radiographs and conventional tomographs of 1-3 cm peripheral pulmonary lesions, including 60 bronchogenic carcinomas and 40 tuberculomas.

RESULTS

The results confirmed that, besides the previously known interlobular septal fibrosis with pleural retraction, the pathologic basis also included the pleural puckering and adhesion with fluid collection for the 'tail' and 'rabbit ears' signs, and pleural dimpling with fluid collection and peripheral fibrous hyperplasia for the 'triangular shadow' signs. In the retrospective group, the pleural signs with adjacent pleural thickening was significantly more frequent in tuberculomas than in carcinomas (P < 0.05, chi 2-test).

CONCLUSION

Pleural signs associated with adjacent pleural thickening seems to contribute to differentiating granulomas from carcinomas. The pathological basis for this radiological finding includes visceral pleural fibrosis with the inflammatory cell infiltration, and the wide and shallow pleural dimpling filled with reactive pleural fluid.

[The solitary pulmonary nodule: the preliminary results in differential diagnosis by high-resolution computed tomography with a contrast medium]

INTRODUCTION

High-resolution computed tomography (HRCT) with iodinated contrast material has been used by many authors to study solitary pulmonary nodules (SPNs). The degree of enhancement was correlated with the nodule malignancy.

MATERIAL AND METHODS

Forty adult patients were examined, before and after contrast agent administration, with incremental dynamic CT. We selected 22 patients with SPNs (3-30 mm phi, except one with 40 mm phi). The CT numbers of the inner nodule were calculated before and 1, 2 and 3 minutes after the i.v. administration of a weight-related dose (1.5 mL/kg/min) of nonionic iodinated contrast agent. A dose of 100 mL contrast agent was used in the first 6 patients. The difference in CT numbers between unenhanced images and the images with maximum enhancement (max. attenuation) was also calculated.

RESULTS

Histologic diagnoses included 4 tuberculomas, 3 hamartomas and 15 malignant tumors (9 adenocarcinomas, 5 squamous cell carcinomas and 1 non-Hodgkin lymphoma). The CT numbers (in Hounsfield units, HU) of malignant nodules ranged 12-31 HU (mean: 21.5 HU) before contrast agent administration; the "long-standing" tuberculomas ranged 11-22 HU (mean: 16.5 HU) and the hamartomas had a mean density of 10.5 HU. We excluded for the study two "fresh" tuberculomas, one of which was surrounded by a low-attenuation infiltrate (the halo sign). We selected a threshold value of 20 HU on enhanced CT images to distinguish malignant (> or = 20 HU) from benign (< or = 20 HU) nodules. All lung cancers had complete enhancement (mean density: 35.5 HU). With 20 HU as the threshold value for a positive test, sensitivity was 100%, specificity 85.7%, positive predictive value 93.8% and negative predictive value 100%; test bias was 1.067.

CONCLUSION

Positron emission tomography (PET) with 2-[fluorine-18] fluoro-2-deoxy-D glucose is reported to be as accurate as enhanced HRCT, but it does not provide accurate morphological information, is not widely available and it is quite expensive: therefore, in our opinion, CT should be preferred. After examining over 100 patients, we may use our results in the decision analysis comparing surgical risk with cancer risk.

Pulmonary tuberculosis after lung transplantation

During a 5-year study period, we diagnosed pulmonary tuberculosis in two (2%) of 94 lung and heart-lung transplant recipients. Each infection occurred 3 months after bilateral lung transplantation in the presence of evidence implicating donor-to-recipient transmission of the pathogen. The radiographic patterns of pulmonary tuberculosis were subtle: narrowing of the middle lobe bronchus of the right lung caused by an endobronchial granulomatous mass (n = 1) and a focal cluster of small nodules in the upper lobe of the left lung and small bilateral pleural effusions (n = 1). Each patient achieved complete clinical and radiographic response after antituberculous therapy. We conclude that Mycobacterium tuberculosis may be transmitted directly by a donor lung and may involve bronchial mucosa, pulmonary parenchyma, and pleura.

CT in simple partial seizures in children: a clinical and computed tomography study

INTRODUCTION

Therapeutic relevance of computed tomography (CT) in children with simple partial seizures (SPS) is reported to be remarkably low (1-2%). There are not studies, however, from the developing countries where neuroinfections are among important causes of seizures. The present study from India is aimed at evaluating the significance of CT in the management of SPS in children and to determine the difference in clinical features of children with and without focal brain lesions in CT.

PATIENTS AND METHODS

CT scans of all patients aged 15 years of younger with SPS, seen over a period of 15 months, were reviewed. The clinical features of the patients with focal lesions in the CT were compared with those of children without focal abnormalities.

RESULTS

Focal structural lesions were present in 117 (59.09%) of 198 children. These included: solitary contrast enhancing CT lesion-16.16%, focal calcification-12.12%, cysticerosis-10.10%, focal atrophy-9.59%, tuberculoma-6.56% and infarction-6.06%. Neuroinfections or their sequelae were responsible for seizures in 89 children (44.94%). There were no statistically significant differences in clinical features of patients with and without focal lesions in CT.

CONCLUSIONS

CT study in children with SPS in developing countries has significant therapeutic relevance. It is not possible to clinically differentiate children with focal lesions from those without focal lesions in CT.

[Clinical investigation on 42 cases of pulmonary tuberculoma]

OBJECTIVE

For the purpose to find the possible reasons causing pulmonary tuberculoma been misdiagnosed as lung cancer.

METHODS

Clinical symptoms, chest X ray films, tomographic and CT manifestations as well as laboratory data of 42 cases of pulmonary tuberculoma pathologically proved were thoroughly reviewed. All the radiological appearances were compared with pathological findings.

RESULTS

Shallow lobulated contour, spurlike shadow formation, vacoule sign, satellite lesions, pleural involvement, calcified spots were found very important for differential diagnosis of these 2 diseases.

CONCLUSIONS

It is difficult to differentiate pulmonary tuberculoma from lung cancer. By paying special attention to the above mentioned appearance, evaluating them very carefully and considering them with positive laboratory findings, it might be possible to avoid misdiagnosis before surgical operation.

[Radiographic differential diagnosis of surgical diseases of the lungs: diagnostic errors and their causes]

This study examines the reasons for complete divergences between the results of complex radiation study and the morphological verification of a diagnosis. A hundred and fifty cases with peripheral and central diseases of the lung were examined. There were 16 (10.7%) divergences of CT and X-ray conclusions with the histological verification of a diagnosis. The reasons of errors of complex radiation diagnosis were due both to the same type of symptoms, their latency and subjective ideas when the symptoms were analyzed. The greatest differentially diagnostic difficulties arose when peripheral formations were estimated.

[Coincidence of pulmonary cryptococcoma in an immunocompetent patients with a chondrohamartoma and chronic tuberculoma--differential diagnostic considerations concerining pulmonary coin lesions]

Of primary importance in the differential diagnosis of multiple circular foci in the lungs are the lung metastases. This study involves a patient with three circular foci, each of which could have been metastases. They proved, however, to be a rare coincidence of three benign lung affections, namely, an old tuberculoma, a chondrohamartoma, and a seldom encountered pulmonary cryptococcoma. Computerized tomography utilizing the spiral technique was valuable diagnostically, as it led to the discovery of the smallest of the three circular foci in the basodorsal left lower lobe. The form of the cryptococcosis among immunocompetent patients--only rarely localized in our experience--must be included in the differential diagnostical considerations of a circular focus in the lungs. In the event there are multiple circular foci with an unknown primary tumor, surgical intervention with a pathohistological clarification regarding a possible malignancy is absolutely necessary.

The challenge of solitary pulmonary nodules: HRCT evaluation

Both enhancement and morphologic analysis have been shown important in the HRCT study of solitary pulmonary nodules (SPNs). In our prospective study, 25 adult patients with benign (N = 8) or malignant (N = 17) SPNs were examined before and after contrast agent. We obtained three serial thin section CT scans every 60 s after the onset of the injection of contrast material. All 17 malignant nodules did enhance very significantly (P < 0.001). Benign nodules did not enhance significantly (P > 0.05). Using 20 HU as a threshold for positivity of the contrast test, our sensitivity was 100%, specificity was 74%, positive predictive value was 89.5%, negative predictive value was 100%, and accuracy was 92%; test bias was 1.118. In our opinion, HRCT evaluation of SPNs is the most widely available tool to save cost and decline in morbidity in management.

[Radiological aspects of hepatic tuberculoma. 3 cases]

Localized macronodular tuberculosis of the liver is rare. Tuberculous involvement of the liver is usually a diffuse process. We report 3 cases in which clinical and imaging features suggested the diagnosis of macronodular hepatic tuberculoma which was pathologically confirmed by percutaneous biopsy. In the first case, abdominal CT-scan showed a noncalcified hypodense nodular lesion in segment IV of the liver with an enhancing peripheral rim. In the second case, ultrasound showed 4 homogenous hypoechoic hepatic nodules. In the third case, a nodule was incidentally identified in segment VII of the liver. The lesion was hypoechoic with ultrasound, hypodense without enhancement on CT-scan, and hyperintense on both T1- and T2-weighted MR imaging. After percutaneous biopsy, pathologic examination showed peripheral granulomous lesions in all patients with central caseous necrosis consistent with tuberculosis in two patients despite a negative for Zielh stain. Specific M. tuberculosis culture was positive in the first patient, negative in the second patient, and was not performed in the third patient. Appropriate treatment resulted in disappearance of hepatic lesions on follow-up imaging examinations. These 3 cases show that clinical and imaging features of hepatic tuberculoma are not specific and that percutaneous biopsy of lesions provides a definite diagnosis.

Sellar tuberculoma: report of two cases

Hypophyseal tuberculomas are exceptionally rare. We report two patients with sellar tuberculoma but with no evidence of concurrent extrasellar disease. Although the lesion is often mistaken for adenoma, there are characteristic radiological features: intense enhancement on contrast CT and thickening of the pituitary stalk on MRI in 86% of cases. Accurate diagnosis is important because pituitary tuberculoma is curable.

[Echographic aspects of renal tuberculosis]

In this study the Authors examine the utility of the ultrasonographic investigation in the preoperative evaluation of 22 patients submitted to nephrectomy for tubercular lesions, comparing the informations obtained from this procedure with the histologic report. The renal ultrasonography execute with a Toshiba 3.5 Mhz probe, has been utilized to value morphology, volume, parenchymal echostructure and hydronephrosis. According to the Author's series, the ultrasonography has shown a 100% sensitivity permitting to well value the presence of parenchymal lesions and hydronephrosis. As regards the tubercular renal injuries the ultrasonography is non-specific because it does not allow to have pathognomonic images. The results obtained from the U.S. are overlapping to the Results Related from the literature for abdominal CT. The Authors argue that U.S., rapid and economical investigation is an efficient complement to the urography for an exhaustive preoperative evaluation of patients suffering from renal Tuberculosis.

Tuberculoma arising in the inguinal portion of the spermatic cord: a case report

A 50-year-old man was treated with excisional surgery for an asymptomatic inguinal spermatic cord mass. The lesion was proved to be tuberculous, and there was no apparent coexisting active disease elsewhere in the body. In addition to an intraoperative frozen-section examination, clinical findings of a strongly positive tuberculin skin test and normal erythrocyte sedimentation rate are considered to be helpful in establishing the diagnosis of a tuberculoma arising in either the scrotal or inguinal position.