Radiologic manifestations of pulmonary tuberculosis in patients of intensive care units

AbstractBackgroundTuberculosis (TB) is a serpent disease with various pulmonary manifestations, and timely diagnosis of the disease is paramount, since delayed treatment is associated with severe morbidity, particularly in intensive care units (ICU). Therefore, it is imperative that intensivists understand the typical distribution, patterns, and imaging manifestations of TB.AimTo describe different manifestations of pulmonary TB in patients in the ICU.MethodsIn a retrospective study, all patients with a clinical and a laboratory-confirmed diagnosis of TB who were admitted to the ICU were entered in the study. All patients had a confirmatory laboratory diagnosis of TB including positive smears. The patterns of parenchymal lesions, involved segments and presence of cavity, bronchiectasis and bronchogenic spread of the lesions with computed tomography (CT) and chest/X-ray (CXR) were recorded and analyzed.ResultsData of 146 patients with TB were entered in the study. The most common finding in CT was acute respiratory distress syndrome (ARDS)-like radiologic manifestations (17.1%), followed by parenchymal nodular infiltration (13.6%) and cavitation (10.9%), consolidation (10.2%), interstitial involvement (9.5%), calcified parenchymal mass (8.3%), ground-glass opacities (7.5%), and pleural effusion or thickening (6.9%). Radiologic evidence of lymphadenopathy was seen in up to 43% of adults. Miliary TB was observed in 2.3% of patients, mostly in those older than 60years of age. ARDS-like (64.5%) manifestations on CT and miliary TB (85.5%) had the highest mortality rates among other pulmonary manifestations.ConclusionARDS, interstitial involvement, and Parenchymal nodular infiltration are the most common manifestations of pulmonary TB. Various features of TB in ICU patients could be misleading for intensivists

Extra-pulmonary Pneumocystis jiroveciinfection: a case report

In physical examination abdominal tenderness, gate disturbance and penile herpetic lesions were detected. Decreased disc height at T11-T12 level was detected in chest X-ray. Abdominal sonography and CT scan revealed hypo dense lesions in Lt left Lobe of liver and multiple hypo dense splenic and pancreatic lesions, ascitis, Lt left sided pleural effusion, thickening of jejuneal mucosa and edema of bowel wall. Vertebral body lesion and paravertebral abscess, bony calvarial involvement and adjacent extra axial brain lesion were observed in imaging were other findings. RNA analysis for HIV was positive. Vertebral lesion biopsy and aspiration of splenic lesion were performed and pathology revealed Pneumocystis jirovecii suggestive of extra pulmonary Pneumocystis carinii infection

Thoracic Kidney: Extremely Rare State of Aberrant Kidney

The thorax is the rarest place among all forms of renal ectopia. We report a rare case of an unacquired thoracic kidney. Only about 200 cases of the thoracic kidney have ever been reported in medical literature worldwide. In this paper we present the rarest form of nontraumatic nonhernia associated, truly ectopic thoracic kidney. The differential diagnosis and management options and classification of this rare form of aberrant kidney are discussed

Normal dimensions of trachea and two main bronchi in the Iranian population

Background: The purpose of this study was to determine the normal diameters of larger airways in the Persian population, since these demographic variables are essential for interpretation of chest CTs and/or plain X-rays. Material/Methods: During a 6-month period, sagittal and coronal diameters of tracheas of all cases admitted for a chest CT to the radiology department of the National Research Institute of Tuberculosis and Lung Disease (NRITLD) were measured. The patients had to accept to take part in the study and had to fulfill the inclusion and exclusion criteria of the study. Ninety-nine percent confidence intervals (99% CI) were used to define the upper and lower limits of normal. Results: Two hundred subjects, including 132 men and 68 women aged 20-85 years, were studied. Coronal and sagittal diameters of tracheas in the upper part were as follows: 1.8±0.24 and 2.06±0.27cm for men, and 1.48±0.20 and 1.49±0.24 for women, respectively. For the lower part that was: 1.8±0.23, 1.86±0.27, 1.51±0.18, and 1.46±0.23, respectively. For the right and left mainstem bronchi the values were as follows: 1.16±0.17 and 1.02±0.22 for men and 0.93±0.13 and 0.81±0.13 for women, respectively. Conclusions: The values determined by us had a narrower range of normality than the ones found in the previous reports, so they will stay more friendly for interpretation of individual cases

Comparison of clinicoradiologic manifestation of nonspecific interstitial pneumonia and usual interstitial pneumonia/idiopathic pulmonary fibrosis: A report from NRITLD

<b>Background: </b> Ever since Katzenstein and Fiorelli introduced the term nonspecific interstitial pneumonia (NSIP) to denote those cases of interstitial pneumonia that cannot be categorized as any of the other types of idiopathic interstitial pneumonias (IIP), there has been continuing debate on whether it is a real clinical entity or not. The American Thoracic Society/European Respiratory Symposium task group tried to identify idiopathic NSIP as a separate disease and exclude it from the category of IIP. However, it appears that the clinical presentation of NSIP and usual interstitial pneumonia (UIP) are the same. <b> Objective :</b> To show that the radiologic features of NSIP and UIP should be relied upon, instead of clinical presentation and pathologic findings, to differentiate between the two. <b> Materials and Methods:</b> Consecutive patients who had received a diagnosis of either NSIP or UIP on the basis of open lung biopsy between January 2001 and December 2007 were identified for inclusion in this retrospective review. The study included 61 subjects: 32 men and 29 women with a mean age of 59.39 &#x00B1; 14.5 years. Chest computed tomography images of all the cases were collected for a review. High resolution computed tomography (HRCT) and all pathologic specimens were also evaluated. A weighted kappa coefficient was used to evaluate whether radiology can be used instead of biopsy for the diagnosis of NSIP and UIP. Comparison of the mean ages and the time intervals (i.e., interval between symptom onset and the time of diagnosis) in the UIP and NSIP groups was done using the Mann-Whitney U test. Association between gender and biopsy result was evaluated by the Fisher exact test. Data were evaluated using SPSS, v.13. <b> Results :</b> Sixty-one patients were included in this study, 32 were male and 29 were female. On the basis of biopsy findings, 50 (82&#x0025;) patients had UIP and 11 (18&#x0025;) had NSIP. Thirty (60&#x0025;) of the 50 patients who had UIP were male and 20 (40&#x0025;) were female; 2 (18.2&#x0025;) of the 11 patients who suffered from NSIP were male and 9 (81.8&#x0025;) were female. Based on HRCT findings, 36 (60&#x0025;) patients were diagnosed to have UIP and 24 (40&#x0025;) were diagnosed with NSIP. When diagnosis was based on biopsy findings, the time interval in the UIP group was 13.59 &#x00B1; 8.29 months and in the NSIP group it was 7.90 &#x00B1; 4.18 months. When diagnosed on the basis of HRCT findings, the time interval in the UIP group was 14.22 &#x00B1; 8.94 months and in the NSIP group it was 10.54 &#x00B1; 5.78 months. When diagnosis was on the basis of biopsy, the mean age in the UIP group was 61.30 &#x00B1; 14.18 years and in the NSIP group it was 50.73 &#x00B1; 13.14 years. <b> Conclusion :</b> HRCT can be used instead of invasive methods like lung biopsy to differentiate between UIP and NSIP

Hypermetabolic Thyroid Incidentaloma on Positron Emission Tomography: Review of Laboratory, Radiologic, and Pathologic Characteristics

Introduction. Incidental hypermetabolic thyroid lesions on Positron Emission Tomography have significant clinical value and may harbor malignancy. In this study we evaluated laboratory, radiologic, and pathologic characteristics of incidental hypermetabolic thyroid lesions. Materials and Methods. We evaluated 18 patients prospectively with various malignancies and hypermetabolic thyroid incidentaloma. The thyroid function tests, ultrasound assessment, and guided FNA biopsy were performed on all cases. Results. We included 9 male and 9 female patients with mean age of 51 years. Most common malignancy was colon cancer. Metabolic activity quantification using maximum standard uptake value demonstrated range between 1.4 and 65.4 with mean value of 9.4. We found highest metabolic activity in patients with lung adenocarcinoma, B-cell lymphoma, and colon adenocarcinoma. On ultrasound exam most thyroid lesions were of solid, hypoechoic, noncalcified nature with either normal or peripheral increased vascularity. FNA biopsy report was benign in 15 cases and malignant or highly suggestive for malignancy in 3 other cases. Two of the three malignant cases demonstrated metabolic activity higher than average SUV max. Conclusion. Most thyroid hypermetabolic incidentalomas are benign lesions, while higher values of SUV max are in favor of malignancy. This mandates further evaluation of incidentally found thyroid hypermetabolic lesions on routine PET/CT scans

Multidrug resistant tuberculosis versus non-tuberculous mycobacterial infections: a CT-scan challenge

INTRODUCTION: Clinical, laboratory and imaging findings in patients with multidrug resistanttuberculosis (MDR-TB) and non-tuberculosis mycobacterium (NTM) are similar, and the majority of these patients present with positive smear for Acid Fast Bacilli (ADB) and no response to first line anti-TB treatment, so sputum culture and PCR are necessary, especially in NTM. OBJECTIVE: In this study we evaluate more details of imaging findings to help earlier diagnosis of pathogens. MATERIALS AND METHODS: 66 patients with positive smear for AFB and no response to first line anti-TB drugs were divided into two groups by PCR and culture: MDR-TB (43 patients) and NTM (23 patients). Age, sex, history of anti-TB treatment, smoking and CT-scan findings (parenchymal, pleural and mediastinal variables) by details and lobar distribution were analyzed. RESULTS: Mean age of NTM patients was slightly higher (52 versus 45) and there is no significant difference in sex and smoking. In MDR-TB group, history of anti-TB treatment and evidence of chronic pulmonary disease such as calcified and fibrodestructed parenchyma, volume loss and pleural thickening were higher significantly. Cavities in MDR-TB were thickwall in the background of consolidation, while NTM cavities were more thin-walled with adjacent satellite nodules in same segment or lobe. Prevalence of bronchiectasis was similar in both groups, while bronchiectasis in MDR-TB group was in fibrobronchiectatic background in upper lobes, and in NTM group the distribution was more uniform with slightly middle lobes predominance. Prevalence and distribution of nodular infiltrations were similar more in Tree in Buds and scattered pattern. Calcified or non-calcified lymph nodes and also pleural changes were more frequent in MDR-TB but prevalence of lymphadenopathy was mildly higher in NTM. CONCLUSION: A check-list with multiple variables is helpful for differentiation between the two groups

Radiographic manifestations of Tuberculosis in HIV positive patients: Correlation with CD4+ T-cell count

Background: Observations on Tuberculosis/HIV co-infection in addition to epidemiologic molecular studies have recently provided strong evidence for the state of immune system as the major determinant of the TB imaging spectrum. However, the presence of any correlation between radiographic findings and the degree of immunosuppression in HIV+ patients still remains controversial. The present study aimed to investigate the TB radiographic manifestation in HIV+ patients and its relationship to the CD4 cell count. Method and material: Chest radiography of 15 HIV+ patients with a definite diagnosis of pulmonary Tuberculosis in Masih Daneshvari Hospital, between 2013 and 2014, were retrospectively reviewed. Radiographic findings and severity were categorized as typical (upper lobe infiltration/cavity) and atypical (middle/lower lobe opacity, adenopathy, pleural effusion and normal X-ray). Demographics and CD4+ cell count were also recorded. Data analysis was performed using SPSS version 23 (frequency and mean for descriptive quantitative variables and Logistic regression analysis for correlation, p <0.05). Results: Of a total 15 patients (86.7% men and 13.3% women), 78.6% had CD4+ counts <350 (mean ± SD; 229.15 ± 199.45). The most common radiographic findings in descending order of frequency were adenopathy (53.3%), pleural effusion (26.7%) and cavitation (6.7%) with an overall atypical presentation of 93.3%. This study failed to reveal any statistically significant correlation between CD4+ cell count and radiographic manifestation as well as severity. Conclusion: In CD4+ cell count <500, the dominant radiographic pattern of Tuberculosis is atypical presentation. At this level of immunity, CD4+ T cell dysfunction may play a deterministic role in TB radiographic manifestation

Radiologic manifestations of pulmonary tuberculosis in ICU

Background: Pulmonary tuberculosis (TB) is an important disease with various manifestations in intensive care units (ICU). Despite the availability of effective treatments for TB, the mortality for patients admitted with TB to an ICU remains high. Additionally, the history of exposure to TB may not be present, and evidence of active TB is present in less than 50% of cases. Therefore, understanding the typical distribution, patterns, and imaging manifestations of TB is crucial. Methods: In this retrospective study, all patients admitted to ICU with clinical and laboratory-confirmed TB were enrolled. The classic information, i.e., chest X-ray (CXR) and computed tomography (CT), for each patient was analyzed. Likewise, the presence of a cavity, involved segments and patterns of parenchymal lesion were assessed. Finally, tentative diagnosis and disease activity, bronchogenic spread of the lesion with CT and bronchiectasis were recorded. Results: Among the studied cases, 146 were laboratory-confirmed TB patients. The majority of patients had acute respiratory distress syndrome (ARDS) (16.0%, n = 24), followed by interstitial involvement (13.0%, n = 19), parenchymal nodular infiltration (12.0%, n = 18), alveolar consolidations (11.6%, n = 17), cavitary TB (11.0%, n = 16), pleural effusion (10.0%, n = 15), calcified parenchymal masses (9.0%, n = 13), ground glass opacities (8.0%, n = 12) and other manifestations (8.0%, n = 12). Radiographic evidence of lymphadenopathy was seen in up to 43% of adults and 96% of children. In the 73% of cases with parenchymal infiltration, more than one pulmonary segment was involved. Miliary TB was also observed in 5% of studied patients. Conclusion: Different features of TB patients in the ICU may be easily misled, and internists should have a comprehensive knowledge of various radiologic manifestations of TB in order to use this information and not ignore it