Disseminated Tuberculosis Revealed by Conus Medullaris Tuberculoma

A 29-year-old man from Comoros presented with rapidly progressive paraplegia and sexual dysfunction. Magnetic resonance imaging (MRI) showed a contrast-enhanced conus medullaris lesion. Differential diagnoses included tumors, abscesses, and inflammatory diseases. Neurosurgery was delayed to complete examinations. Cerebral MRI showed three abscesses. Body computed tomography scan showed supracentimetric polyadenopathies, pulmonary nodules, prostatic lesion, and enhanced seminal vesicle, with hypermetabolism on positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-D-glucose scan. Histology of lymph node biopsy showed granulomatous infiltration without acid-fast bacilli, and positive polymerase chain reaction for Mycobacterium tuberculosis. Lymph node culture was positive after 2 months, urine culture after 3 weeks, but cerebrospinal fluid and sputum cultures were negative. A 1-year antituberculosis therapy was initiated, associated with corticosteroids because the patient developed tuberculosis-immune reconstitution syndrome, revealed by the recurrence of neurological symptoms. After 2 months the patient completely recovered and could run. MRI showed stability of the voluminous tuberculoma with decrease of medullary edema. Avoiding surgery in those cases may prevent iatrogenic neurological deterioration.

Unilateral solitary choroidal tuberculoma as the presenting sign in disseminated tuberculosis in an immunocompetent patient

INTRODUCTION

Tuberculosis can involve any organ in the body including ocular tissue of which the uveal tissue is most commonly infected. Choroidal involvement ranges from choroidal tubercles to granulomas. This is one of the few cases of a solitary choroidal granuloma with no other systemic symptoms in an immunocompetent child.

METHOD

A case report.

RESULTS

A 12-year-old female, presented with diminution of vision in the left eye for a month. The anterior segment of her left eye was normal. A fundus examination revealed an isolated orangish-yellow choroidal mass, 4 DD in size, involving the posterior pole with overlying subretinal exudation. CT scan of the thorax showed large pulmonary, cervical and pancreatic lymph nodes, along with lytic lesions of the thoracic vertebrae. Excision biopsy of the cervical lymph nodes showed caseating granulomas with no e/o malignancies on histopathology. The patient was started on anti-tubercular therapy. Six months after the treatment, the lesion had reduced in size and her vision had improved.

CONCLUSION

Isolated choroidal tuberculomas can be present in eyes with little associated ocular inflammation and no other symptoms of systemic tuberculosis. High suspicion, early diagnosis and rapid initiation of medication are important for the treatment of ocular and systemic tuberculosis.

MULTIMODAL IMAGING OF AN INTRARETINAL TUBERCULAR GRANULOMATOUS NEURORETINITIS

PURPOSE

To report a rare case of an intraretinal tuberculoma and associated neuroretinitis.

METHODS

The patient was evaluated with various imaging modalities including fundus photography, fluorescein angiography, magnetic resonance imaging, and optical coherence tomography; her extensive laboratory workup returned positive for tuberculosis.

RESULTS

After initially presenting with no light perception, 13 weeks of antitubercular therapy allowed for visual acuity recovery to 20/30.

CONCLUSION

We demonstrate the spectral domain optical coherence tomography characteristics of an intraretinal tuberculoma.

Giant cerebral tuberculoma mimicking a high-grade tumour in a child

We present an 11-year-old girl who manifested with unprovoked right-sided focal motor seizures. CT revealed a large lobulated hypodense mass in the left temporoparietal lobe, with perilesional oedema and postcontrast peripheral enhancement. Diagnostic uncertainty resulted in further neuroimaging, which included MRI with modalities including diffusion-weighted imaging, perfusion imaging, as well as spectroscopy. We discuss the radiological features of the lesion, which steered us in the direction of an infective cause. Definitive diagnosis was achieved by brain needle biopsy, which demonstrated necrotising granulomatous inflammation indicative of tuberculous infection on histology. In addition, GeneXpert yielded a positive result. We believe this unique case highlights the diagnostic dilemma clinicians face in differentiating ring-enhancing lesions on neuroimaging in tuberculosis-endemic regions. It also highlights the potential benefit of a brain needle biopsy (histology and GeneXpert) in cases of uncertainty.

FDG PET/CT in Disseminated Intracranial and Intramedullary Spinal Cord Tuberculomas

ABSTRACT

A 54-year-old woman was referred because of dizziness with fatigue for 2 months. MRI of the head and spinal cord revealed multiple ring or homogeneous enhancing nodules in the brain and spinal cord, concerning for metastases. FDG PET/CT showed multiple hypermetabolic nodules in the brain and spinal cord corresponding to the gadolinium-enhanced nodules and diffuse FDG uptake in the bilateral lower lobes of the lungs. Chest high-resolution CT showed diffuse, bilateral miliary opacities, most predominant in the lower lobes. The imaging findings and results of cerebrospinal fluid analysis were consistent with disseminated central nervous system tuberculomas with miliary pulmonary tuberculosis.

Thalidomide in the treatment of human immunodeficiency virus-negative tuberculous meningitis: A case report

INTRODUCTION

Tuberculous meningitis (TBM) is the most fatal type of tuberculosis in which corticosteroids are added with antitubercular therapy to prevent permanent brain damage. However, this treatment may produce paradoxical reactions. In such cases, thalidomide use might reduce central nervous system inflammation and improve the outcome. We present the case of a human immunodeficiency virus-negative patient with TBM who developed paradoxical reactions manifesting as multiple intracranial tuberculomas that were resistant to standard care (antitubercular drugs and corticosteroids) but responded well to thalidomide.

PATIENT'S MAIN CONCERN AND CLINICAL FINDINGS

The patient was a 40-year-old Chinese female, who was admitted with a 10-day history of headaches, night sweats, and cough. She was healthy before contracting the infection and had no history of contact with tuberculosis patients.

DIAGNOSES, INTERVENTION, AND OUTCOME

We diagnosed the patient with TBM complicated by the occurrence of pulmonary tuberculosis. Positive results were obtained from Gram and Ziehl-Neelsen staining of the sputum and acid-fast bacilli sputum culture. Standard treatment was initiated with antitubercular drugs (daily isoniazid, rifampicin, ethionamide, and pyrazinamide) and corticosteroids (dexamethasone). However, 3 months later the magnetic resonance imaging of the head revealed some new tuberculoma lesion. Thus, a specific therapy of antitubercular drugs and thalidomide was introduced. On completion of a 12-month course of antitubercular drugs with 2 months of thalidomide, the patient showed favorable outcomes without neurologic sequelae. Moreover, thalidomide appeared safe and well tolerated in the patient.

CONCLUSION

In addition to the specific anti-tubercular and adjuvant corticosteroid therapies for TBM, thalidomide can be used as a "salvage" antitubercular drug in cases that are unresponsive to corticosteroids.

Radiomics nomogram for preoperative differentiation of lung tuberculoma from adenocarcinoma in solitary pulmonary solid nodule

PURPOSE

To investigate the preoperative differential diagnostic performance of a radiomics nomogram in tuberculous granuloma (TBG) and lung adenocarcinoma (LAC) appearing as solitary pulmonary solid nodules (SPSNs).

METHOD

We retrospectively recruited 426 patients with SPSNs from two centers and assigned them to training (n = 123), internal validation (n = 121), and external validation cohorts (n = 182). A model of deep learning (DL) was built for tumor segmentation from routine computed tomography (CT) images and extraction of 3D radiomics features. We used the least absolute shrinkage and selection operator (LASSO) logistic regression to build a radiomics signature. A clinical model was developed with clinical factors, including age, gender, and CT-based subjective findings (eg, lesion size, lesion location, lesion margin, lobulated sharp, and spiculation sign). We constructed individualized radiomics nomograms incorporating the radiomics signature and clinical factors to validate the diagnostic ability.

RESULTS

Three factors - radiomics signature, age, and spiculation sign - were found to be independent predictors and were used to build the radiomics nomogram, which showed better diagnostic accuracy than any single model (all net reclassification improvement p < 0.05). The area under curve yielded was 0.9660 (95% confidence interval [CI], 0.9390-0.9931), 0.9342 (95% CI, 0.8944-0.9739), and 0.9064 (95% CI, 0.8639-0.9490) for the training, internal validation, and external validation cohorts, respectively. Decision curve analysis (DCA) and stratification analysis showed the nomogram has potential for generalizability.

CONCLUSION

The radiomics nomogram we developed can preoperatively distinguish between LAC and TBG in patient with a SPSN.

Miliary tuberculosis and choroidal tuberculoma in a three-month old baby girl: Diagnosis and follow-up of a case

A three-month old baby girl presented with fever of unknown origin and with signs of worsening of this episode. Funduscopy showed a solitary choroidal lesion in her left eye, as well as extraocular lesions suggesting disseminated tuberculosis. A favourable outcome was achieved after quadruple antibiotic course and cortisone therapy. Disseminated tuberculosis should be considered in cases of fever of unknown origin in children with an unsatisfactory evolution. Ocular examination is mandatory, due to the possible posterior uveitis signs that can help with early diagnosis and treatment of some diseases.

Concurrent Intramedullary and Intracranial Tuberculomass

Tuberculosis of the central nervous system (CNS) is well known. CNS involvement can occur in the form of tubercular meningitis (TBM), tuberculous vasculitis, tuberculoma and rarely brain abscess. Tubercular granulomas generally solitary and occur in the brain but they may be multiple and involve other areas such as spinal cord, epidural space and subdural space also. Tuberculoma in the spinal cord is rare. Co-occurrence of intracerebral and intramedullary spinal tuberculoma is extremely rare in children with only few cases reported till date. We are reporting one such case in children and review of literature.

Spinal intramedullary tuberculoma following pulmonary tuberculosis: A case report and literature review

RATIONALE

Spinal intramedullary tuberculoma (IMTB) is a rare disease that accounts for 1 to 2/100,000 patients with tuberculosis. We presented a case with pulmonary tuberculosis and concurrent IMTB at C3 to C5 level and reviewed the recent case series and discussed the diagnosis, treatment, and outcome.

PATIENT CONCERNS

A 33-year-old male had concurrent pulmonary TB and IMTB at the C3 to C5 level. He had quadriplegia (muscle power 0 at 4 limbs) and sensory loss below C5 level. He also had incontinence, anal tone loss, and paradoxical respiratory pattern.

DIAGNOSIS

Spinal magnetic resonance imaging (MRI) showed a 25 11mm intramedullary lesion at C3/C4 level. Under the impression of IMTB, he underwent surgery.

INTERVENTION

We performed C3 to C5 laminectomy and en bloc removal of the tumor. The patient kept receiving anti-TB medications after the surgery.

OUTCOME

His 4 limbs muscle power had improved but could not be liberated from the endotracheal tube, so tracheostomy was performed. Muscle power gradually increased to 3 points in his upper limbs and to 2 points in his lower limbs. Sensation in his 4 limbs gradually improved as well.

LESSONS

IMTB is a rare disease that should be treated with a combination of medication and surgery. For patients with prominent spinal cord compression and neurological symptoms, early operation to remove the tumor is necessary.

Application of dynamic CT to identify lung cancer, pulmonary tuberculosis, and pulmonary inflammatory pseudotumor

OBJECTIVE

To determine the value of dynamic enhanced computed tomography (CT) scanning in diagnosing lung cancer, pulmonary tuberculosis, and pulmonary inflammatory pseudotumor.

PATIENTS AND METHODS

We recruited 30 patients with pulmonary tuberculoma, 38 with lung cancer, and 16 with pulmonary inflammatory pseudotumor. All patients received CT scanning, dynamic enhanced CT scanning for 20, 30, 45, 60, 75, 90, and 120 s, and scanning for 3, 5, 8, 12, and 15 min. Then, we compared several parameters to determine which ones help with each diagnosis.

RESULTS

The time-density curve for patients with pulmonary tuberculoma was low and flat, and significantly different from lung cancer and inflammatory pseudotumor. The 15 min clearance value and the clearance value for lung cancer and inflammatory pseudotumor were significantly different. The type II time-density curve was common in lung cancer group, whereas the type III time-density curve was common in inflammatory pseudotumor.

CONCLUSIONS

Dynamic enhanced CT scanning demonstrated the ability to differentiate lung cancer, pulmonary tuberculosis, and pulmonary inflammatory pseudotumor, indicating its diagnostic value.

Pituitary tuberculoma with subsequent drug-resistant tuberculous lymphadenopathy: an uncommon presentation of a common disease

We report a case of pituitary tuberculosis which presented as a non-functioning pituitary macroadenoma, and subsequently developed multidrug-resistant tuberculous lymphadenopathy. Pituitary tuberculosis continues to be a rare presentation of tuberculosis, but incidence and prevalence are expected to grow with increasing numbers of multidrug-resistant tuberculosis. Isolated pituitary tuberculosis is rare. Tuberculosis should be considered in the differential diagnosis in evaluation of a sellar mass.

[Multiple meningeal and cerebral involvement revealing multifocal tuberculosis in an immunocompetent patient]

Tuberculosis is a public health problem in Morocco. Central nervous system involvement is nevertheless rare, occurring in the context of multifocal or miliary tuberculosis. However, it may be a mode of revelation even in an immunocompetent subject. We report the case of a 30-year old man with language disorder accompanied by significant impairment of general condition. Clinical examination showed Broca's motor aphasia, right-sided pyramidal syndrome and latero-cervical adenopathies. HIV serologic test was negative. Brain MRI showed lesions associating multiple intracranial tuberculomas and meningoencephalitis. Thoracic CT scan showed multiple pulmonary micronodules, cavity wall thickening and bronchiectasia of the right fowler and culmen. Lymph node biopsy revealed typical architecture of a TB granuloma. The diagnosis of multifocal tuberculosis was retained and the patient received anti-bacillary therapy associated with corticosteroid therapy with good clinico-radiological evolution. This study is peculiar due to the appearance and the seat of tuberculous lesions on brain imaging, the absence of immunodeficiency, a good evolution under treatment. It highlights the role of active and exhaustive assessment of associated extracerebral tuberculous infection in the case of cerebromeningeal lesion suggestive of tuberculosis.

Tumor or abnormality identification from magnetic resonance images using statistical region fusion based segmentation

In this article, a statistical fusion based segmentation technique is proposed to identify different abnormality in magnetic resonance images (MRI). The proposed scheme follows seed selection, region growing-merging and fusion of multiple image segments. In this process initially, an image is divided into a number of blocks and for each block we compute the phase component of the Fourier transform. The phase component of each block reflects the gray level variation among the block but contains a large correlation among them. Hence a singular value decomposition (SVD) technique is adhered to generate a singular value of each block. Then a thresholding procedure is applied on these singular values to identify edgy and smooth regions and some seed points are selected for segmentation. By considering each seed point we perform a binary segmentation of the complete MRI and hence with all seed points we get an equal number of binary images. A parcel based statistical fusion process is used to fuse all the binary images into multiple segments. Effectiveness of the proposed scheme is tested on identifying different abnormalities: prostatic carcinoma detection, tuberculous granulomas identification and intracranial neoplasm or brain tumor detection. The proposed technique is established by comparing its results against seven state-of-the-art techniques with six performance evaluation measures.

[A case of pleural tuberculoma with new pulmonary infiltration during anti-tuberculosis therapy]

A 61-year-old woman who had received treatment for tuberculous pleurisy for 2 months visited our outpatient clinic. Chest computed tomography (CT) showed the presence of a lens-shaped pleural mass with pulmonary infiltration, despite the decreased pleural effusion. Two weeks later, chest CT showed an increase in the size of the mass and expansion of the intrapulmonary shadow. Percutaneous CT-guided lung biopsy was performed, and histopathological examination revealed granulomatous inflammation without caseous necrosis or acid-fast bacilli. Sputum culture was negative for acid-fast bacilli. Anti-tuberculosis medication was continued, and the lesions eventually resolved. These lesions were diagnosed as pleural tuberculomas, and the intrapulmonary infiltration was considered to be due to the paradoxical worsening of the patient's condition.

Distinguishing small primary lung cancer from pulmonary tuberculoma using 64-slices multidetector CT

OBJECTIVE

To evaluate which CT findings help in distinguishing small primary lung cancer from tuberculoma.

MATERIAL AND METHOD

Forty-two chest CT studies with pathological diagnosis of primary lung cancer (n = 27) and tuberculoma (n = 15) were retrospectively reviewed by two radiologists who were blind to the pathological results. The CT findings of number; size, shape, border and location of the nodules, the presence or absence of satellite nodule, contrast enhancement, internal air bronchogram, internal calcification, internal cavitation, bronchovascular invasion, and bony destruction were evaluated.

RESULTS

About 96% of primary lung cancer had a solitary lesion compared to only 60% among tuberculoma (p < 0.05). The nodule size > 2-3 cm is more likely to be primary lung cancer compared with tuberculoma (p = 0.058). Both primary lung cancer and tuberculoma can occur in all lobes of both lungs but more frequently in the upper lobe, which has no statistically significant difference between these two groups. Tuberculoma seems to be round or polygonal shape and primary lung cancer is more likely to be lobulated shape. The smooth border nodule is found only in tuberculoma (27%) whereas 93% of primary lung cancer had spiculated border compared to 73% among tuberculoma (p < 0.05). Tuberculoma seems to have more satellite nodule than primary lung cancer (47% vs. 22%, p = 0.163). The enhancement of nodule and air bronchogram are significantly found in primary lung cancer compared with tuberculoma (p < 0.05). Tuberculoma seems to have dense central calcification and primary lung cancer seems to have punctate calcification (p < 0.05). Most of the primary lung cancer and tuberculoma do not have internal cavity. The presence of bronchovascular invasion was significantly found in primary lung cancer compared with tuberculoma (p < 0.05). No evidence of bony destruction was observed in both pulmonary tuberculoma and primary lung cancer groups.

CONCLUSION

The solitary lesion size < 3 cm in diameter with spiculated border contrast enhancement, presence of air bronchogram, punctate calcification and bronchovascular invasion are useful CT findings for diagnosis of primary lung cancer However, the lesions with inconclusive findings, tissue diagnosis may be necessary.

Pulmonary cryptococcosis and tuberculoma mimicking primary and metastatic lung cancer in 18F-FDG PET/CT

18F-fluorodeoxyglucose positron emission tomography (FDG-PET) has been widely incorporated in cancer management. Although, it has increased sensitivity, 18F-FDG is not tissue specific thus posing diagnostic dilemma in certain situations. False positivity in pulmonary nodules have been seen in various inflammatory, infective as well as post operative conditions while false negativity is common with adenomas, low grade lymphomas, bronchoalveolar carcinomas and carcinoid tumors. We present two cases of granulomatous diseases as pulmonary cryptococcosis and tuberculosis showing false positivity in a resected colorectal cancer patient and highlight the importance of recognition of this entity in an endemic region for granulomatous infections.

[Dynamic enhanced CT evaluation of solitary pulmonary nodules]

OBJECTIVE

To evaluate the value of dynamic enhanced-CT in differential diagnosis of solitary pulmonary nodules.

METHODS

Sixty-three solitary pulmonary nodules were evaluated by dynamic enhanced multi-slice CT. Images were obtained before and at 20 s, 30 s, 45 s, 60 s, 75 s, 90 s, 120 s, 180 s, 300 s, 540 s, 720 s, 900 s and 1200 s after the injection of contrast media. All lesion enhanced parameters and morphological features were recorded. The differences between benign and malignant nodules were analyzed. The diagnostic sensitivity and specificity of solitary pulmonary nodules were evaluated by receiver operator characteristic analysis.

RESULTS

CT enhancement value at 120 s [(29.5 ± 30.2) HU vs. (32.5 ± 14.7) HU, P = 0.023], washout at 20 min [(36.5 ± 24.6) HU vs. (15.6 ± 16.6) HU, P = 0.044], washout ratio at 20 min [(36.5 ± 24.6)% vs. (17.8 ± 14.5)%, P = 0.006], slope of washout at 20 min [(0.006 ± 0.005)%/s vs. (0.002 ± 0.0016)%/s, P = 0.001], type II (24/42 vs. 4/21, P = 0.004) and III (5/42 vs. 9/21, P = 0.005) curves were significantly different between benign and malignant nodules. Using the above mentioned parameters, the results of receiver operator characteristic analysis had a sensitivity of 64.3% and specificity of 84.2% for identification of malignant tumors. The morphological features including round-like, triangle-like, multi-angle, spiculation, light lobulation, the degree of edge (sharp, clear, blur), vessel convergence sign, vacuole sign, airing of bronchi, cut-off of the bronchi and depression of pleura were significantly different between benign and malignant nodules. The results of ROC analysis showed that the above mentioned morphological features had a sensitivity of 92.9% and specificity of 100% for differentiating malignant tumors from benign nodules. The results of ROC analysis showed that combination of morphological features and dynamic enhancement parameters had a sensitivity of 95.2% and specificity of 100% for identification of malignant tumors.

CONCLUSIONS

Dynamic enhanced CT images can evaluate morphological and enhancement features of solitary pulmonary nodules. Combination of morphological features and enhancement characteristics can improve the accuracy of diagnosis.

[The findings of fluorodeoxyglucose F18 imaging of coincidence single photon emission computed tomography in the lung tuberculoma]

OBJECTIVE

To assess the uptake of Fluorodeoxyglucose F18 ((18)F-FDG) coincidence single photon emission computed tomography (SPECT) imaging in lung tuberculoma.

METHODS

We enrolled 27 cases with 29 tuberculomas confirmed by clinical diagnosis. (18)F-FDG triple-head coincidence imaging was performed. The intensity of uptake was graded by visual method and the relationship of the uptake and attenuation was analyzed.

RESULTS

The uptake of (18)F-FDG was graded by visual method. There were 10 lesions (34.5%) in grade 0, including 7 (24.1%) lesions that showed focal lack of uptake and 3(10.3%) lesions showed normal uptake in tomograph imaging. Eleven lesions (37.9%) were graded as 1 - 2, 5 lesions (17.2%) as 3, and 3 lesions as 4. With grade 0 - 2 being regarded as benign, the false positive rate was 8/29. The intensity of (18)F-FDG uptake was divided into 3 groups (grade 0, grade 1 - 2, grade 3 - 4) and the intensity of uptake was compared with the attenuation of tuberculomas. There was a statistically significant difference among the 3 groups (χ(2) = 13.29 - 18.02, P < 0.01).

CONCLUSIONS

The intensity of (18)F-FDG uptake was influenced by the attenuation of the lesion. Most lung tuberculomas for (18)F-FDG coincidence imaging were of low uptake, and lower uptake than the background was a characteristic finding for tuberculoma. The combination with CT imaging was useful for the differentiation from malignant lesions.

[Dynamic contrast-enhanced CT patterns and pathologies of noncalcified pulmonary tuberculomas]

OBJECTIVE

To analyze characteristic CT enhancement patterns of noncalcified pulmonary tuberculomas and their pathological basis.

METHOD

Fifty-six patients with noncalcified pulmonary tuberculomas underwent surgical resection of the tuberculomas. Enhanced CT images of these tuberculomas were reviewed and analyzed in relation to the histological findings.

RESULTS

Of the 56 patients, 45 showed no enhancement in the tuberculomas, which were histologically characterized by central caseous necrosis and a poorly vascularized peripheral fibrotic zone. Eleven patients showed ring-like or eggshell enhancement, and the central low density region was histologically confirmed to be caused by caseous or liquefied necrosis, while the ring enhancement resulted pathologically from moderately or well vascularized peripheral fibrotic or granulomatous tissues.

CONCLUSIONS

Pulmonary tuberculomas consists mainly of caseous necrotic tissues characterized by no enhancement and ring or eggshell enhancement on dynamic contrast-enhanced CT.

[Clinical, pathological and radiological characteristics of 83 cases of pleural tuberculoma]

OBJECTIVE

To investigate the clinical, pathological and radiological characteristics of pleural tuberculoma, so as to improve the understanding of this disease.

METHODS

We retrospectively analyzed the clinical, laboratory, pathological and radiological data of 83 cases of pleural tuberculoma diagnosed by pathology and(or) bacteriology in Shanghai Pulmonary Hospital Affiliated to Tongji University.

RESULTS

In the recruited 83 cases, there were 50 males and 33 females, aged from 7 to 85 years old, with a mean age of 37.8 years. Cough, fever and chest pain were common symptoms, but no significant symptoms were seen in 25 patients (31.3%). Some patients had positive physical signs, such as dullness to percussion and low breath sound. Pulmonary tuberculosis was also present in 36 patients (43.3%) with pleural tuberculoma. A history of tuberculous pleurisy was elicited in 80 patients, among whom 45 (56.3%) received delayed antituberculous treatment and 42 (52.5%) received nonstandard treatment. Forty-eight cases (60.0%) did not receive corticosteroids. Fifty-nine cases underwent CT-guided percutaneous biopsy, while 24 underwent thoracoscopic surgery, and tuberculosis was pathologically confirmed in 62 (74.7%). Pathological profiles included granuloma, coagulation or caseation necrosis, lymphocyte infiltration, epithelioid cells, inflammatory cells, histiocytes and scar tissue. Fifteen (18.1%) specimens from percutaneous biopsy were anti-fast smear positive, while Mycobacterium tuberculosis was obtained by culture in 21 (25.3%) cases. Chest X-ray showed that solitary lesions were seen in 68 cases, multiple foci in 15. The lesions of 46 cases (55.4%) occupied the lower right lobes. Round-like shadows were the most common signs, which were present in 63 cases (75.9%). CT examination demonstrated homogeneous density in 20, heterogeneous density in 40, calcification in 9, central attenuation in 34, and peripheral intensification in 28 cases.

CONCLUSIONS

Pleural tuberculoma is an important sequelae of tuberculous pleurisy. Understanding its clinical, pathological and radiological characteristics is helpful for the differential diagnosis of pleural and lung diseases.

[Lung carcinoma in patient with previously excised tuberculoma]

The paper presents a case of right lung carcinoma diagnosed 7 years after tuberculoma excision performed in the same lung. The diagnosis was based on observing the increase of a non suspicious mass. It is unclear whether the cancer developed from metaplasia, or was a primary tumor, mistaken for a tuberculoma. Patient underwent a successful excision of the neoplastic mass, with 4-year recurrence free survival.

Radiologische Diagnostik der Lungentuberkulose

The radiologic knowledge of tuberculosis-associated lung disease is an essential tool in the clinical diagnosis of tuberculosis. Chest radiography is the primary imaging method, but the importance of CT is still increasing, as CT is more sensitive in the detection of cavitation, of hilar and mediastinal lymphadenopathie, of endobronchial spread and of complications in the course of the disease. In addition, CT has been proven as a valuable technique in the assessment of tuberculosis activity, especially in patients where M. tuberculosis has not been detected in the sputum or in patients with multidrug-resistant tuberculosis. Depending on the immune status of the patient, the morphologic spectrum of tuberculosis is quite variable. Early diagnosis of tuberculosis is essential to prevent further spread of the disease.

Unilateral asymptomatic adrenal tuberculoma: the role of percutaneous biopsy

We report the case of a 55-year-old male with a large left adrenal mass that conformed to the normal shape of the adrenal gland. Percutaneous biopsy revealed tuberculosis and, following anti-tuberculosis therapy, there was a >75% decrease in the size of the mass. In large tumefactions of the adrenal glands in which a normal adrenal contour is maintained, a percutaneous biopsy may obviate the need for major intervention.

[Diagnostic values of CT perfusion imaging in pulmonary masses]

BACKGROUND & OBJECTIVE

Blood flow patterns with CT perfusion imaging (CTPI) had been innovated to delineate abnormal hemodynamic lesions in the liver, brain, and kidney. This study was to evaluate the blood flow patterns of pulmonary masses by CTPI, and determine the value of CTPI in differential diagnosis among benign, malignant, and inflammatory masses.

METHODS

Fifty-two patients with previously diagnosed pulmonary masses (37 with malignant masses, 7 with benign masses, and 8 with inflammatory masses) underwent dynamic CTPI. Time-density curves (TDC) of artery, vein, and pulmonary masses as well as mass perfusion images and parameters including perfusion volume (PV), peak height (PH), mean transit time (MTT) and blood volume (BV) were obtained by Phlips CT-perfusion software.

RESULTS

The values of PV, PH, and BV were significantly higher in malignant masses and active inflammatory masses than in benign masses [(27.63+/-15.06) ml.min(-1).ml(-1) and (30.80+/-20.33) ml.min(-1).ml(-1) vs. (11.81+/-3.74) ml.min(-1).ml(-1), (28.46+/-12.07) Hu and (32.15+/-15.89) Hu vs. (10.41+/-3.77) Hu, (21.64+/-10.97) ml/100 g and (28.38+/-14.55) ml/100 g vs. (10.61+/-5.33) ml/100 g, P<0.01]. However, the differences of MTT among malignant, inflammatory, and benign masses were not significant [(28.39+/-21.66) s, (25.91+/-14.57) s, and (29.86+/-13.57) s, P=0.928]. No significant differences in the 4 parameters were found between malignant and inflammatory masses. When PV >20 ml.min(-1).ml(-1) and pH >15 Hu were set as a diagnostic threshold (excluded active inflammatory masses), the sensitivity, specificity, and accuracy were 91.9%, 100%, and 84.1%, respectively.

CONCLUSION

CT perfusion imaging provides quantitative information about blood flow patterns of pulmonary masses and is an applicable diagnostic method for differentiating pulmonary masses.

Differentiation between malignant and benign solitary pulmonary nodules with proton density weighted and ECG-gated magnetic resonance imaging

OBJECTIVE

To estimate performance of MRI for differentiating malignant from benign solitary pulmonary nodules (SPN) using morphological characteristics.

MATERIAL AND METHODS

MRI in 46 patients with SPN (mean diameter: 19 mm) was carried out on 1.0 Tesla scanner using ECG-gated, gradient echo sequence. Morphological signs of SPN were determined and compared with previously performed helical-CT, where final diagnosis served as reference with 52% frequency of malignancy. Furthermore, three observers evaluated all images.

RESULTS

Significant differences between the two groups were found for nodules shape, margin, inhomogeneity and the vessel-sign in MRI, nodules shape, margin, the vessel-sign, and presence of spicules in CT. Using these signs, AUC were 0.746 for MRI and 0.765 for CT. The mean sensitivity, specificity, and accuracy of observers for MRI/CT were 89%/95%, 42%/41%, 66%/68%, respectively.

CONCLUSIONS

Despite discrepancies in morphologic appearance, no significant difference of accuracy between MRI and CT was determined. Further investigations are necessary to demonstrate the clinical use in combination with functional parameters, establishing MRI as a comprehensive diagnostic modality for SPN.

Massive primary hepatic tuberculoma mimicking hepatocellular carcinoma in an immunocompetent host

Tuberculoma of the liver is rare in an immunocompetent individual. We report a 26-year-old man with upper abdominal pain, abnormal liver function, and raised inflammatory markers. Abdominal computed tomography (CT) scan revealed a mixed attenuation lesion measuring 6 x 5 cm occupying most of the left lobe of the liver. Subsequent histology and culture confirmed tuberculous abscess. Following antituberculous therapy, repeat CT scan revealed complete resolution of the initial findings. This case illustrates the diagnostic difficulties of hepatic tuberculosis (TB) and the importance of considering TB in patients with hepatic lesions.

Clinical and radiological features of symptomatic central nervous system tuberculomas

Tuberculomas may present with meningitis, may lead to meningitis, or may develop during the treatment of TBM. In this study, we report a series of 22 adult cases of symptomatic central nervous system tuberculomas, in eight of them tuberculomas were coexisting with TBM on admission and in 14 of them symptomatic tuberculomas developed during anti-tuberculosis therapy. We also aimed to compare the clinical, laboratory and outcome data of the 14 TBM patients that developed symptomatic tuberculomas, with the data of 41 TBM that did not, under the same treatment regimen. Most of the patients developed symptomatic tuberculomas in the first 6 weeks of treatment. Five patients developed late tuberculomas. The characteristics of tuberculomas and the role of corticosteroids in TBM patients are discussed. In conclusion, although steroids may diminish neurologic symptoms and improve outcome, tuberculomas may appear during the course of anti-tuberculosis and steroid treatment. Because of the possibility of late development of tuberculomas after initial successful treatment, all TBM patients need to be followed-up carefully for a long period.

Extrapulmonary small-cell carcinoma of the liver

A 53-year-old man was admitted to our hospital for the evaluation of a mass (13 x 10 cm) in the left lobe of the liver seen by imaging studies. On subsequent biopsy of the mass, the lesion was histologically diagnosed as malignant small round-cell tumor, consistent with metastatic small-cell carcinoma. Segment IV segmentectomy was performed. On pathological examination, the mass showed a yellowish-gray granular appearance with multifocal hemorrhage and necrosis. The phenotypes shown by immunohistochemistry revealed characteristic patterns of small-cell carcinoma (neuron-specific enolase [NSE]+, synaptophysin+, c-Kit+, cluster designation [CD]56+, epithelial membrane antigen [EMA]+, cytokeratin [CK]7-). High resolution-computed tomography (HRCT) revealed inactive pulmonary tuberculosis with small calcified tuberculoma in the right upper lobe. Sputum cytology was negative for malignancy. The postoperative course was uneventful, and platinum-based chemotherapy (cisplatin, etoposide) was initiated.

Hepatic tuberculomas. A case report

BACKGROUND

The liver is often involved secondarily by sytemic/extrahepatic vascular, metabolic, infectious, granulomatous, and malignant processes.

CASE REPORT

A 57-year old woman was admitted because of fatigue, malaise, night sweating and right upper abdominal quadrant pain. Physical findings revealed pale skin and mucosae, and hepatomegaly. Laboratory data showed normocytic, normochromic anemia and marked inflammatory syndrome. Real-time ultrasonography revealed one hypo-echogenic nodule, 25 mm in size, in the segment II of the liver, and three hypoechogenic nodules, 11-25 mm in diameter, in segments III and IV. Enlarged lymph nodes, 20-50 mm, were observed in the region of the pancreatic head. Histo-pathological examination of the liver and peritoneum biopsies evidenced granulomas with caseous necrosis and multinuclear Langhans' giant cells, indicating hepatic and peritoneal tuberculosis. The tuberculostatic chemotherapy (isoniazid 300 mg/24h; rifampycin 600 mg/24h and pyrazinamid 2000 mg/24h) was applied for 12 months. The patient responded well to the treatment, followed-up for 6-12 months.

CONCLUSION

In the differential diagnosis of focal liver lesions, pseudotumoral hepatic tuberculomas must be considered.

Lung infection in radiology: a summary of frequently depicted signs

For most clinicians, the definition of pneumonia is the presence of an abnormal opacity on chest X-ray and symptoms of respiratory infection such as cough, mucus production, fever. The radiological signs of infection of the lower bronchial tree can be covered by other lung diseases and these signs can mimic also other lung diseases. A chest X-ray is a first chosen step in radiological imaging in patients suspected of a pulmonary infection. Only when symptoms persist and/or become worse or when the radiological imaging is unclear, a spiral CT or HRCT of the chest will be taken in consideration. The role of medical imaging in pulmonary infection is to determine the presence, localisation and extent of the infection, to detect predisposal factors, to detect complications and in the follow-up of the infection. The radiological signs are often not very typical and they have also a limited value in predicting the causal organism. However there are some radiological signs, which are very suggestive in predicting the causal organism or in predicting the way of spread of the infection.

The infected liver: radiologic-pathologic correlation

Recent technologic advances have significantly enhanced the role of imaging in the detection, characterization, and management of infectious diseases involving the liver. In addition, imaging-guided percutaneous drainage has greatly improved the clinical treatment of patients with focal liver abscess. Infectious liver diseases can be accurately evaluated with ultrasonography (US), computed tomography (CT), and magnetic resonance (MR) imaging. Characteristic changes in US echogenicity, CT attenuation, or MR imaging signal intensity and typical enhancement patterns can contribute to the diagnosis of specific infectious diseases, including abscesses, parasitic diseases, fungal diseases, granulomatous diseases, viral hepatitis, and other less common infections. CT is particularly helpful in revealing the presence of calcifications and gas and in detailing the enhancement pattern. The multiplanar capability of MR imaging and its sensitivity to small differences in tissue composition increase its specificity for certain hepatic infections, including hydatid cyst and candidiasis. Radiologic findings may be sufficient to obviate aspiration or histologic examination, although in most instances they are less specific. Nevertheless, imaging findings taken together with appropriate clinical information may provide the most likely diagnosis, even if biopsy is sometimes required for confirmation.

[Linear tomographic scan filtration in the diagnosis of pulmonary globular and cavitary masses]

To enhance the informative value and validity of X-ray study in detecting destructive changes in infiltrates, tuberculomas, and blocked caverns, the authors treated their computed tomographic scans by linear spatial filtration and identification of equidensite fields. In this case, after treatment of an image, the phase of decay in the presence of filtrates was 14.2% and increased up to 36.1%. Cavernous processes are detectable when the scans of blocked caverns that are frequently taken as infiltrates are treated.

Coexistence of lung cancer and tuberculoma in the same lesion: demonstration by high resolution and contrast-enhanced dynamic CT

We report a case of coexistence of lung cancer and tuberculoma in the same lesion. The component parts of lung cancer and tuberculoma were identified on the basis of morphology on high-resolution CT as well as enhancement patterns and time-attenuation curves by contrast-enhanced dynamic CT.

Radiological manifestations of pulmonary tuberculosis

Pulmonary tuberculosis (TB) is a common worldwide lung infection. The radiological features show considerable variation, but in most cases they are characteristic enough to suggest the diagnosis. Classically, tuberculosis is divided into primary, common in childhood, and postprimary, usually presenting in adults. The most characteristic radiological feature in primary tuberculosis is lymphadenopathy. On enhanced CT, hilar and mediastinal nodes with a central hypodense area suggest the diagnosis. Cavitation is the hallmark of postprimary tuberculosis and appears in around half of patients. Patchy, poorly defined consolidation in the apical and posterior segments of the upper lobes, and in the superior segment of the lower lobe is also commonly observed. Several complications are associated with tuberculous infection, such as hematogenous dissemination (miliary tuberculosis) or extension to the pleura, resulting in pleural effusion. Late complications of tuberculosis comprise a heterogeneous group of processes including tuberculoma, bronchial stenosis bronchiectasis, broncholithiasis, aspergilloma, bronchoesophageal fistula and fibrosing mediastinitis. Radiology provides essential information for the management and follow up of these patients and is extremely valuable for monitoring complications.

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.