JK Amorosa Flip - Flop TB R1

Tuberculosis Primary –selflimiting Infection in patients previously not exposed to M tuberculosis (under age 5 in the past, now common in adults also) Postprimary-progressive Reactivation and reinfection

Chest X-ray is normal in TB in 50% 75% 15%

Manifestations of Primary TB are: Parenchymal disease Lymphadenopathy Miliary disease Pleural Effusion

Manifestations of Postprimary TB are: Upper lobe distribution Cavity Absence of adenopathy Airway involvement

Human disease causing mycobacteria are more likely: Slow growing Fast growing

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

Transmission Respiratory Desiccated bacilli remain airborne for long time – indoor close many months contact is necessary for transmission Laryngeal, transbronchial, cavitary disease produce most bacilli Ventillation reduces infectiousness

Lung Parenchymal involvement Primary

57 yo f with chronic cough

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Tuberculous mediastinal adenopathy

TB mediastinal adenopathy 19 f

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

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

TB Lymphadenopathy Central low attenuation Active disease Necrosis R hilar is most common

Pathogenesis TB bacilli in the body elicit acute inflammatory response – no symptoms Macrophages ingest bacilli and transport them to regional lymph nodes If not contained in local LNs, hematogenous dissemination of bacilli occurs and usually is contained, if not, then: miliary, meningeal, GU, MSK

Miliary

60 f smoker Langerhans Histiocytosis

Miliary Granulomatous, Inflammatory Disorders Bronchiocentric granulomatosis/lung Granulomatous lung disease Sarcoidosis Sarcoidosis, pulmonary Neoplastic Disorders Lymphomas Metastatic lung lymphatics/carcinoma Alveolar cell carcinoma, lung Carcinoma, thyroid, anaplastic Chickenpox pneumonia Tuberculosis, disseminated Blastomycosis, disseminated Coccidioidomycosis, disseminated Cryptococcosis Histoplasmosis, disseminated Melioidosis Blastomycosis Coccidioidomycosis, pulmonary, chronic Cryptococcosis, pulmonary Filariasis Fungal lung infection Histoplasmosis Histoplasmosis, pulmonary Parasitic lung infection Pulmonary larval infestation/nematodes Pulmonary larval migrans Schistosomiasis

Miliary cont Anatomic, Foreign Body, Structural Disorders Atelectasis, pulmonary Reference to Organ System Respiratory distress (newborn) syndrome Pulmonary fibrosis Pulmonary microlithiasis, alveolar Poisoning (Specific Agent) Silicosis Organ Poisoning (Intoxication) Pneumoconiosis Allergic, Collagen, Auto- Immune Disorders Pulmonary arteritis/vasculitis Rheumatoid lung disease Metabolic, Storage Disorders Histiocytosis, pulmonary Histiocytosis X Hereditary, Familial, Genetic Disorders Tuberous Sclerosis

Pleural Effusion TB

TB pleurisy Unilateral Exudative: high protein content, High WBC, low glucose Lymphocyte predominance Complications: B-P fistula, empyema 1/3 negative TB skin test

Pleural Effusion exudative Malignancy Pneumonia Tuberculosis Pulmonary embolism Fungal infection Pancreatic pseudocyst Intra-abdominal abscess After coronary artery bypass graft surgery Postcardiac injury syndrome Pericardial disease Meigs syndrome Ovarian hyperstimulation syndrome Rheumatoid pleuritis Lupus erythematosus Drug-induced pleural disease Asbestos pleural effusion Yellow nail syndrome Uremia Trapped lung Chylothorax Pseudochylothorax Acute respiratory distress syndrome Chronic pleural thickening Malignant mesothelioma

Pleural Effusion transudate: <3 g protein, low WBC, normal glucose Congestive heart failure (most common) Cirrhosis with hepatic hydrothorax Nephrotic syndrome Peritoneal dialysis/continuous ambulatory peritoneal dialysis Hypoproteinemia Glomerulonephritis Superior vena cava obstruction Fontan procedure Urinothorax CSF leak to the pleural space

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TB bacilli spread to meninges via: Inhalation to lymphnodes to bloodstrean to meninges Inhalation to lymphnodes to meninges Ingestion to peritoneum to CSF Intravenous introduction to meninges

TB bacilli spread to meninges via: Inhalation to lymphnodes to bloodstream to meninges Inhalation to lymphnodes to meninges Ingestion to peritoneum to CSF Intravenous introduction to meninges

Manifestations of Postprimary TB are: Upper lobe distribution Cavity Absence of adenopathy Airway involvement

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40 m with cough

Cavity vs cyst vs bulla Cavity: Gas-filled space in an area of lung consolidation or mass or nodule produced by the expulsion of a necrotic part of the lesion via the bronchial tree; wall thickness varies Cyst: wall thickness is 4 mm or less Bulla: wall thickness < 4 mm Often difficult to distinguish the 3 Clin Microbiol Rev. 2008 April; 21(2): 305–333

Cavity - causes Abscess TB Ischemic necrosis (infarct) PCP Fungal process Malignancy Wegener’s granulomatosis Sarcoidosis – rare COP (Cryptogenic Organizing Pneumonia -rare

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Cavity T bacilli grow in cavities which communicate with bronchi and spread infection MDR bacilli grow in cavities exclusively Hydrolytic enzymes break down lung Tuberculosis Volume 89, Issue 4 , Pages 243- 247, July 2009

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Cryptococcus

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Aspergillus AML

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Primary lung ca with mets

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Bronchopneumonia

 Invasive bronchiolar aspergillosis in a patient who underwent bone marrow transplantation RadioGraphics, http://pubs.rsna.org/doi/abs/10.1148/rg.253045115 Aspergillus

Five causes of tree-in-bud are: Bronchopneumonia Fungal Viral ABPA TB

Tree –in-bud pattern Rossi, SE et al: May/June 2005 Radiographics 25,3

Cocaine 23 m

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TB in HIV

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

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76 m emphysematous pericarditis, streptococcal

TB - healing Lung destruction: bronchiectasis Bronchial stenosis

LUL atelectasis, bronchiectasis TB

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Radical mastectomy & rad Rx

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The History of Tuberculosis The Hebrew word for phthisis or consumption (schachepheth) means to waste away occurs twice in the Bible: Leviticus 26:16 I, in turn, will do this to you: I will appoint over you a sudden terror, consumption and fever that will waste away the eyes and cause the soul to pine away; also you will sow your seed uselessly, for your enemies will eat it up. Deuteronomy 28:22 The Lord will smite you with consumption and with fever and with inflammation and with fiery heat and with the sword and with blight and with mildew and they will pursue you until you perish.

The History of Tuberculosis By 1650 consumption was the leading cause of mortality and became a reference in some of Shakespeare's plays- one of the consumptive lovers, in "Much A Do About Nothing" , as well as scrofula in "Macbeth"

The History of Tuberculosis Early attempts at treatment can be found throughout history Greeks believed cutting off cool air eventuated in a burning up of the tissues Romans put importance of diet Hebrews control disease from diet to the destruction of clothing Early "cures" from physicians Warm sea air Milk from pregnant women Seaweed placed under the pillow Cold baths Deep breathing

The History of Tuberculosis The first breakthrough came when German bacteriologist named Robert Koch isolated the infectious agent known as tuberculosis bacteria or tubercle bacilli in 1882. He was later awarded the Nobel Prize for physiology or medicine in 1905

The History of Tuberculosis The first sanatorium opened in 1854 in Gorbersdorf, Germany. Sick patients were given wholesome food and plenty of fresh air. This became the modern way to fight the disease. The sanatoriums provided medical care for almost 100 years and became one of the most remarkable and unique periods of medical care in history. By 1889 in the USA the National Tuberculosis Association fully realized that TB was distinctly preventable and not directly inherited No real progress was made until new antibiotics were used between 1945-1960 It has taken almost three thousand years to understand the full nature of Tuberculosis

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References Joshua Burrill, Christopher J. Williams, Gillian Bain, Gabriel Conder, Andrew L. Hine, Rakesh R. Misra RadioGraphics, 2007, Vol.27: 1255-1273, 10.1148/rg.275065176 Santiago Enrique Rossi, Tomas Franquet, Mariano Volpacchio, Ana Giménez, Gabriel Aguilar RadioGraphics, 2005, Vol.25: 789-801 JR Cohen, JK Amorosa, PR Smith –The air-fluid level in cavitary pulmonary TB, Radiology, 1978 - radiology JK Amorosa, PR Smith, JR Cohen, C Ramsey… - …, Tuberculous mediastinal lymphadenitis in the adult 1978 – radiology Medscape Tuberculosis (TB), a multisystemic disease ….JK Amorosa….

Famous people who had TB Gaius Valerius Catullus (ca. 84 BC – ca. 54 BC), Roman poet Bronte sisters Elizabeth Barrett Browning Albert Camus Anton Chekhov Maxim Gorky Franz Kafka Eugene O'Neill Eugene O'Neill Molière Robert Louis Stevenson Dylan Thomas Voltaire Paul Gauguin Amedeo Modigliani Frédéric Chopin Niccolò Paganini Igor Stravinsky Cardinal Richelieu Simón Bolívar

Opera, Theatre, Novels - TB Puccini: La boheme Verdi: La Traviata Thomas Mann: The Magic Mountain Victor Hugo: Les Miserables Upton Sinclair: The Jungle Johnny Nolan: A Tree Grows in Brooklyn W.Somerset Maugham: Sanatorium Frank McCourt: Angela’s Ashes

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am 9-13-11

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