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Pediatric TB IntensiveHouston, Texas

November 13 2009November 13, 2009

Radiographic Manifestations of Pediatric TB

Susan D. John, MD, FACR

November 13, 2009

Radiologic Presentation of Radiologic Presentation of Childhood TBChildhood TBChildhood TBChildhood TB

Susan D. John, MD, FACRProfessor and Chair

Dept. of Diagnostic and Interventional ImagingImaging

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Imaging TBImaging TB

• Clinical diagnostic features are often non-specific

• Culture of organism is slow and often ineffective

Imaging may provide important• Imaging may provide important and relatively specific clues

ObjectivesObjectives

• Recognize the characteristic imaging findings of tuberculosis inimaging findings of tuberculosis in infants and children.

• Differentiate TB from other conditions with similar imaging findingsfindings.

• Use advanced imaging to solve special diagnostic problems.

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Primary TuberculosisPrimary Tuberculosis

• Any system can be involvedy y

–Thoracic

–Central nervous system

–Abdominal

–Musculoskeletal

• Multimodality imaging

Common Imaging ModalitiesCommon Imaging Modalities

• RadiographsUniversally available–Universally available

–Insensitive

• US–Pleural disease–Joint effusion–Lymphadenopathy–Abdominal findings

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Common Imaging ModalitiesCommon Imaging Modalities• CT

– More sensitive for chest, abdomen ,disease

– Higher radiation exposure– Requires IV, GI contrast

• MRI– Important for CNS diseaseImportant for CNS disease– No ionizing radiation– Requires sedation– Not universally available

Thoracic Primary TuberculosisThoracic Primary Tuberculosis

• Imaging findings reflect progression of infection–Primary focus

–Drainage to regional lymph nodes

Intrabronchial spread–Intrabronchial spread

–Penetration of adjacent spaces

–Hematogenous dissemination

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Primary Pulmonary TBPrimary Pulmonary TB

• Radiograph–Ghon focus

• Variable in size• Often transient, hidden• Mild pleural reactionp• May progress locally or lead to intrabronchial spread

Ghon FocusGhon Focus

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Pulmonary TB in ChildrenPulmonary TB in Children

• Adult-type disease– Uncommon

– Opacity in apical lung segments

• Apical and posterior –Upperpp

• Apical – Lower

– May lead to cavities and fibrosis

PneumatocelesPneumatoceles

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Cavities Cavities

Disseminated Pulmonary TBDisseminated Pulmonary TB

• “Miliary”–Hard to see in early stage

–Typical - <2mm size

–Larger nodules or ill-defined patches can occur in childrenpatches can occur in children

–Bilateral, evenly distributed

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Miliary Nodules Miliary Nodules -- CTCT

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Congenital TBCongenital TB

• Rare form of transmission

• Chest radiograph may resemble other types of neonatal pneumonia

Lymphadenopathy key to the• Lymphadenopathy key to the diagnosis

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LymphadenopathyLymphadenopathy

• Hallmark of primary TB –Only radiologic finding in 50%–More common < 5 yrs of age

• Radiographs–Difficult to see with confidencecu t to see t co de ce–PA and lateral views needed–Hilar, paratracheal most common

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Normal LymphadenopathyNormal Lymphadenopathy

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LymphadenopathyLymphadenopathy

• CT improves visualization–Up to 60% with normal CXR have

LNs on CT • (Delacourt, 1993, Arch Dis Child 69:430.)

• CT technique–Use IV contrast–Multidetector improves resolution

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LymphadenopathyLymphadenopathy

• Sites on CT–Subcarinal (90%)–Hilar (Bilateral 72%)–Anterior mediastinum–Precarinal–Right paratracheal–Multiple sites (96%)

(Andronikou, Pediatr Radiol (2004) 34:232)

TTLymphadenopathy Lymphadenopathy

on CTon CT

ParatrachealHilar

Subcarinal

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Lymphadenopathy in PTBLymphadenopathy in PTB

• Size criteria– Generally use 1 cm or greater

– Not well-established

• Appearance– Low-density center with enhancing rimy g

– Interrupted peripheral enhancement

– Calcification uncommon

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Cervical TB Cervical TB LymphadenopathyLymphadenopathy

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No IV contrastNo IV contrast

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TB Consolidation with TB Consolidation with SubcarinalSubcarinal LNsLNs

Lymphadenopathy on CTLymphadenopathy on CT–– How How Good Are We?Good Are We?

• Andronikou, Pediatr Radiol (2005) 35:425.

– Only moderate agreement between 4 radiologists

• Rt hilar, subcarinal best

• Lt hilar, anterior mediastinal worst

– Thymus causes confusion

• Fletcher, J Clin Oncol (1999) 17:2153– Hodgkins disease – experts don’t agree

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Lymphadenopathy in PTBLymphadenopathy in PTB--ComplicationsComplications

• Airway compromiseAirway compromise–Extrinsic compression

• Obstructive emphysema• AtelectasisLeft > Right• Left > Right

–Bronchial wall granulomas–Intrabronchial caseous material

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AtelectasisAtelectasisAtelectasisAtelectasis

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1 month 1 month laterlaterateate

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Bronchial Compression/Endobronchial Bronchial Compression/Endobronchial GranulomaGranuloma

Penetration of Adjacent SpacesPenetration of Adjacent Spaces

• Pleural effusionU il t l di t d–Unilateral = direct spread

–Bilateral = hematogenous –Transudate most common

• Hypersensitivity response–Size variable

• Pericardial effusion–Subcarinal lymph nodes

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Patchy or Patchy or NodularNodular

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Pleural EffusionPleural Effusion

EE

Previous Pulmonary TBPrevious Pulmonary TB

• Calcifications (15-20% on CT)

O i f ti– Occurs in areas of caseation– 6 mons – 4 yrs after

infection• Not seen in young infants

– Occurs earlier in young childrenchildren

• Other rare findings– Bulla– Bronchiectasis

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Calcified Lymph Nodes with Calcified Lymph Nodes with MiliaryMiliary NodulesNodules

CNS TB in ChildrenCNS TB in Children

• Hematogenous most common–Spread from calvarium, middle ear

• Manifestations–Focal disease–Meningitise g t s–Infarction–Hydrocephalus

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TB Localized CNS DiseaseTB Localized CNS Disease

• Tuberculoma most common– Abscess uncommon

• CT or MRI (use IV contrast)– Enhancement patterns

• Usually < 2 cm diameter

• Rarely calcify

TuberculomasTuberculomas of Cerebellumof Cerebellum

• Ring enhancement common– Ddx

• Cysticercosis

• Toxoplasma

• CryptococcusCryptococcus

• Metastases

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TB MeningitisTB Meningitis

• Diffuse most common• CT

–Non-contrast – 50% show increased density in basal cisterns

–Contrast – prominent basal enhancement (double line sign)

• MRI – similar findings

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PostPost--meningitic Infarctsmeningitic Infarcts

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Abdominal TB in ChildrenAbdominal TB in Children

• Less common than in adults• Findings

– Lymphadenopathy– Solid organ lesions– Ascites

B l ll i l t– Bowel wall involvement– Inflammatory mass– Omental thickening

Abdominal TBAbdominal TB

• Lymphadenopathy–Para-aortic, mesenteric, periportal

most common–Commonly calcifies

• Solid organs–Calcified or low density lesions–Granulomas, abscess

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12 year old 12 year old with night with night sweats 20sweats 20sweats, 20 sweats, 20 lb wt loss, lb wt loss, and back and back

painpain

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Solid Organ Solid Organ DiseaseDisease

• Microabscess or granuloma

• Liver, spleen• High

frequency ultrasoundultrasound most sensitive

Abdominal TBAbdominal TB

• Ascites–May be high density on CT

(HU 20-45)–US useful but non-specific

• Ileocecal region–Bowel wall thickening–Inflammatory phlegmon

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TB PeritonitisTB Peritonitis

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Skeletal TB in ChildrenSkeletal TB in Children

• Uncommon (1-2% of all cases)• Hematogenous origin

–Primary site often unknown

• Granuloma >> caseating focus >> trabecular destruction >> cortical t abecu a dest uct o co t cadestruction >> periosteal, soft tissue involvement

TB of SpineTB of Spine

• Common site– Deposited in anterior aspect of vertebral

body

– Spread to disc, subligamentous, soft tissues

P t i l t ld i l d– Posterior elements seldom involved

– Multiple contiguous vertebrae (85%)

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TB of SpineTB of Spine

• Not seen early radiographically

• MRI valuable–T1 – low signal

–T2 – heterogeneous high signal

CT• CT–Cortical bone sclerosis, destruction

TB SpondylitisTB Spondylitis

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Spinal Soft Tissue ExtensionSpinal Soft Tissue Extension

• Paravertebral, epidural mass common–May lead to cord compression

• Subligamentous spread• Cervical – retropharyngeal massCe ca et op a y gea ass• Extension along iliopsoas

–Buttocks, groin, chest

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TB ArthritisTB Arthritis

• 2nd most common musculoskeletal site in children

• Monoarticular–Hips, knees most common

M t h l i f ti• Metaphyseal infection–May cross physis to epiphysis

TB ArthritisTB Arthritis

• Imaging findings– Joint effusion– Periarticular demineralization– Cortical irregularity– Osteolytic lesions– Periosteal new bone

• Late findings– Narrowed joint, overgrown epiphyses– Ankylosis

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Joint UltrasoundJoint Ultrasound

Normal Joint effusion

TB Osteomyelitis in ChildrenTB Osteomyelitis in Children

• Uncommon – only 11% of skeletal cases

• Solitary lesions most common• Chest radiograph often normal• Common sites

– Skull– Hands, feet– Ribs

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TB TB OsteomyelitisOsteomyelitis -- PatternsPatterns

• CysticCystic– Most common– Well-defined lytic lesion– Mild sclerosis, expansion

• Infiltrative“M th t ” ill d fi d– “Moth-eaten”, ill-defined

– Nonspecific (Ewings, fungal, chronic pyogenic osteomyelits)

• Spina ventosa (usually dactylitis)

TB of the SternumTB of the Sternum

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Calvarial TBCalvarial TB

• 1% of all skeletal tuberculosis

• 75% of patients are <20 yrs age

• Parietal bone most common site

• > 80% have bone destruction– Frequently visible on radiographsFrequently visible on radiographs

– Discrete lytic circumscribed lesion

• 92% have subgaleal swelling

CalvarialCalvarial TB with Epidural AbscessTB with Epidural Abscess

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ConclusionConclusion

• Primary TB in children has variable d ft ifiand often non-specific appearances

on imaging• Lymphadenopathy remains a key

finding in the chest• Use advanced imaging when• Use advanced imaging when

radiographs are suggestive or confusing