Tuberculosis from head to toe

Hydrothorax, ascites and an abdominal mass: not always signs of a malignancy - Three cases of Meigs' syndrome

This case report presents three cases of Meigs' syndrome: a benign ovarian tumor with ascites and a hydrothorax. After removal of the ovarian tumor, the symptoms resolved and the patients became asymptomatic. In daily practice, Meigs' syndrome is at first sight often mistaken for ovarian cancer. With this case report we would like to emphasize that the clinical presentation of an ovarian tumor might be ovarian cancer, but can masquerade as something uncommon like Meigs' syndrome. In a time span of two years we encountered three cases.

Case of victims of modern imaging technology: Increased information noise concealing the diagnosis

We present a case of tubercular arthritis who underwent numerous unnecessary investigations what is known as “victims of modern imaging technology” or VOMIT. Today there is an exponential rise in the volume of the medical imaging, part of which is contributed by unnecessary and unjustified indications. We discuss about the untoward effects of the uninhibited and careless use of modern imaging modalities and possible ways to avoid. Skeletal manifestation of the tuberculosis is still common in the endemic countries like India. Although the final diagnosis of the skeletal tuberculosis like tubercular arthritis is made by bacteriological and histological studies, few demographic, clinical and radiological features might help making early diagnosis.

The HIV manifestations within the gastrointestinal tract: A pictorial review

The aim of the pictorial review are to review the HIV manifestations within the gastrointestinal tract. We have detailed five conditions, with reference to the patients’ CD4 count – gastrointestinal tuberculosis, Kaposi’s sarcoma, small bowel lymphoma, cytomegalovirus colitis and anal carcinoma.

[Extrathoracic manifestations of tuberculosis]

CLINICAL/METHODICAL ISSUE

Besides the lungs, tuberculosis (TB) can affect any organ system. In most cases, extrathoracic TB occurs in immunosuppressed patients as part of a severe illness via hematogenous spread. Extrathoracic involvement most commonly involves abdominal organs, especially the urogenital tract and less commonly the central nervous system (CNS) and the musculoskeletal system. Most frequently, computed tomography (CT) is used for detecting extrathoracic TB manifestations, except for CNS and musculoskeletal manifestations, where contrast-enhanced magnetic resonance imaging (MRI) is the gold standard. Extrathoracic manifestations of TB may be indistinguishable from inflammatory or malignant causes. Due to unspecific symptoms the diagnosis is often delayed. This article summarizes and discusses the various radiological manifestations of extrathoracic manifestation of TB.

STANDARD RADIOLOGICAL METHODS

Radiological modalities for screening extrathoracic TB are CT and MRI. Conventional X‑radiographs do not play a role in the diagnosis of extrathoracic TB.

PRACTICAL RECOMMENDATIONS

The possibility of extrathoracic TB should be considered particularly in immunosuppressed patients, such as the homeless, alcoholics or drug addicts or in patients with an immigrant background from the endemic areas of TB. The most likely site of extrathoracic TB is the abdomen; however, infections of the CNS or musculoskeletal systems and multisystem infections can also occur. In patients with suspected extrathoracic TB, radiological modalities for screening are CT, especially for abdominal infections and lymphadenopathy and MRI with contrast media for the musculoskeletal system and the CNS.

Multidetector CT urography in urogenital tuberculosis: use of reformatted images for the assessment of the radiological findings. A pictorial essay

Urogenital tuberculosis (UGTB) is the most common form of extrapulmonary TB and is responsible for a destructive inflammation of the renal parenchyma and urinary tract often leading to the loss of kidney function. For these reasons, the early diagnosis of this disease, once considered disappeared in developed countries, is very important to establish a prompt and efficient treatment. However, the subtle and non-specific symptoms, often represented by recurrent and persistent lower urinary tract symptoms, can confound and delay the diagnosis. Therefore, an adequate and comprehensive imaging study is necessary in patients with persistent urinary tract infections not responding to the antibiotics and can suggest the hypothesis although bacteriological and/or histologic analysis is required for a definitive diagnosis. In the past years, intravenous urography (IVU) has allowed a comprehensive study of the urinary excretory tract, promoting the knowledge of the radiological findings of this disease. Nowadays, computed tomography urography (CTU), with the implementation of multidetector (MD) technology, has replaced IVU in all its indications; the MDCTU improves the assessment of renal and urinary tract lesions using reformatted images [such as multiplanar reconstruction (MPR) and maximum intensity projection (MIP)]. Therefore, our paper aims to provide a guide for radiologist for searching the classic signs of UGTB on MDCTU, encouraging the use of the MPR and MIP reformatted images.

Imaging of thoracic tuberculosis in children: current and future directions

Tuberculosis continues to be an important cause of morbidity and mortality worldwide. It is the leading cause of infection-related deaths worldwide. Children are amongst the high-risk groups for developing tuberculosis and often pose a challenge to the clinicians in making a definitive diagnosis. The newly released global tuberculosis report from World Health Organization reveals a 50% increase in fatality from tuberculosis in children. Significantly, diagnostic and treatment algorithms of tuberculosis for children differ from those of adults. Bacteriologic confirmation of the disease is often difficult in children; hence radiologists have an important role to play in early diagnosis of this disease. Despite advancing technology, the key diagnostic imaging modalities for primary care and emergency services, especially in rural and low-resource areas, are chest radiography and ultrasonography. In this article, we discuss various diagnostic imaging modalities used in diagnosis and treatment of tuberculosis and their indications. We highlight the use of US as point-of-care service along with mediastinal US and rapid MRI protocols, especially in mediastinal lymphadenopathy and thoracic complications. MRI is the ideal modality in high-resource areas when adequate infrastructure is available. Because the prevalence of tuberculosis is highest in lower-resource countries, we also discuss global initiatives in low-resource settings.

Extrapulmonary involvement in pediatric tuberculosis

Tuberculosis in childhood is clinically challenging, but it is a preventable and treatable disease. Risk factors depend on age and immunity status. The most common form of pediatric tuberculosis is pulmonary disease, which comprises more than half of the cases. Other forms make up the extrapulmonary tuberculosis that involves infection of the lymph nodes, central nervous system, gastrointestinal system, hepatobiliary tree, and renal and musculoskeletal systems. Knowledge of the imaging characteristics of pediatric tuberculosis provides clues to diagnosis. This article aims to review the imaging characteristics of common sites for extrapulmonary tuberculous involvement in children.

Adnexal masses associated with peritoneal involvement: diagnosis with CT and MRI

Given the unique intra-peritoneal anatomic location of the adnexa, tubo-ovarian diseases can commonly spread into the peritoneal cavity. Peritoneal seeding may occur in a spectrum of adnexal conditions including infectious diseases, endometriosis, and benign or malignant primary or secondary ovarian tumors. CT is usually the imaging modality on which the concomitant involvement of the peritoneum and the ovary is depicted. The first diagnosis to be considered by the radiologist is generally peritoneal carcinomatosis from ovarian cancer but other conditions cited above have also to be borne in mind and may be suggested on the basis of careful assessment of CT findings or on further MR findings. MRI may indeed help characterize the lesions in some cases. The purpose of this review is to describe the clinical and imaging patterns of peritoneal involvement that may be found in association with different ovarian lesions. Familiarity with these patterns and diagnoses will help the radiologist narrow the differential diagnosis and make an accurate diagnosis, thus facilitating patient management and avoiding unnecessary invasive treatment.

A 6500-year-old Middle Neolithic child from Pollera Cave (Liguria, Italy) with probable multifocal osteoarticular tuberculosis

Clear skeletal evidence of prehistoric tuberculosis (TB) is rare, especially in children. We describe and differentially diagnose the pathological changes displayed by a five-year-old child, Pollera 21 (PO21) dated to the Middle Neolithic of Liguria (Italy), or 5740±30 BP (Beta-409341; 6635-6453cal BP, 2σ, OxCal 4.2). PO21 shows a number of osteoarticular lesions, mainly of a lytic nature with very little bone proliferation: the vertebral column, the shoulder and pelvic girdles, and the ribcage are involved. Given the nature and pattern of the lesions, we propose a diagnosis of multifocal (or multiple) bone TB. Attempts to detect TB aDNA through molecular analysis gave negative results, but this alone is not sufficient to prove that PO21 was not infected with TB. The lesions observed in PO21 share similarities with other published evidence, such as spinal and joint involvement, and disseminated cyst-like lesions. Conversely, PO21 does not show diffuse bone deposition, such as hypertrophic osteoarthropathy (HOA) or endocranial modifications such as serpens endocrania symmetrica (SES). PO21 adds to our knowledge of patterns of TB manifestation in archaeological skeletal remains, which is especially important considering the variability in types and patterns of osteoarticular lesions seen today in people with TB.

Imaging Manifestations of Thoracic Tuberculosis

Despite significant improvements in the diagnosis and treatment of tuberculosis achieved during the last 3 decades, tuberculosis still remains one of the deadliest communicable diseases worldwide. Tuberculosis is still present in all regions of the world, with a more significant impact in developing countries. This article reviews the most common imaging manifestations of primary and postprimary tuberculosis, their complications, and the critical role of imaging in the diagnosis and follow-up of affected patients.

Imaging the posterior mediastinum: a multimodality approach

The posterior mediastinum contains several structures that can produce a wide variety of pathologic conditions. Descending thoracic aorta, esophagus, azygos and hemiazygos veins, thoracic duct, lymph nodes, adipose tissue, and nerves are all located in this anatomical region and can produce diverse abnormalities. Although chest radiography may detect many of these pathologic conditions, computed tomography and magnetic resonance are the imaging modalities of choice for further defining the relationship of posterior mediastinal lesions to neighboring structures and showing specific imaging features that narrow the differential diagnosis. This review emphasizes modality-related answers to morphologic questions, which provide precise diagnostic information.

Imaging in extrapulmonary tuberculosis

Tuberculosis (TB) remains a major global public health problem, with 1.5 million deaths annually worldwide. One in five cases of TB present as extrapulmonary TB (EPTB), posing major diagnostic and management challenges. Mycobacterium tuberculosis adapts to a quiescent physiological state and is notable for its complex interaction with the host, producing poorly understood disease states ranging from latent infection to active clinical disease. New tools in the diagnostic armamentarium are urgently required for the rapid diagnosis of TB and monitoring of TB treatments, and to gain new insights into pathogenesis. The typical and atypical imaging features of EPTB are reviewed herein, and the roles of several imaging modalities for the diagnosis and management of EPTB are discussed.

Cerebral hemorrhage due to tuberculosis meningitis: a rare case report and literature review

Tuberculosis (TB) is a common disease to threaten human health. TB of the central nervous system (CNS) is rare but the most serious type of systemic TB because of its high mortality rate, serious neurological complications and sequelae. In this case report, we describe a woman who presented with walking instability, intracerebral hemorrhage and leptomeningeal enhancement due to tuberculosis meningitis. The patient had no significant medical history and the initial clinical symptoms were walking instability. On analysis, the cerebrospinal fluid was colorless and transparent, the pressure was more than 400 mm H₂O, there was lymphocytic pleocytosis, increased protein, and decreased glucose levels present. No tuberculosis or other bacteria were detected. The patient's brain computed tomography image showed intra-cerebral hemorrhage (ICH) and contrast magnetic resonance imaging showed ICH in the right frontal lob, and leptomeningeal enhancement. CNS TB is rare but has a high mortality rate. As this disease has no unique characteristics at first presentation such as epidemiology and obvious clinical manifestation, a diagnosis of CNS TB remains difficult.

Tuberculosis Penis with 'Watering Can Penis' Appearance: Report of a Rare Case with Retrograde Urethrography and Voiding Cystourethrography Findings

Background

A ‘watering can penis’ secondary to penile tuberculosis is an extremely rare clinical entity. Retrograde Urethrography – Voiding Cystourethrography evaluation of the urethra and the urinary bladder plays a very important role in the diagnostics as well as further management of the urethral abnormalities. To the best of our knowledge, this is only the second case in literature where a ‘watering can penis’ was noted secondary to penile TB. This is also the first documented case of ‘watering can penis’ as a consequence of venereal transmission of TB.

Case Report

A 50-year-old male presented with multiple discharging sinuses along the penis. RGU revealed multiple, contrast-filled, narrow, irregular, fistulous tracts arising from the pendulous part of the anterior urethra. This distal segment of the pendulous part of the anterior urethra also showed significant distortion and irregular, beaded narrowing. VCUG showed a markedly-contracted and small-capacity urinary bladder with a thickened, irregular and edematous wall with multiple hypertrophied trabeculae along its walls. The patient was administered anti-tubercular treatment. At the end of this treatment regimen, a repeat RGU-VCUG will be performed and decision regarding urethroplasty and further management will be planned depending upon the presence of any remaining fistulas or strictures involving the urethra.

Conclusions

‘Watering can penis’ as a result of penile TB is a very rare clinical entity. The differential diagnoses of a ‘watering can penis’ should be kept in mind in the evaluation of these patients. RGU and VCUG evaluation is an important conventional imaging modality used in the evaluation of urethral strictures and fistulas in case of ‘watering can penis’.

A case report of racemose pattern of intracranial tuberculoma with brain stem and hypophyseal involvement developing paradoxically during treatment

Tuberculosis involving the central nervous system, a source of considerable morbidity and mortality, forms 5-10% of the disease burden associated with tuberculosis. Central nervous system tuberculosis may present as meningitis, tuberculoma, abscesses, cerebritis or miliary tuberculosis. The most common site of tuberculoma has been reported to be at the grey–white matter junction and the periventricular region. They may even be found in the epidural, subdural and subarachnoid spaces, and the brain stem, with the rarer sites of involvement being the cavernous sinus, sella turcica, hypophysis, hypothalamus, sphenoid sinus and the mastoid air cells. Although tuberculosis is very common in developing countries, with the increasing prevalence of immunosuppression owing to human immunodeficiency virus and patients surviving chemotherapy or organ transplantation, the incidence of tubercular infections has been rising in developed countries. The authors report a case of intracranial tuberculosis in a human immunodeficiency virus-negative patient, who underwent incomplete treatment for tubercular peritonitis and presented with unilateral ptosis. Tuberculous involvement was noted in a racemose pattern in the subarachnoid space, cavernous sinuses, suprasellar cistern and parasellar region. To the best of our knowledge, the term racemose pattern of tuberculoma has not been described before, while about 10 cases of tuberculoma involving the cavernous sinuses have been reported in the literature. Furthermore, the racemose pattern of tuberculosis in the subarachnoid space, as well as involvement of the cavernous sinus, hypothalamus, pituitary and the cisterns, developed paradoxically after initiation of antitubercular chemotherapy.

Inflammatory bowel disease imaging: Current practice and future directions

The purpose of this paper is to evaluate the role of imaging in inflammatory bowel disease (IBD), including detection of extraluminal complications and extraintestinal manifestations of IBD, assessment of disease activity and treatment response, and discrimination of inflammatory from fibrotic strictures. IBD is a chronic idiopathic disease affecting the gastrointestinal tract that is comprised of two separate, but related intestinal disorders; Crohn’s disease and ulcerative colitis. The paper discusses, in detail the pros and cons of the different IBD imaging modalities that need to be considered in order to optimize the imaging and clinical evaluation of patients with IBD. Historically, IBD evaluation of the bowel has included imaging to assess the portions of the small bowel that are inaccessible to optical endoscopic visualization. This traditionally was performed using barium fluoroscopic techniques; however, cross-sectional imaging techniques (computed tomography and magnetic resonance imaging) are being increasingly utilized for IBD evaluation because they can simultaneously assess mural and extramural IBD manifestations. Recent advances in imaging technology, that continue to improve the ability of imaging to noninvasively follow disease activity and treatment response, are also discussed. This review article summarizes the current imaging approach in inflammatory bowel disease as well as the role of emerging imaging modalities.

Prevalence and Clinical Characteristics of Mycobacterial Diseases in the Barletta-Andria-Trani Province, Italy (2005-2013)

Tuberculosis remains one of the major worldwide problems regarding public health. This study evaluates the burden of this disease in the BAT Province of the Apulia region (Italy); 12,295 patients were studied, including 310 immigrants. Tubercular disease and mycobacteriosis were found in 129 patients. The number of new TB cases/year ranged from three in 2005 to 12 in 2009. TB was more frequently localized in the lung (70.5%). 14.4% of cases were institutionalized patients for severe neurological and/or psychiatric disease. The database evidenced certain aspects of our study population: the large number of TB patients institutionalized between natives, but no larger presence of TB among HIV-positive patients in immigrants compared to Italians. Our findings should help to redefine the alarm regarding the spread of an epidemical form of TB but also to present certain criticisms regarding patient management (especially immigrants) regarding costs, hospitalization, and difficulty of reinstating the patient in the community. Further our data underscore the importance of prevalence of TB in bedridden, institutionalized patients.

Beyond ureterolithiasis: gamut of abnormalities affecting the ureter

Nephrolithiasis is the most common condition involving the ureters. However, various other entities can affect the ureters, albeit less frequently. Imaging plays a crucial role in diagnosis, management, and follow-up of ureteral pathology. In the past decade, computed tomography urography has replaced traditional methods of ureteral imaging due to its high spatial resolution, multiplanar imaging, and rapid acquisition time. More recently, magnetic resonance urography has also been explored in evaluating ureteral abnormalities. In this review, we briefly discuss current imaging techniques used in assessment of the ureters and present a diverse group of diseases affecting the ureters. We begin with primary and secondary ureteral malignancies, followed by uncommon infectious/inflammatory diseases that can involve the ureters including tuberculosis, xanthogranulomatous pyelonephritis, and graft-versus-host disease. We then discuss the imaging characteristics of endometriosis and retroperitoneal fibrosis as two important examples of pelvic and retroperitoneal processes that occasionally obstruct the ureters and present with clinical symptoms similar to that of renal stones. We end with a brief discussion of miscellaneous conditions that affect the ureters, including ureteral hemorrhage, ureteral intussusception, ureteral pseudodiverticulosis, Malacoplakia, and ureteritis cystica. Knowledge of these entities and their characteristic imaging manifestations along with patient's clinical presentation allows accurate diagnosis and timely patient management.

Primary cystic peritoneal masses and mimickers: spectrum of diseases with pathologic correlation

Cystic lesions within the peritoneum have been classified classically according to their lining on histology into four categories-endothelial, epithelial, mesothelial, and others (germ cell tumors, sex cord gonadal stromal tumors, cystic mesenchymal tumors, fibrous wall tumors, and infectious cystic peritoneal lesions). In this article, we will proceed to classify cystic peritoneal lesions focusing on the degree of radiological complexity into three categories-simple cystic, mildly complex, and cystic with solid component lesions. Many intra-abdominal collections within the peritoneal cavity such as abscess, seroma, biloma, urinoma, or lymphocele may mimic primary peritoneal cystic masses and need to be differentiated. Clinical history and imaging features may help differentiate intra-abdominal collections from primary peritoneal masses. Lymphangiomas are benign multilocular cystic masses that can virtually occur in any location within the abdomen and insinuate between structures. Ultrasound may help differentiate enteric duplication cysts from other mesenteric and omental cysts in the abdomen. Double-layered wall along the mesenteric side of bowel may suggest its diagnosis in the proper clinical setting. Characteristic imaging features of hydatid cysts are internal daughter cysts, floating membranes and matrix, peripheral calcifications, and collagenous pericyst. Non-pancreatic psuedocysts usually have a fibrotic thick wall and chylous content may lead to a fat-fluid level. Pseudomyxoma peritonei appears as loculated fluid collections in the peritoneal cavity, omentum, and mesentery and may scallop visceral surfaces. Many of the primary cystic peritoneal masses have specific imaging features which can help in accurate diagnosis and management of these entities. Knowledge of the imaging spectrum of cystic peritoneal masses is necessary to distinguish from other potential cystic abdominal mimicker masses.

Hepatic tuberculosis: a multimodality imaging review

OBJECTIVES

We aim to illustrate the multimodal imaging spectrum of hepatic involvement in tuberculosis (TB). Whilst disseminated tuberculosis on imaging typically manifests as multiple small nodular lesions scattered in the liver parenchyma, isolated hepatic tuberculosis remains a rare and intriguing entity.

METHODS

Indubitably, imaging is the mainstay for detection of tubercular hepatic lesions which display a broad spectrum of imaging manifestations on different modalities. While sonography and computed tomography (CT) findings have been described in some detail, there is a paucity of literature on magnetic resonance imaging (MRI) features. Due to a significant overlap with other commoner and similar appearing hepatic lesions, hepatic tuberculosis is often either misdiagnosed or labelled as indeterminate lesions. This article is a compendium of cases highlighting the spectrum of imaging patterns that can be encountered in patients with isolated primary hepatic tuberculosis as well as disseminated (secondary) disease. Rare patterns of primary disease such as tubercular cholangitis, hypervascular liver masses, and those with vascular complications are also illustrated and discussed.

CONCLUSIONS

Imaging plays a valuable role in the detection of tubercular hepatic lesions. Also, imaging can be helpful in their characterisation and for assessing associated complications.

TEACHING POINTS

• Hepatic TB has myriad imaging manifestations and is often confounded with neoplastic lesions. • Imaging patterns include miliary TB, macronodular TB, serohepatic TB and tubercular cholangitis. • Concurrent splenic, nodal or pulmonary involvements are helpful pointers towards the diagnosis. • Miliary calcifications along the bile ducts are characteristic of tubercular cholangitis. • Histological/microbiological confirmation is often necessary to confirm the diagnosis.

High-resolution CT findings of pulmonary Mycobacterium tuberculosis infection in renal transplant recipients

OBJECTIVE

Renal transplantation recipients are at increased risk of Mycobacterium tuberculosis infection because of immunosuppression. The aim of this study was to assess high-resolution CT (HRCT) findings in renal transplantation recipients diagnosed with pulmonary tuberculosis (TB).

METHODS

We reviewed HRCT findings from patients diagnosed with pulmonary TB, established by M. tuberculosis detection in bronchoalveolar lavage, sputum or biopsy sample. Two observers independently reviewed HRCT images and reached consensus decisions on the presence and distribution of: (i) miliary nodules, (ii) cavitation and centrilobular tree-in-bud nodules, (iii) ground-glass attenuation and consolidation, (iv) mediastinal lymph node enlargement and (v) pleural effusion.

RESULTS

The sample comprised 40 patients [26 males, 14 females; median age, 45 years (range, 12-69 years)]. The main HRCT pattern was miliary nodules (40%), followed by cavitation and centrilobular tree-in-bud nodules (22.5%), ground-glass attenuation and consolidation (15%), mediastinal lymph node enlargement (12.5%) and pleural effusion (10%). The distribution of findings in patients with miliary nodules was random. In patients with cavitation and centrilobular tree-in-bud nodules, 66.6% of abnormalities were found in the upper lobes. Pleural effusion was unilateral in 75% of cases. The overall mortality rate was 27.5%. This rate was 50% in patients with miliary nodules, and 72.6% of all deaths occurred in this group. Thus, mortality was increased significantly in patients with miliary nodules (p < 0.05).

CONCLUSION

The main HRCT finding in renal transplantation recipients with pulmonary TB was miliary nodules, followed by cavitation and centrilobular tree-in-bud nodules. Miliary nodules were associated with a worse prognosis in these patients.

ADVANCES IN KNOWLEDGE

We report the first series on HRCT findings of microbiologically confirmed pulmonary TB exclusively in renal transplantation recipients. The main HRCT finding was miliary nodules, and mortality was increased significantly in these patients.

Computed tomography detection of clinically unsuspected skeletal tuberculosis

OBJECTIVE

To report the frequency of clinically unsuspected axial skeletal tuberculosis (STB) and findings on computed tomography (CT).

MATERIALS AND METHODS

An evaluation of CT chest, abdomen, and pelvis of patients with tuberculosis was done. Bone window images were evaluated for skeletal involvement.

RESULTS

Of the 726 CT studies, 34 (4.7%) patients had skeletal involvement. Thoracic spine was the most commonly affected site with involvement of body in 58% cases. Intervertebral disc involvement, soft tissue abscess, and epidural extension were identified in 83%, 53%, and 39% of cases, respectively.

CONCLUSION

Evaluation of bone window on CT can detect axial STB.

Chest tuberculosis: Radiological review and imaging recommendations

Chest tuberculosis (CTB) is a widespread problem, especially in our country where it is one of the leading causes of mortality. The article reviews the imaging findings in CTB on various modalities. We also attempt to categorize the findings into those definitive for active TB, indeterminate for disease activity, and those indicating healed TB. Though various radiological modalities are widely used in evaluation of such patients, no imaging guidelines exist for the use of these modalities in diagnosis and follow-up. Consequently, imaging is not optimally utilized and patients are often unnecessarily subjected to repeated CT examinations, which is undesirable. Based on the available literature and our experience, we propose certain recommendations delineating the role of imaging in the diagnosis and follow-up of such patients. The authors recognize that this is an evolving field and there may be future revisions depending on emergence of new evidence.

Abdominal tuberculosis: a radiological review with emphasis on computed tomography and magnetic resonance imaging findings

Tuberculosis is a disease whose incidence has increased principally as a consequence of HIV infection and use of immunosuppressive drugs. The abdomen is the most common site of extrapulmonary tuberculosis. It may be confused with several different conditions such as inflammatory bowel disease, cancer and other infectious diseases. Delay in the diagnosis may result in significantly increased morbidity, and therefore an early recognition of the condition is essential for proper treatment. In the present essay, cases with confirmed diagnosis of abdominal tuberculosis were assessed by means of computed tomography and magnetic resonance imaging, demonstrating the involvement of different organs and systems, and presentations which frequently lead radiologists to a diagnostic dilemma. A brief literature review was focused on imaging findings and their respective prevalence.

Tuberculosis of the cervical spine

A 25-year-old male state-prisoner presented with altered mental status, right neck pain, and uncontrolled hypertension.

[The role of imaging in thoracic tuberculosis]

Tuberculosis is an infectious disease mostly due to Mycobacterium tuberculosis. It is frequent in developing countries and its incidence is rising in developed countries. Lungs are the most involved organs of the chest but other structures can be affected. Imaging is fundamental in the management of the disease. Confirmation of diagnosis can be made only by bacteriologic and/or histologic exams. The first approach of diagnosis is based on clinical symptoms and chest X-ray signs. Radiologic signs depend on patient's age, his immune status and his previous contact with M. tuberculosis. Conventional chest X-ray remains the first-line exam to realize. It can suggest the diagnosis on the appearance and location of the lesions. CT scan is recommended for the positive diagnosis in case of discrepancy between clinical and radiographic signs, as for the diagnosis of parenchymal, vascular, lymph nodes, pleural, parietal or mediastinal complications. It is also essential for the evaluation of parenchyma sequelae. MRI and PET-scan have limited indications. The purpose of this article is to illustrate different radiological forms of chest tuberculosis, its sequelae and complications and to highlight the role of each imaging technique in the patient's management.

Imaging in tuberculosis

Despite many advances in both diagnosis and treatment, tuberculosis still remains one of commonest causes of morbidity and mortality from any infectious cause in the world. Although the overall incidence and mortality rate for tuberculosis has decreased over the years, timely and accurate diagnosis of tuberculosis is essential for the health of the patient as well as the public. For the diagnosis of tuberculosis, a high degree of clinical suspicion is required, and this becomes much more important in high-risk populations. Tuberculosis may masquerade as any disease; therefore, tissue and microbiological assessment is sometimes important for establishing the diagnosis. However, in daily practice, the clinician and radiologist should be familiar with the imaging features of pulmonary and extrapulmonary tuberculosis, as well as manifestations of tuberculosis in immunocompromised patients. Imaging provides a very important role in the diagnosis and management of tuberculosis. Although chest X rays remain the basic imaging modality for pulmonary tuberculosis, computed tomography, magnetic resonance imaging, and nuclear medicine techniques, including positron emission tomography/computed tomography, are extremely helpful in the assessment of both pulmonary and extrapulmonary tuberculosis.

Atypical imaging features of tuberculous spondylitis: case report with literature review

Spinal tuberculosis in its typical form that shows destruction of two adjacent vertebral bodies and opposing end plates, destruction of the intervening intervertebral disc and a paravertebral or psoas abscess, is easily recognized and readily treated. Atypical tuberculous spondylitis without the above mentioned imaging features, although seen infrequently, has been well documented. We present, in this report, a case of atypical tuberculous spondylitis showing involvement of contiguous lower dorsal vertebral bodies and posterior elements with paravertebral and epidural abscess but with preserved intervertebral discs. The patient presented in advanced stage with progressive severe neurological symptoms due to spinal cord compression. Non-enhanced magnetic resonance imaging led to misdiagnosis of the lesion as a neoplastic process. It was followed by contrast enhanced computed tomography of the chest and abdomen that raised the possibility of an infectious process and, post-operatively, histopathological examination of the operative specimen confirmed tuberculosis. This case indicates the difficulty in differentiating atypical spinal tuberculosis from other diseases causing spinal cord compression. The different forms of atypical tuberculous spondylitis reported in the literature are reviewed. The role of the radiologist in tuberculous spondylitis is not only to recognize the imaging characteristics of the disease by best imaging modality, which is contrast enhanced magnetic resonance imaging, but also to be alert to the more atypical presentations to ensure early diagnosis and prompt treatment to prevent complications. However, when neither clinical examination nor magnetic resonance imaging findings are reliable in differentiating spinal infection from one another and from neoplasm, adequate biopsy, either imaging guided or surgical biopsy is essential for early diagnosis.

Altered CD8(+) T cell frequency and function in tuberculous lymphadenitis

CD8(+) T cells secreting Type1 and Type 17 cytokines and cytotoxic molecules play a major role in immunity and protection against pulmonary tuberculosis (PTB), although their role in tuberculous lymphadenitis (TBL) is not well known. To identify the distribution and function of CD8(+) T cells expressing Type1, Type 2 and Type 17 cytokines and cytotoxic molecules in TBL, we examined baseline and mycobacterial-antigen specific immune responses in the whole blood of individuals with PTB and compared them with TBL. TBL is characterized by elevated frequencies of baseline and mycobacterial-antigen stimulated CD8(+) T cells expressing Type 1 (IL-2 and TNFα) and Type 17 (IL-17A and IL-17F) cytokines in comparison to PTB individuals. In contrast, TBL individuals exhibited diminished frequency of CD8(+) T cells expressing perforin, granzyme B and CD107a. The blockade of IL-1R and IL-6R during antigenic stimulation resulted in significantly diminished frequencies of CD8(+) T cells expressing Type 1 and Type 17 cytokines in TBL. Therefore, our data suggest that TBL is characterized by an IL-1 and IL-6 dependent expansion of CD8(+) T cells expressing Type 1 and Type 17 cytokines as well as altered frequencies of cytotoxic molecules, reflecting an important association of these cells with the pathogenesis of TBL.

Central nervous system tuberculosis

Tuberculosis (TB) has shown a resurgence in nonendemic populations in recent years and accounts for 8 million deaths annually in the world. Central nervous system involvement is one of the most serious forms of this infection, acting as a prominent cause of morbidity and mortality in developing countries. The rising number of cases in developed countries is mostly attributed to factors such as the pandemic of acquired immunodeficiency syndrome and increased migration in a globalized world. Mycobacterium TB is responsible for almost all cases of tubercular infection in the central nervous system. It can manifest in a variety of forms as tuberculous meningitis, tuberculoma, and tubercular abscess. Spinal infection may result in spondylitis, arachnoiditis, and/or focal intramedullary tuberculomas. Timely diagnosis of central nervous system TB is paramount for the early institution of appropriate therapy, because delayed treatment is associated with severe morbidity and mortality. It is therefore important that physicians and radiologists understand the characteristic patterns, distribution, and imaging manifestations of TB in the central nervous system. Magnetic resonance imaging is considered the imaging modality of choice for the study of patients with suspected TB. Advanced imaging techniques including magnetic resonance perfusion and diffusion tensor imaging may be of value in the objective assessment of therapy and to guide the physician in the modulation of therapy in these patients.

Tuberculosis--the great mimicker

Tuberculosis is an immense health problem in the developing world, and it remains a health care challenge in the developed world. It can affect virtually any organ system in the body. Diagnosis of tuberculosis is often difficult. Many patients with tuberculosis present with nonspecific symptoms, negative purified protein derivative skin test result, and negative findings on culture specimens. Cross-sectional imaging with ultrasound, multidetector computed tomography, and magnetic resonance imaging plays an important role in the diagnosis of tuberculosis. Tuberculosis demonstrates a variety of radiologic features depending on the organ involved and can mimic a number of other disease entities. Cross-sectional imaging alone is insufficient in reaching a conclusive diagnosis. Tuberculosis is a great mimicker as its radiologic manifestations can simulate numerous other diseases across the body systems. However, recognition and understanding of the common and uncommon radiologic manifestations of tuberculosis should alert considering tuberculosis in the high-risk population and correct clinical setting to enable appropriate treatment.

Tuberculosis of the genitourinary system-Urinary tract tuberculosis: Renal tuberculosis-Part I

Tuberculosis (TB) remains a worldwide scourge and its incidence appears to be increasing due to various factors, such as the spread of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). The insidious onset and non-specific constitutional symptoms of genitourinary tuberculosis (GUTB) often lead to delayed diagnosis and rapid progression to a non-functioning kidney. Due to hematogenous dissemination of TB, there is a potential risk of involvement of the contralateral kidney too. Imaging plays an important role in the making of a timely diagnosis and in the planning of treatment, and thus helps to avoid complications such as renal failure. Imaging of GUTB still remains a challenge, mainly on account of the dearth of literature, especially related to the use of the newer modalities such as magnetic resonance imaging (MRI). This two-part article is a comprehensive review of the epidemiology, pathophysiology, and imaging findings in renal TB. Various imaging features of GUTB are outlined, from the pathognomonic lobar calcification on plain film, to finer early changes such as loss of calyceal sharpness and papillary necrosis on intravenous urography (IVU); to uneven caliectasis and urothelial thickening, in the absence of renal pelvic dilatation, as well as the hitherto unreported 'lobar caseation' on ultrasonography (USG). Well-known complications of GUTB such as sinus tracts, fistulae and amyloidosis are described, along with the relatively less well-known complications such as tuberculous interstitial nephritis (TIN), which may remain hidden because of its 'culture negative' nature and thus lead to renal failure. The second part of the article reviews the computed tomography (CT) and MRI features of GUTB and touches upon future imaging techniques along with imaging of TB in transplant recipients and in immunocompromised patients.

Tuberculosis of the genitourinary system-Urinary tract tuberculosis: Renal tuberculosis-Part II

This article reviews the computed tomography and magnetic resonance imaging (MRI) features of renal tuberculosis (TB), including TB in transplant recipients and immunocompromised patients. Multi detector computed tomography (MDCT) forms the mainstay of cross-sectional imaging in renal TB. It can easily identify calcification, renal scars, mass lesions, and urothelial thickening. The combination of uneven caliectasis, with urothelial thickening and lack of pelvic dilatation, can also be demonstrated on MDCT. MRI is a sensitive modality for demonstration of features of renal TB, including tissue edema, asymmetric perinephric fat stranding, and thickening of Gerota's fascia, all of which may be clues to focal pyelonephritis of tuberculous origin. Diffusion-weighted MR imaging with apparent diffusion coefficient (ADC) values may help in differentiating hydronephrosis from pyonephrosis. ADC values also have the potential to serve as a sensitive non-invasive biomarker of renal fibrosis. Immunocompromised patients are at increased risk of renal TB. In transplant patients, renal TB, including tuberculous interstitial nephritis, is an important cause of graft dysfunction. Renal TB in patients with HIV more often shows greater parenchymal affection, with poorly formed granulomas and relatively less frequent findings of caseation and stenosis. Atypical mycobacterial infections are also more common in immunocompromised patients.

The immune response in tuberculosis

There are 9 million cases of active tuberculosis reported annually; however, an estimated one-third of the world's population is infected with Mycobacterium tuberculosis and remains asymptomatic. Of these latent individuals, only 5-10% will develop active tuberculosis disease in their lifetime. CD4(+) T cells, as well as the cytokines IL-12, IFN-γ, and TNF, are critical in the control of Mycobacterium tuberculosis infection, but the host factors that determine why some individuals are protected from infection while others go on to develop disease are unclear. Genetic factors of the host and of the pathogen itself may be associated with an increased risk of patients developing active tuberculosis. This review aims to summarize what we know about the immune response in tuberculosis, in human disease, and in a range of experimental models, all of which are essential to advancing our mechanistic knowledge base of the host-pathogen interactions that influence disease outcome.

Imaging findings of Pott's disease

Tuberculosis (TB) continues to be an important public health problem in developed countries especially in deprived socioeconomic groups, older people, immunocompromised patients, drug-therapy resistant cases and the immigrant population. The spine is the most frequent location of musculoskeletal TB. The wide range of clinical presentations results in difficulties and delays in diagnosis. Advanced disease mimics other infections and malignancy. The diagnosis of spinal infections relies on three main factors: clinical symptoms, imaging and bacteriological culture. Advanced imaging such as Magnetic Resonance Imaging (MRI), Multidetector Computed Tomography (MDCT) and Fluor18-Deoxiglucose Positron Emission Tomography combined with CT (F-18 FDG PET-CT) demonstrate lesion extent, serve as guide for biopsy with aspiration for culture, assist surgery planning and contribute to follow-up. Diagnosis of TB cannot be established solely on the basis of clinical tests or imaging findings and biopsy may be required. Differential diagnosis between tuberculous and pyogenic spondylitis is of clinical importance, but may be difficult on the basis of radiological findings alone. Findings not pathognomonic but favoring tuberculous etiology include: slow progression of lesions with late preservation of disk space, involvement of several contiguous segments, large intraosseous and paraspinal abscesses containing calcifications, and body collapse with kyphotic deformity. In this essay the highlights of TB imaging are reviewed through published literature. In addition, we review retrospectively the radiological findings of 48 patients with tuberculous spondylitis treated from 1993 to 2010. There were 23 male and 25 female patients with a mean age of 53 years.

Phalangeal microgeodic disease: report of two cases and review of imaging

Phalangeal microgeodic disease is a rare disease that is frequently (though not invariably) related to cold exposure. In most cases, the clinical and radiographic findings of phalangeal microgeodic disease are sufficient to reach the diagnosis. The magnetic resonance imaging (MRI) findings of phalangeal microgeodic disease have been described in four cases in the English literature with two additional cases presented here. MRI allows a greater appreciation of affected bone areas and adds specificity to radiography with regard to diagnosis. In this sense, MRI is a helpful investigation in those cases of phalangeal microgeodic disease when doubt still exists following clinical and radiographic assessment.