 Hello everyone and welcome to Indian Radiologist. My name is Dr Sanjeev Mani and today's tutorial is on X-ray findings in pulmonary tuberculosis. Before we begin I would just request you all to subscribe to our channel if you find the content useful as well as click on the bell icon to receive notifications. Another shout out is for Sonobas 2021. This is a virtual online conference that is being held from Jan 3rd to 10th in 2021 and we have a tremendous array of speakers both national and international lecturing at this event. So we would request you to please register for this event. Thank you. Before we begin with the lecture a quick statistic we know that the year 2020 has been one of COVID-19 and as of today more than 1.48 million people have died with COVID out of a total 64 million cases that have been detected worldwide. But if we put this statistic across the one of tuberculosis of 2019 from WHO 1.4 million people have died of tuberculosis in 2019 out of an estimated 10 million people who fell ill with tuberculosis. So we should understand that this is a serious disease it is a disease of the developing countries. Developed countries also see it but not to that much of an extent as we do in countries like India and Southeast Asia. India in fact leads the cases with TB globally. Now we know that tuberculosis is caused by the bacteria mycobacterium tuberculosis and more often than not affects the lungs. There are other bacteria involved like the atypical mycobacteria as well. Besides the pulmonary manifestation there are extra pulmonary tuberculosis lesions that can occur. These occur usually because of hematrogen is spread or sometimes direct extension from adjacent organs. Now what are the organs that are affected almost every organ of the human body? So it could be lymph nodes with the pleura, the GI tract, the GI tract, the central nervous system, bones as well as the larynx. Now we should know that most extra pulmonary diseases are not contagious with the exception of laryngeal tuberculosis. Now what are the typical symptoms of active tuberculosis? These include cough, haemoptysis, a low-grade fever usually that comes up in the evenings or nights. There may be night sweats and typically the patient will have fatigue, malaise and sometimes even weight loss. Now imaging plays a very vital role in the diagnosis and management of tuberculosis and in this tutorial our plan is to understand the radiological features and the value it has in management of tuberculosis. Now traditionally primary tuberculosis was considered a disease of childhood and post primary tuberculosis is believed to represent a reactivation of this latent infection in adults. So the first common lesion that we see is a Gorn's complex. Now what exactly is Gorn's complex? It is made up of A, a lesion that is seen in the lung that is caused by tuberculosis and P, an adjacent enlarged midiastinal node. These two the pulmonary lesion as well as the lymph node together form the Gorn's complex. This lesion usually heals and once it heals it can undergo calcification either the pulmonary lesion or the midiastinal node and that is known as a rankase complex. A rankase complex is not specific for tuberculosis and it can also be seen as a sequelin other grandomatous infections. Now let's come down to the parankymal findings of tuberculosis. Now commonly it is seen as a consolidation or an area of opacity which may have a segmental or lower distribution. Now these consolidations are usually inhomogeneous. So we see on this frontal radiograph an inhomogeneous consolidation involving the right upper zone as well as the mid zone. You can see areas of breakdown also within this lesion. Now this is classic tuberculosis. Why? Because it is affecting the upper lobe, usually it affects the upper lobe as well as the superior segment of the lower lobes. And once you have a lesion which is inhomogeneous which shows areas of breakdown like we see here your diagnosis is more likely to be tuberculosis than a bacterial infection. Let's have a look at another radiograph. Here we see much more subtle lesions. In fact we call these classically infiltrates. We can see them here in the left upper and mid zone. Again it is upper lobe and superior segment of the lower lobe. So this is more often than not likely to be tuberculosis. We see another view here. Again a much more denser consolidation and you can see almost an air bronchogram seen within this lesion. But once again upper lobe lesion more likely than not to be tuberculosis. You look for other subtle signs of tuberculosis also and you will find them. You see a little small nodule layer which could very well represent a tuberculoma. Next case much denser consolidation again in the upper lobe here as well as the mid zone. This patient also had a small pleural left fusion as we can see here and histopathic examination of the pleural fluid revealed tuberculosis. So let's have a look at this CT scan here. What we can see are inhomogeneous consolidates seen in the apicopostria segment of the left upper lobe as we see here and we can see the fissure over here. So we know the structure behind happens to be the superior segment of the left lower lobe. So you see inhomogeneous consolidates as well over here. You see areas of breakdown and small cavity formation. These findings are the hallmark of pulmonary tuberculosis. Now tree in bud appearance is another sign that has been attributed to pulmonary tuberculosis and it is the appearance of areas of sentry lobionner nodules with a linear branching pattern. It was earlier believed to occur only in endobronchial tuberculosis but not anymore and bronchios filled with pus in bronchonemonia or tumor emboli can also give rise to this tree in bud appearance. This finding of course is not visible on x-ray and is seen only on HRCT. Once the consolidation is larger it starts breaking down. So we get areas of breakdown and if those breakdowns get larger and coalesced together what we get is a cavity. So you can see here again a lesion which is inhomogeneous in nature a consolidation initially to begin with in the right upper zone and mid zone but what you can see also is a very thick walled cavity which has formed as a result of the breakdown. This again is tuberculosis. Remember when you're reading x-ray chess you can diagnose a cavity when you can very clearly see 75% of the walls of that cavity. It is only then that you will call it a lung cavity. As tuberculosis starts healing you get fibrosis. So this is a patient who is undergoing treatment currently on treatment and has come up for follow-up and what we see are areas of fibrosis seen in the upper lobe over here. We can see formation of bullet right here. We can see a pleural effusion which appears to have got organized and we can see some retrocardiac bronchiactatic lesions as well. And here's another x-ray. We see a patient with heel tuberculosis and what we get here are fibrotic lesions in the mid zone. There is tinting of the dome of diaphragm as we can see here. There's a bit of pleural thickening or organized pleural effusion. You see cardiometeanal shift so you can see the trachea deviated to the right and the heart also coming across to the right side pulled by the fibrotic lesions. So fibrotic changes, fibro bronchiactatic changes, pleural thickening, tinting of dome of diaphragm and lung volume loss are classic signs of sequelae of pulmonary tuberculosis. Now once there is a cavity of course the treatment protocols differ but once this cavity has healed there is always a danger. There's a danger of this lesion persisting after treatment and that persistence can predispose to bacterial super infection, fungal ball formation or even erosion of adjacent vasculature which could result in hemoptysis. We see here in this case we can see a thin wall cavity with the soft tissue lesion well within it. This mag view here shows the cavity wall right there and a soft tissue mass lesion well seen within this cavity. This is nothing but a fungal ball. Now one more thing in pulmonary manifestations before we move to the pleura is milliary motling. A milliary motling occurs because of hematogenous spread and what you see are discrete nodules seen across the entire lung. This is commonly seen in children, teenagers as well as in immunocompromised patients. You must also remember that the DD is fungal sometimes metastasis and even sarcoidosis. So you will end up doing a CT scan to try to differentiate these as well. So these are the more common parent time manifestations of tuberculosis. From parent time we move on to pleura and what we commonly get is pleural effusion. So what you got to watch out for are the costofrenic angles right here. You can see this one is clear but over here you can see that the right dome of diaphragm is elevated. You can see blunting of the costofrenic angle as well as a little bit of fluid that is moving up almost towards the axilla. This is a pleural effusion with a sub pulmonic component. One more case here you see this pleural effusion on the left blunting out the costofrenic angle. You see the right side over here very clearly and we see the left side which is blunted and you see the soft tissue density lesion moving up towards the axilla with a nice concave contour. This is nothing but a pleural effusion. Also as radiologists we must react to this pleural effusion. It's not a bio area always. To get an ultrasound done of this patient establish the amount of pleural fluid that's there. Speak to the clinician and complete a pleural tap that can aid in quick diagnosis of tuberculosis. Sometimes patients present later with pleural effusion and the picture may be different. You may get multiple septae in that pleural fluid once we do the ultrasound and this is not very amenable to therapeutic tapping. Lymph nodes are another manifestation of tuberculosis so what we can see here are enlarged paratructile nodes on the right side as well as enlarged hyla nodes. Once we see this picture and if you are suspecting tuberculosis the next best thing of course is to do a CT scan chest with contrast where you will see typical tuberculosis enhancement. So how do you see this enhancement? You can see classical rim enhancement with central caseation necrosis that is a hallmark of tuberculosis. You can see this picture this is an enlarged subcarinal node almost conglomerate with central areas of necrosis that represent caseation necrosis. So there are two questions the clinician asks us. One does this patient have pulmonary tuberculosis and once the patient is on treatment they ask us whether it is still active or is it healing. So that's a tricky question but let's answer the first question. So when a patient comes to you and comes with symptoms and if you get any of these findings like consolidation or cavitation, malaria remotelling or lymphadenopathy, pleural effusion, you know that you're dealing with a patient who has currently active pulmonary tuberculosis. The treatment for these patients is usually medical and they are put on AKT for their prescribed period of six to 12 months and intermittent x-rays are taken to see that the lesions are in check and are not increasing. Now coming to the second question whether this lesion is still active or is it healing or not. So if you see a regression of the lesions that you have seen on the previous radiograph, if you start seeing fibronodular scarring, if you see the pleural effusion organizing, you know that these are signs that this is healing. This information for the physician is very important because then he or she knows that they can continue the prescribed schedule as has been decided from the very beginning. So we end this tutorial with this x-ray. This x-ray was seen a lot in the past. We don't see it now anymore and what is it exactly? So this is surgical procedure known as thoracoplasty that was designed to permanently collapse cavities of pulmonary tuberculosis by removing ribs from the chest wall. By doing this, the resection would allow the opposition of parietal to the visceral or mediasal pleura and make the cavities collapse. This procedure has been replaced by lobectomy or pneumonectomy if the situation so demands.