Axial and Extraaxial Skeletal Tuberculosis :Patterns and ... · PDF file1.Tubercular arthritis...

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Axial and Extraaxial Skeletal Tuberculosis :Patterns andMimics on imaging
Poster No.: C-0922
Congress: ECR 2011
Type: Educational Exhibit
Authors: C. Kakkar1, A. M. Polnaya2, C. M. shetty3, K. Rajagopal1, P.
Koteshwara1, N. M. MULIMANI1, S. Sripathi1, V. R. K. Rao1;1Manipal, Karnataka/IN, 2Mangalore, Karnataka/IN, 3manipal, ka/IN
Keywords: Tropical diseases, Infection, Diagnostic procedure, Digitalradiography, CT, MR, Musculoskeletal spine, Musculoskeletaljoint, Musculoskeletal bone
DOI: 10.1594/ecr2011/C-0922
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Learning objectives
1. To illustrate the various patterns of skeletal tuberculosis on imagingmodalities with emphasis on MR imaging.
2. To discuss the diagnostic features of skeletal tuberculosis at various sites.3. To illustrate the patterns of multifocal skeletal tuberculosis and discuss the
differential diagnosis.
Background
Extra-pulmonary tuberculosis occurs in 20% cases of tuberculosis with musculoskeletaltuberculosis occurring in 1-3% of cases.
Spine is the most common site of skeletal tuberculosis accounting for 50% cases ofskeletal tuberculosis followed by knee or hip in 30% cases.
Pubis, wrist, shoulder, and sacroiliac joint are rarer sites.
Extra-axial manifestations:
1.Tubercular arthritis 2. Osteomyelitis 3.Tenosynovitis and bursitis 4.Pyomyositis.
Multifocal skeletal tuberculosis is an even rarer entity accounting for 10% of total cases ofskeletal tuberculosis and should suggest an immunocompromised status of the patient.
Active pulmonary focus in skeletal tuberculosis is seen in less than 50% of cases.
Imaging plays a significant role in diagnosis and knowing the extent of disease.
Radiography:
Insensitive to early changes of disease. Late stages characteristic manifestations canbe seen as Phemister's triad in tubercular arthritis, spina ventosa in cases of tuberculardactylitis , spondylodiscitis with paraspinal abscesses especially with evidence ofcalcification.
Sonography useful for assessment of soft tissue involvement particularly tenosynovitis

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Cross sectional imaging in the form of CT and MRI sensitive for detection of early disease.
Detection of marrow changes and better contrast makes MRI the modality of choice atvarious sites.
Final diagnosis requires either histopathology , culture or PCR assay.
Imaging findings OR Procedure details
Patterns of spinal Involvement : Spondylitis and Spondylodiscitis , Discal sparing ,posterior elements involvement . Various forms can be paradiscal , central ,subligamentous and neural arch tuberculosis.
Tubercular osteomyelitis : Difficult to distinguish from other causes of osteomyelitis.
Tubercular arthritis : Characteristic findings like Phemister's triad, late stages fibrousankylosis can occur.
Tenosynovitis and bursitis:Compound palmar ganglion characterized by a swelling inthe distal part of volar aspect of wrist and communicating with another swelling over palmacross the flexor retinaculum.
Joint tuberculosis :
Tubercular arthritis or synovitis.
Sacroiliitis:
Unilateral involvement.On imaging may be indistinguishable from Brucellosis.
Multifocal tuberculosis:
Multifocal spondylitis or osteomyelitis. Strong mimic of aggressive pathologies suchas Langerhans cell histiocytosis , haematological and lymphoreticular malignancies inpediatric age group .In adults may be indistinguishable from secondaries or lymphoma.
Images for this section:

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Fig. 1: A) Lateral radiograph in adult patient showing a kyphotic deformity atthoracolumbar junction(gibbus)with intervertebral disc space reduction (Black arrow).B) Lateral radiograph in a child showing significant reduction in vertebral height withdestruction of intervertebral disc(White arrow).

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Fig. 2: Lateral radiograph of thoracolumbar spine showing disc space reduction and endplate irregularity (arrowhead).Paravertebal soft tissue noted on AP projection (arrows)

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Fig. 3: A) Paradiscal Spondylodiscitis: Lateral radiograph of Lumbosacral spine showsdisc space reduction with end plate irregularities at L4-L5 (arrow).

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Fig. 4: B contd.)T1 weighted sagittal image shows marrow hypointensity with reductionin the disc space (dotted arrow). C and D) On T2 and STIR images the marrow ishyperintense (arrows) with discal hyperintensity.There is reduction in the anterior heightof the L5 vertebra. E) Post contrast there is marrow enhancement , discal enhancementand epidural abscess (arrowhead).

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Fig. 5: Central Tuberculosis: A and B)T1 and T2 images shows altered signal intensityin the marrow of L3 vertebra(arrow).

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Fig. 6: C(contd.) Fat saturated image shows marrow hyperintensity(arrow) with a rightparavertebral soft tissue(arrowhead) .

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Fig. 7: D and E (contd.):Post contrast sagittal and coronal image shows marrowenhancement(arrow) with enhancing paravertebral soft tissue (arrowhead).
Fig. 8: Subligamentous spondylodiscitis: A,B,C and D) Sagittal T1,T2, STIR and postcontrast images show altered marrow signal intensity with prevertebral soft tissue(arrowhead) discal changes (dotted arrow)and epidural soft tissue (arrow). Post contrastsequence shows discal enhancement, peripherally enhancing prevertebral soft tissueand enhancing epidural soft tissue

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Fig. 9: E)contd.Coronal post contrast sequence shows peripherally enhancingsubphrenic collection (asterisk) with multiple small paravertebral collections (arrows)anddisc enhancement(arrowhead).

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Fig. 10: Subligamentous Tuberculosis: A)T2 fat saturated image shows prevertebral softtissue(arrow)with marrow hyperintensity (arrowhead). B) The prevertebral soft tissue isshowing peripheral enhancement on post contrast T1 image(arrow).
Fig. 11: C and D(contd.):Pre and Post contrast T1 images shows peripherally enhancingprevertebral soft tissue(arrow).

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Fig. 12: A and B) T1 and T2 Sag images show prevertebral soft tissue(arrow) ,epiduraltissue(arrowhead) with vertebral marrow changes(asterisk). C)Post contrast imageshows enhancing marrow ,prevertebral and epidural soft tissue.
Fig. 13: D and E (contd) : Pre and Post contrast T1 images show enhancingprevertebral,paravertebral soft tissue (arrow) with associated epidural component(arrowhead).Final Diagnosis : B-cell Lymphoma.

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Fig. 14: Neural Arch Tuberculosis: A and B) T1 and T2 axial images show altered signalintensity in the region of pedicle and lamina(arrowhead).Posterior element involvementcan lead to a diagnostic dilemma between an infective versus malignant process.

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Fig. 15: A and B: STIR sagittal image shows altered marrow signal intensity in the lowerlumbar vertebrae(arrow)with compression fracture of L4. There is hyperintensity notedinvolving the posterior elements(arrowhead).

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Fig. 16: C and D (contd.): T1 pre and post contrast image shows marrow hypointensityin L3 and L4 vertebra(arrow) with homogenous post contrast enhancement in bodyand posterior elements (dotted arrow). There is an enhancing epidural soft tissueposteriorly(arrowhead). No discal enhancement noted.
Fig. 17: A and B) Craniovertebral Junction Tuberculosis: Sagittal STIR image showsa hyperintense prevertebral soft tissue (arrowhead) which is isointense on T1. C)

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Post contrast enhancement with a non enhancing area suggestive of necrosis.Subtleenhancement of the marrow of dens noted(arrow).
Fig. 18: D and E(contd.): Post contrast enhancement noted in the right lateral mass ofC1(arrow) with prevertebral abscess at C2-C3 level (dotted arrow).
Fig. 19: Elderly patient with severe back ache.A and B) T1, T2 images show apathological fracture with convex posterior bulge (arrowhead) at L2 vertebra with alteredmarrow signal intensity(arrow).

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Fig. 20: C and D (contd.):On STIR sequence the marrow is hyperintense withenhancement post contrast(arrow).Diagnostic possibility of malignant pathology wasconsidered.Final diagnosis:Tubercular osteomyelitis

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Fig. 21: A) T1 coronal images show marrow hypointensity in the left iliac bone (arrows)with a small focal hypointensity in the right sacral ala (arrow) B) T2

Axial and Extraaxial Skeletal Tuberculosis :Patterns and ... · PDF file1.Tubercular arthritis...

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