Tuberculous adenopathies

Anatomic recall

Most frequent localisations of TB adenopathies

Hilar adenopathies: -Opacities with convexe external edge - opacities overlapping normal vascular opacities

Bilateral adenopathies

Hilar adenopathy Normal hilus

The tuberculous adenopathies are: Sometimes unilateral (latero-tracheal ) Most often bilateral and asymetric Sometimes compressive, especially in children Some lesions are possible inside the bronchi: compression or fistula Adenopathies are frequent in cases of AIDS: they are often bulky and associated with other pulmonary lesions or extra-pulmonary TB AFB are most often negative in sputum, except in cases of pulmonary lesions (pneumonia, cavern..) associated with adenopathies

The most important differential diagnosis are: Metastatic adenopathies of bronchial cancer Lymphoma and hodgkin disease Sarcoïdosis (incidence in developping countries ?) Do not forget 2 radiological differential diagnosis: - overlap sign of the hilus (anterior or posterior) - vascular hypertrophy (convergence sign of the hilus)

Don’t forget: For a good analysis of the mediastinum, it is necessary to have a good quality chest x-ray: Strictly front view Complete inspiration Patient standing up, postero-anterior incidence

Bilateral tb adenopathies

Right latero-tracheal opacity: Tuberculous adenopathies Normal CXR Right latero-tracheal opacity: Tuberculous adenopathies

Man, 20 years old , Asymptomatic, Good condition, HIV - systematic chest radio. AFB negative in sputum

Right latero-tracheal and precarena space adenopathies. AFB-, Diagnosis made by mediastinoscopy: epithelioid and gigantocellular granuloma. Culture +

Young woman, 22 years old. Weight loss and cough Young woman, 22 years old. Weight loss and cough. Contact with a tuberculous case 6 monthes ago. Positive skin test with phlyctena Normal chest x-ray

African woman, 27 years old. Left cervical adenopathy Left latero-aortic adenopathies in superior mediastinum

Puncture of the cervical adenopathy: Pus with AFB+

Tuberculous right hilar adenopathy

Widening of the mediastinum: adenopathies of superior and middle mediastinum Normal chest x-ray

is usefull for diagnosis of adenopaties / In subcarena and inter tracheo bronchial areas (red arrows) , lateral view is usefull for diagnosis of adenopaties

Rx normale Lateral view is very usefull for diagnosis of mediastnum adenopathies in sub carena and inter tracheo bronchial areas

Notice mediastinum enlargment Chest x ray: bilateral adenpathies, nearly symetric. It could be TB adenopathies. In this case it is sarcoïdosis Right hilar adenopathy. Is there mediastinum associated adenopathies? Notice mediastinum enlargment

Normal lateral view Left side, previous case : hilar and mediastinum adenopathies.. On the right side normal lateral view. Lateral view is useful to confirm hilar and mediastinum adenopathies (red arrow) in the carena area. Notice partial atelectasis of the middle lobe (yellow arrow).

Bulky left hilar adenopathy. Associated mediastinum adenopathies are well visible on the lateral view

Normal lateral view

Young child, one year old: TB primary-infection Notice the bilateral adenopathies with inferior lobe atelectasis (left inferior bronchus compressed by adenopathy )

Tuberculous bulky adenopathies. AIDS context Tuberculous bulky adenopathies. AIDS context. Infiltration into the surrounding lung tissu

Tuberculous adenopathies with endo-bronchial fistula (endoscopic view)

Fistula in the right para-cardiac bronchus Fistulas coming from TB adenopathies

Tuberculosis / HIV +

Tuberculosis with mediastinal adenopathies and pneumonia in a patient with AIDS. AFB++ in sputum

is very indicative of Tuberculosis, and often, HIV context. The association of unilateral or bilateral pneumonia with mediastinal adenopathies is very indicative of Tuberculosis, and often, HIV context.

Normal chest radiography Adenopathy in left aorto-pulmonary space( and widening of superior mediatinum due to TB adenopathies) Normal chest radiography

Node calcifications: sequela of primary infection

Left hilar calcification: sequela of a TB primary infection

However, the mediastinal adenopathies are not always tuberculous…

Male, poor health condition, smoker, dyspnea Right inferior lobe cancer and metastatic adenopathies (laterotracheal space). Notice the associated emphysema.

Small cell carcinoma with bulky mediastinal adenopathies

Evolution after 6 cycles of chemotherapy

Bronchial cancer with superior vena cava syndrome (No superior vena cava syndrome in tubercular adenopathies)

Bronchial cancer with right hilar metastatic adenopathy

Man, 60 years old, weight loss and asthenia, cough with hemoptoic sputum. AFB-

Right superior bronchus Bronchial cancer! Right superior bronchus Spur infiltrated by the cancer normal bronchus

Lymphoma (hodgkin disease)

Sarcoidosis

Trap: mediastinum enlargement in an older woman with cyphoscoliosis

Differential diagnosis: vascular bulky hilus: Convergence sign of the hilus

Differential diagnosis: posterior overlap sign

Differential diagnosis: Posterior overlap sign (2)

Differential diagnosis: anterior overlap

Differential diagnosis: Anterior overlap sign (courtesy of Dr. Bellamy)

anterior overlap