The Imaging of Tuberculosis: With Epidemiological, Pathological, and Clinical Correlation

154 Pages·2012·14.402 MB·English

by  P.E.S. Palmer

P.E.S. Palmer
The Imaging
of Tuberculosis
With Epidemiological,
Pathological, and Clinical Correlation
With contributions byS. J. Wambani and P. Reeve
Consultants: M. M. Reeder, D. H. Connor,and I. J. Dunn
With 104Figuresin514SeparateIllustrations
Springer
P.E.S. PALMER, MD, FRCP, FRCR
Em. Professor of Radiology
821 Miller Drive
Davis, CA 95616
USA
Originally published in P.E.S. Palmer, M.M. Reeder (2001) The Imaging of Tropical Diseases, VOL. 1,
ISBN 978-3-642-62610-4
Library of Congress Cataloging-in-Publication Data
Palmer, Philip E. S.
The imaging of tuberculosis : with epidemiological. pathological. and clinical
correlation I P.E.S. Palmer. with contributions by S.J. Wambani and P. Reeve ;
consultants. M.M. Reeder, D. H. Connor. and I.J. Dunn.
p.;cm.
Includes bibliographical references and index.
ISBN 978-3-642-62610-4 ISBN 978-3-642-56282-2 (eBook)
DOI 10.1007/978-3-642-56282-2
1. Tuberculosis--Imaging. 2.T uberculosis--Epidemiology. 1. Wambani. S. J. II. Reeve.
P. (Paul). 1957- III. Title
[DNLM: 1. Diagnostic Imaging--methods. 2. Tuberculosis--diagnosis. 3.
Tuberculosis--epidemiology. 4. Tuberculosis--pathology. WF 220 PI75i 2001]
RC311.2 .P35 2001
616.9·950754--dc21 2001040050
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Introduction
Thisbookwillserveasareminderofthemanydifferentpatternsoftuberculosis.
Onceagainamajorpublichealththreatallovertheworld,tuberculosiscanbea
chronicandalmostbenigninfectionoranacutelife-threateningtragedy.Itmay
respondtotreatmentandleavenoafter-effects;oritmayberesistanttoanycure,
withdisastrous results for the individualandoften thefamily orcommunityas
well.
Although originallywritten as achapterin The ImagingofTropicalDiseases
(P.E.S.Palmerand M.M.Reeder,Springer,Heidelberg,2001),the clinicalcourse
andtheimagesdescribedarenolongerfoundonlyinthetropicsorinthedevel
opingworld.Thewaysinwhichtuberculosisaffectseachindividualareareflec
tion ofthe immune statusofthepatientandwhetherithasbeencompromised
byAIDS,malnutrition,thecontinuousonslaughtoftoomanyparasitesorother
infections,chemotherapy,radiation oranyothercauseofimmunosuppression.
Addedtothismustbethesensitivityorresistanceoftheparticularbacteriumto
the drugswhich areavailable andhowwellthepatientcomplieswith thetreat
ment regimen. Interpreting the patient's clinical status and the images is chal
lenging: an acute fulminating tuberculous infection does not mean that the
patientisHIV+ve,afavourable earlyresponse to treatmentdoes notmean that
thepatientwillbecured.
As a result ofthese differences in patients and organisms,tuberculosis pre
sentsawidespectrumofimages.Anypartofthebodymaybeinfected,literally
from theskininwards.Notissueororganisexempt.Theinfectionisoftenmul
ticentricand canmimicalmostanyotherdisease.Unfortunately,itis notpossi
bleto decidefrom oneortwo imageswhetherthe infectionisactive,healingor
cured,norcanimagingimmediatelyindicatedrugresistanceorrecogniseanyof
the manyvariantsoftheMycobacterium tuberculosis.
Thereisareal needfor closecooperationbetweenclinicansand radiologists
in the management oftuberculosis,aneedwhich maybe lost in the numerous
notes and images which are the records ofanypatientwith this infection.The
main source of error for all who interpret the images is failing to remember
tuberculosis as the possible cause of almost any abnormal patterns, however
much the clinicalillness maysuggest some otherorigin.Mostofthe images in
this book come from the tropics and the developing world,but similar images
may be seen wherever the patient lives. Some might be better technically,
because imaging equipment improves all the time. But their message is clear.
No-oneofanyageisexemptfrom tuberculosisandthis mustnotbeforgotten.
Davis P.E.S.PALMER

ListofContributorsandConsultants
DANIELH.CONNOR,MD
11351 MorningGateDrive
Rockville,MD20852
USA
IANJ.DUNN,PHD,MD FRCP(C)
ClinicalAssistantProfessor
UniversityofBritishColumbia
BurnabyGeneralHospital
3935KincaidStreet
Burnaby,BCV5G 2X6
Canada
MAURICEM.REEDER,MD
12646TravilahRoad
Potomac,MD20854
USA
PAULREEVE,MB,MRCP(U.K.)
SpecialistPhysican
HealthWaikatoLtd.,TaumarunuiHospital
PrivateBag1002
Taumarunui
NewZealand
(previouslyinMalawiandVanuatu)
S.J.WAMBANI,MB,M.Med.(R)
DepartmentofDiagnosticRadiology
CollegeofHealthSciences,FacultyofMedicine
KenyattaNationalHospital,UniversityofNairobi
P.O.Box 19676
Nairobi
Kenya
Contents
Synonyms.......................................................... 2
Definition.......................................................... 2
GeographicDistribution ............................................. 2
EpidemiologyandPathology.......................................... 3
LaboratoryDiagnosis. ............................................... 4
ClinicalCharacteristics............................................... 5
TuberculosisoftheRespiratoryTract. ................................. 5
TuberculosisoftheUpperRespiratoryTract 5
Primary(Nonimmune)Tuberculosis................................ 6
LobarPneumonia ................................................ 8
Bronchopneumonia 13
HilarandMediastinalLymphadenopathy. ........................... 15
TheDestroyedLung .............................................. 19
PleuralandPericardialEffusions. .................................. 24
MiliaryTuberculosis.............................................. 30
Silicosis......................................................... 33
ImmuneTuberculosis(AlsoknownasSecondary,Hyperergic,
Reactivation,orAdultTuberculosis) 34
ClinicalCharacteristics 35
ImagingDiagnosis ............................................... 35
Tuberculoma .................................................... 43
IsoniazidCysts. .................................................. 45
ChronicPleuralDisease........................................... 45
ChestWall....................................................... 45
CongenitalTuberculosis 45
Immunizationwith BCG .......................................... 45
PPDConversion.................................................. 47
Clubbing 47
TheOtherMycobacterioses. .......................................... 48
TuberculosisoftheAlimentaryTract .................................. 49
TuberculosisoftheEsophagus ..................................... 49
TuberculosisoftheStomach....................................... 50
TuberculosisoftheDuodenumandSmallIntestine. .................. 51
TuberculosisoftheCecum
(HyperplasticTuberculosisoftheGlTract) .......................... 58
TuberculosisoftheLargeIntestine 61
TuberculosisoftheRectum........................................ 65
Enteroliths ...................................................... 67
TuberculosisofthePeritoneumandAbdominalLymphNodes. .......... 67
TuberculousPeritonitis 67
TuberculousAbdominalLymphNodes............................. 69
ThberculosisoftheLiver,Spleen,andPancreas......................... 71
TuberculosisoftheUrinaryTract..................................... 75
KidneysandUreters. ............................................ 75
Bladder........................................................ 81
AdrenalTuberculosis ............................................ 81
GenitalTuberculosis............................................. 81
TuberculosisofBone ............................................... 84
TuberculosisoftheSpine............................................ 85
Synonyms...................................................... 85
ClinicalCharacteristics........................................... 85
Clinico-pathological-radiologicalCorrelation:
SpinalTuberculosis.............................................. 85
ImagingofSpinalTuberculosis....................................... 86
VertebralBody.................................................. 86
ParavertebralAbscess............................................ 94
Scanning,Paraplegia,andMyelography ............................ 101
DifferentialDiagnosis 104
TuberculosisofBonesandJoints(Nonspinal) .......................... 104
TuberculousArthritis............................................ 104
SynovialTuberculosis............................................ 107
OsteoarticularTuberculosis. ...................................... 107
TuberculosisofBones(Nonspinal). ................................ 110
DifferentialDiagnosis............................................ 120
TuberculosisoftheCentralNervousSystem ......................•.... 125
Tuberculousmeningitis.......................................... 128
Tuberculomas. .................................................. 128
TuberculosisInvolvingOtherSites ................................... 134
TuberculousLymphadenopathy. .................................. 134
TuberculosisoftheBreast ........................................ 134
TuberculosisoftheParotidGland ................................. 134
OcularTuberculosis ............................................. 135
Bibliography 137
SubjectIndex...................................................... 143

I see alilyon the brow
With anguish moist and fever dew
And on thy cheek a fading rose
Fast withereth too.
La Belle Dame San Merci
John Keats, 1795-1821
There was a time in the eighteenth and nineteenth But the bacillus which had undoubtedly affected his
centuries when tuberculosis was a fashionable afflic tory by killing so many in their youth may well
tion. All the best poets, musicians, and writers, not have the same power once again. In 1993 the World
to mention politicians and heroines of operas, suf Health Organization (WHO) declared that tuber
fered from consumption and died either beautifully culosis was a global emergency and estimated that
or in interesting ways. Ofcourse, the unknown poor it would kill 30 million people in the next decade.
simply died, often unpleasantly, ofthe white plague. In 1996 it was the leading cause of deaths due to
There were many names for this common disease, micro-organisms: there are eight million new cases
which has been recognized and described for centu every year. One-third of the world's population
ries: the earliest definitive record is of pulmonary (1.7 billion) have been infected at some time and
and spinal tuberculosis in the mummy of a 5-year 20million currently have active tuberculosis. (On
old Egyptian child ofabout 3400 B.C. Alater mum average, about 10% of those infected go on to
c.,
my ofa young man, dated at about 1000 B. had a develop clinically active disease.) More than half of
psoas abscess as well as spinal lesions. In the Amer all those who have been infected live in Asia and
icas, a naturally mummified middle-aged Peruvian Africa. WHO estimates (1995) that only 10% of tu
woman who died about 1000 years ago had primary berculous patients also have AIDS, but in the next
pulmonary tuberculosis with calcified hilar lymph decade there may be seven million with the com
nodes. Tuberculosis was identified in this case be bined infection, rising to 14 million by the year
cause a unique DNA segment was identified in a 2010. Almost every patient with both diseases will
lung lesion, using the polymerase chain reaction. have active tuberculosis, because the AIDS virus
The word "tubercle" was first used in the seven destroys the cell which normally controls the mico
teenth century by a Dutchman, Franciscus Silvius, bacteria.
ofLeyden, to describe the lung lesions. Later (1839), The global rise in population, the wars and disputes
Johann Schonlein called the disease "tuberculosis:' which have caused refugees and migration, and the
It was not until 1882 that Robert Koch identified decline in the level ofpublic health services are also
and described Mycobacterium tuberculosis. With to blame for the recent reemergence oftuberculosis.
this discovery much of the romance and many of WHO has shown (in Tanzania) that it is possible to
the myths vanished. find and cure over 80% ofinfectious cases and that
If the source had been found, the cure had not, and 6-8 months of proper treatment will achieve this
tuberculosis continued as a major cause of death goal. The sputum bacterial counts fall rapidly and
and no respecter of social rank: it was familiar and the sputum becomes negative for bacilli within 2
fatal to everyone. Probably more than 25% of the months of adequate treatment, resulting in control
graves in the cemeteries of Europe and America of the epidemic spread. In 1997, WHO was a little
were filled by people ofall ages who had died oftu more optimistic that tuberculosis might be leveling
berculosis. There is a large and interesting literature off but warned that failure to treat the infection
on the disease and the remarkable ways in which it promptly would result in drug resistance, which is
was treated. Most were in some way or other un already at a level ofat least 7% and rising and often
comfortable for the patient, and none were very takes the form ofmultidrug resistance.
successful. Then in 1943, Selman Waksman, a mi Against this background it is important to add that
crobiologist at Rutgers University, fortuitously dis "tropical" tuberculosis is not a product ofthe AIDS
covered streptomycin while investigating a peculiar epidemic. This chapter in the first edition of "The
fungus which was killing chickens. This discovery, Radiology of Tropical Diseases" (1981) started by
together with the development of two other drugs stating that "The causative organism of tuberculo
in the next few years, led to the apparent conquest sis, Koch's bacillus, is morphologically and cultu
oftuberculosis. rally the same in the tropics as in non-tropical