1. Nodules and infiltrates

2. Pulmonary TB, main radiological aspects and differential diagnoses
Common TB in adults
Miliary
Serous membrane TB
Node TB
Pleural TB
Sequela
Tuberculosis and AIDS: AIDS modifies the clinical and radiological course of TB. Differential diagnoses are many. It is important to know them, in order to chose the adapted treatment

3. Common adult TB Basic radiological images:
Nodule
Infiltrate
Cavity
Tuberculous pneumonia

4. These elements are very often associated in the same patient
- These images can follow in time :
nodule  macronodule  excavated nodule  caverna
These elements are very often associated in the same patient
The association of several images of different ages and different aspects is very indicative for TB
Round picture with a diameter > 3 cm, non- excavated, is very rarely TB

5. Nodule: isolated or grouped in the superior lobes or in the apical segment of the inferior lobes. Infiltrate: group of various-sized nodules with unequal dimensions. The excavation is not always visible on the chest x-ray. If the excavation exists, the bacterial analysis of the sputum is generally positive: TPM+. (The TDM could show the excavation even if it is not visible on the chest x-ray)

6. .
For the supra clavicles area analysis, the chest x-ray with antero posterior incidence is usefull.

7. Probable TB infiltrate
Tuberculine skin test 5U = 15mm Good performance status, FS = 0, Physical signs = 0 Inflammatory S = 0 Expectoration: AFB - Cultures -
Probable TB infiltrate

8. TB infiltrate
TPM-

9. Probable TB infiltrate
Non productive cough Good performance status,
FS = 0,
Physical signs = 0 Inflammatory S = 0 Expectoration: AFB - Cultures -
Probable TB infiltrate

10. Cough, chronic fever. Hemoptoïc sputum. AFB neg. in sputum

12. Man, 55 years old
Antecedent of pleural effusion
Fever, cough, weight loss
Hemoptoic sputum
Chest x-ray: left pleural sequela, retractile
Right nodular infiltrate. AFB+ in sputum

13. cavited nodules >>> AFB+

14. Woman 48years old. Close contact with patient AFB+ in sputum.
PCR positive in sputum for mycobacterium tuberculosis in sputum

15. San view of the previous case : microcavity in the nodule

16. Man ,heavy smoker, cough, dyspnea and worsening condition
AFB + in sputum

17. cavited nodule
Tubercular pneumonia

18. AFB positive in sputums
cavity.
AFB positive in sputums
Bronchoscopic view: tubercular endobronchic lesion
With tubercular granulomas
In the biopsy samplings

19. Small TB infiltrate TPM-

20. Bilateral nodules. AFB- in sputum. BK Cultures negative

22. nodule  macronodule  cavited nodule  cavity In this case, association of an infiltrate in the right superior lobe and cavity in the left inferior lobe is highly indicative of TB

23. TB nodules and infiltrates are most often isolated or grouped in the superior lobes or in the apical segment of the inferior lobes.
- They are difficult to see in the retro-clavicle area
- These lesions are often AFB- because non-excavated, no communication with bronchi and pauci-bacillar
- The association of lesions with different seniority (nodules, cavity, sequelas) or with extra pulmonary localisations is very indicative of TB.

24. Nodules and infiltrates are often AFB- in sputum
Nodules and infiltrates are often AFB- in sputum. So the risk of contamination is low (but not zero).
AFB is negative in sputum, but sometimes cultures are positive.
Even if the risk of contamination is low, it is important to detect these patients and treat them because these patients can develop severe and contaminent TB

25. Cough, fever, weight loss, asthenia
Male, 30 years old
Cough, fever, weight loss, asthenia
T left upper lobe infiltrate not noticed
by the physician (not good quality
of CXR)
Amoxicillin treatment…

26. 4 months later: left superior excavation with important infiltrate,
AFB +++

27. Nodules and Infiltrate -Summary
Sometimes difficult to see (small, retroclavicular areas)
Sometimes AFB+ if cavity (not always visible on CXR)
Most often no cavitation and AFB-
They are true TB on the beginning and must be treated by anti TB
They are true TPM -
Physicians of national TB program hesitate to treat these patients but they treat a lot of “TPM – who are not real TB (bronchial cancer, inactive sequella bronchectasis, aspergilloma…)
It is absolutely necessary to improve quality of CXR interpretation
Especially for physicians in charge of TB program.