A 52-year-old man presented with dyspnea, fatigue, weight loss, diarrhea and a swollen right testis. Imaging showed hilar lymphadenopathy, a miliary pattern, mediastinal and hilar lymphadenopathy, pericardial effusion, splenomegaly with hypodense lesions, and micronodules in the lungs. A biopsy of the right testis revealed necrosis and acid-fast bacteria, leading to a diagnosis of disseminated tuberculosis. Tuberculosis commonly involves the abdomen and can affect lymph nodes, the peritoneum, gastrointestinal tract, liver, spleen, kidneys and genitals. Imaging plays a key role in the diagnosis and management of abdominal tuberculosis.
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...
52-Year-Old Man With Dyspnea And Weight Loss Diagnosed With Disseminated Tuberculosis
1. A 52-year old man with
dyspnea, fatigue and
loss of weight
M. TORFS
B. CORTHOUTS
B. OP DE BEECK
STAFF MEETING RADIOLOGY, 09-12-2014
2. Case presentation
Medical history:
- HIV (stopped treatment 3 years before, lost to
follow-up by the ITM)
- Depression
Current medical problems:
- Dyspnoea
- Extreme fatigue
- Weight loss (15 kgs in 3-4 months)
- Diarrhea
- Right testis ‘problem’ (R/ ciprofloxacin)
3. Case presentation
Clinical examination:
- Cachexia
- Tachycardia
- Bilateral crepitations on auscultation
- Red, swollen right testis
65. Diagnosis?
R/ Right orchidectomy
Pathology:
- Abcedation and necrosis
- Presence of numerous acid fast bacteria
Diagnosis: Disseminated tuberculosis
66. Tuberculosis: epidemiology
Leading cause of death from infection worldwide
1/3 of world population infected
2010: 8.8 million incident cases worldwide, 1.4 million deaths
1.2 million cases among HIV-infected persons
Largest number of incident cases: India, China, South Africa,
Indonesia, Pakistan
Highest prevalence rates (> 300 cases/100,000 population) in African
region
Increased susceptibility in patients with impaired cellular
immunity
HIV infection, elderly, prisoners, congregate settings,
indigent/homeless
67. Tuberculosis: pathology
M. tuberculosis: Aerobic, nonmotile
bacillus
Stains red with Ziehl-Neelsen stain
Acid-fast: Resists discoloration with acid alcohol
Granulomatous infection/inflammation
Macrophage aggregates transform into
epithelioid cells, epithelioid cells fuse to form
multinucleated Langhans giant cells
Central necrosis, satellite granulomas
May heal as fibrous scar or calcified lesion
69. Abdominal manifestations
in tuberculosis
Abdomen is the most common site of extrapulmonary TB (can be
involved without lung disease)
Abdominal lymphadenopathy is most common manifestation of
abdominal TB
Any abdominal or pelvic organ or structure may be involved
Tuberculosis peritonitis
Gastrointestinal tuberculosis
Hepatosplenic tuberculosis
Renal tuberculosis
70. Abdominal
lymphadenopathy
Enlarged nodes with hypoattenuating centers and
hyperattenuating enhancing rims on CT (40-60%)
With healing, nodes calcify
Enteric TB probably most common cause of mesenteric
nodal calcification
26-year old patient with
disseminated TB
71. Tuberculous peritonitis
Wet type: Large amount of free or
loculated ascites (higher than water
density due to protein and cellular
content)
Dry type: Mesenteric and omental
thickening, fibrous adhesions, and
caseous nodules
Difficult to distinguish from peritoneal
carcinomatosis
72. Gastrointestinal
tuberculosis
Ileocecal region most commonly affected
Cecum & terminal ileum are usually contracted with
wall thickening; ileocecal valve is "gaping"
Regional lymphadenopathy with central caseation
Colon tuberculosis less common
24-year old patient with
intestinal TB and
enterocutaneous fistula
74. Hepatosplenic tuberculosis
• Micronodular, miliary
• Macronodular
CT
Acute lesions are hypoattenuating nodules with ill-defined,
enhancing margins
Chronic: Hepatic and splenic tuberculomas tend to calcify as they
heal
MR
T1WI: Hypotense, minimally enhancing, honeycomb lesions
T2WI: Hyperintense with less intense rim relative to surrounding liver
75. Renal tuberculosis
• 75% unilateral
• Most common CT finding is renal
calcification (50%)
• IVP: "Moth-eaten" calix due to erosions
and progression to papillary necrosis
• Caliectasis & hydronephrosis with irregular
margins and filling defects due to caseous
debris
• Irregular pools of contrast due to renal
parenchymal cavitation
• Strictures of renal pelvis and infundibula
www.statdx.com
76. Ureteric and bladder
tuberculosis
• Ureteric tuberculosis:
- Thickened ureteric wall with
strictures
- Most common in distal 1/3 of
ureter
- Hydronephrosis & hydroureter
can occur upstream
• Bladder tuberculosis:
- Decreased bladder volume
with wall thickening,
ulceration, and filling defects
http://www.isradiology.org/tr
opical_deseases/tmcr/chapt
er5/lymphadenopathy2.htm
77. Genital tuberculosis
Male genital tuberculosis
- Affects seminal vesicles or prostate
gland, rarely testes
- Occasional calcification
Female genital tuberculosis
- Involves fallopian tubes in 94% of cases
- Bilateral salpingitis with strictures ±
occlusion
82. Take home messages
Tuberculosis is leading cause of death from
infection worldwide
TB lymphadenitis is characterised by enlarged
nodes with hypoattenuating centers and
hyperattenuating enhancing rims on CT (tend to
calcify with healing)
Disseminated TB: look at the whole picture!
Axial NECT shows calcification from healed TB granulomas within the retroperitoneal nodes (white curved). The left kidney (white arrow) is totally calcified and nonfunctional, an "autonephrectomy" or "putty" kidney due to chronic renal TB. Small focal calcifications were also present in the adrenals.