TB PNEUMONIA

Chest X-ray Interpretation in TB/HIV Settings Training course Ministry of Health and Social Welfare French-Cambodian Association ICAP Columbia University PharmAccess Foundation Tanzania, 2009

Common adult TB Basic radiological images: Nodule Infiltrate Cavity Pneumonia

TB pneumonia (1)
This is an alveolar image: non-homogenous, not clear margins, except if contact with fissure and with air bronchogram The association with other tuberculous lesions is very frequent: adenopathies, nodules and infiltrates, especially in PLHIV The lesions are often bilateral but asymmetrical

TB pneumonia (2)
AFB is often positive in sputum, because these lesions are very rich in TB bacilli. The spontaneous evolution is development of cavitation and destruction of the lung tissue, retraction and fibrosis: important sequela if treatment is too late. TB pneumonia is frequent among PLHIV. In this cases the pneumonia is frequently in the inferior lobes as is in the superior lobes. it is often associated with adenopathies. The cavitation is infrequent in cases of severe immunosuppression.

Air bronchogram

 woman 30 years old HIV+ worsening condition cough weight loss fever dyspnea CD4: 65 AFB positive

Bilateral TB pneumonia with adenopathies in mediastinal hilar and superior mediastinum

major fissure

Male, 30 years old. Dyspnea, fever, cough and weight loss over 2 months

Right upper lobe pneumonia, retraction and nodules. The association is highly indicative of TB.

CXR at the end of treatment: retractile right upper lobe changes with elevation of the right hilus

Typical TB: right upper lobar tuberculous pneumonia and TB cavities on the left side.

Male, 80 years old, worsening condition, dyspnea, non productive cough, sputum not available

Gastric washing: AFB+++

Oct 1999

Feb 2000

TB pneumonia.

Retractile evolution is an important sequela

Tuberculous pneumonia AFB +

Chest x-ray at the end of the TB treatment

HIV -

HIV+ TB pneumonia is frequent in countries with high incidence of TB among PLHIV and also in immuno-competent patients.

Frequently associated with mediastinal adenopathies

 HIV+ CD4< 100

TB Pneumonia Bilateral lesions localised in left middle and inf. lobe Latero-tracheal adenopathy; No cavitation

 Male 30 years old HIV +

Broncho-aspiration and bronchoalveolar lavage: AFB positive

AFB sputum negative

Right upper lobe pneumonia with hilar adenopathies

 Male 37 years old HIV + CD4 80/mm3 Weight loss Dyspnea Headache Seizures Fever Sputum not available

Widen mediastinum

Probable miliary TB with medastinal adenopathies and right pneumonia

But not all pneumoniae are TB. The clinical context is vital for diagnosis

Young man, no pathological clinical history:

acute onset of fever, chills, thoracic pain

(Streptococcus pneumoniae)

Acute right upper lobe pneumonia

Young woman, 39-40C fever for 48h, non-productive cough and right thoracic pain

Acute pneumonia (probable infection with Strep. pneumoniae)

PLHIV with AFB sputum negative, severe dyspnoea, normal or subnormal auscultation and diffuse bilateral infiltrates

This can be PNEUMOCYSTOSIS

Conclusion 1
TB frequently presents radiologically as pneumonia

PTB lesions are often bilateral and associated with nodules, adenopathies, cavities
If TB penumonia, AFB is often positive, but do not neglect causes of false negative: salivary sputum patient too weak for reliable sputum laboratory error treatment started before sampling

Conclusions 2
TB pneumoniae is frequent among PLHIV: all the lobes can be affected (particularly the inferior lobes) and are often associated with bulky adenopathies. In cases of severe immunodepression, cavitation is rare Differential diagnosis with the other infectious pneumoniae is only possible with the history-taking and clinical examination, which must always be associated with the analysis of the CXR. Anytime you are not sure: make clinical, radiological and sputum/lab follow up

End of the module

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