CHILDHOOD TUBERCULOSIS

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CHILDHOODTUBERCULOSIS

• BERNARD F. LAYA, MD, DO
• Associate Professor of Radiology
• St. Lukes Medical Center-Global City,
  Philippines

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OBJECTIVES

• Overview of demographics, pathogenesis and
  diagnosis of Tuberculosis
• Describe the spectrum of abnormalities seen in TB
• Discuss current imaging utilization and updates
  in the the evaluation of TB

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HISTORICAL FACTS

• Prehistoric humans 8000 BC and Egyptian mummies
  from 2500 - 1000 BC revealed evidence of TB
  disease
• DNA studies of an Inca mummy around 700 AD showed
  evidence of Potts disease
• 18271892 Jean Antoine Villemin proved the
  infectious nature of TB
• In 1882 Robert Koch identified the tubercle
  bacillus
• Early 20th century The TB vaccine, BCG was
  developed by Calmette and Guérin.
• 1943 Streptomycin was discovered by Waksman

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TB EPIDEMIOLOGY

• 1/3 of the worlds population (2 billion) is
  infected
• Common cause of death from any infectious agent
  worldwide (3 million a year)
• Burden is highest in Asia (59) and Africa (26),
  but also seen in Eastern Mediterranean Region
  (7.7), Europe (4.3), and America (3)
• In 2011 alone, there were an estimated 8.7
  million incident cases (125 per 100,000
  population)

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TB EPIDEMIOLOGY

• In Africa (80) and South-East Asia, the
  association between TB and HIV has increased
• - of 8.7 million new TB cases in 2011, 1.1
  million or
• 13 have HIV
• Multidrug-resistant tuberculosis (MDR-TB)
• - resistance to isoniazid and rifampicin
• - inappropriate drug treatment
• - patient non-adherence to treatment
• - 630,000 cases of MDR-TB in 2011
• Extensively drug resistant TB (XDR-TB) has been
  identified in 84 countries

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TUBERCULOSIS in children

• 2012 TB burden in children (lt15 years) is 490,000
  cases (6 of 8.7 million cases a year) and 64,000
  deaths/year
• Often not considered as a possible diagnosis and
  therefore goes undetected
• Tuberculosis in children can be hard to diagnose
• - Most children may not show any symptoms
• - Sensitivity of diagnostic tests are low
• Low AFB smear positive
• 32 40 of gastric aspirates are culture
• - Tuberculin skin test (TST) and IGRA has false
  / -

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IMAGING TESTS

• Radiograph (x-ray) most commonly used imaging
  test
• - Sensitivity of 38.8 and specificity of 74.4
• - Not diagnostic for tuberculosis
• - Normal CXR does not rule out progressive TB
• Computed tomography (CT)
  
• - Gold standard imaging test for lymphadenopathy
  
• - Predicting activity of pulmonary TB
  
• - Suspected TB without microbiologic proof
  
• - Anti-TB treatment with unequivocal CXR
• De Villiers RV, et al.
  Australas Radiol. 2004 Jun 48(2) 148-53

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PRIMARY INFECTION

• Inhalation of organism and settles in the lung
  causing inflammatory reaction attracting
  lymphocytes/macrophages
• Bacilli multiplies and spread via lymphatics
  causing lymphadenopathy
• Ghon complex lung lesion, lymphadenopathy, and
  lymphangitis
• Bacilli are dormant until re-activation (Latent
  TB infection)
• Primary infection is mostly seen in younger
  children
• Radiographs could show lung parenchymal disease,
  lymph node enlargement, both, or could have a
  normal chest x-ray

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RIGHT HILAR LYMPHADENOPATHY AND RML INFILTRATE
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RIGHT HILAR LYMPHADENOPATHY
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LATENT TB INFECTION ( LTBI )

• A pre-clinical state absence of clinical
  symptoms, a positive TST, CXR is normal or may
  show residual changes of infection
• Most children are identified during contact
  investigations or skin test screenings
• The original focus of infection is eradicated
  within weeks or months but bacilli remain viable
  within granulomas which lie dormant
• The primary infection may never heal and could
  develop into an active disease

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LATENT TB INFECTION
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CALCIFIED GHON FOCUS
CALCIFIED RIGHT HILAR LYMPH NODES
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PRIMARY PROGRESSIVE TB disease

• In approximately 5, cell mediated immunity fails
  to contain or eradicate the infection
• Immunocompromised, infants and children lt 4 yrs,
  persons with untreated or inadequately treated TB
  disease
• Clinical symptoms depend on age and degree of
  dissemination. Some have few symptoms or can be
  asymptomatic
• The primary lung disease progresses, or the
  adenopathy progresses, or both lung disease and
  adenopathy progresses causing various
  complications
• Ultimate progression occurs in disseminated TB
  when there is little or no host response

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PRIMARY PROGRESSIVE TB DISEASE
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PRIMARY PROGRESSIVE TB PARENCHYMAL DISEASE WITH
CAVITATION
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PRIMARY PROGRESSIVE TB PARENCHYMAL DISEASE WITH
CAVITATION AND POTTS DISEASE
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LYMPHADENOPATHY

• Common in primary TB
• Usually unilateral
• Predilection to the right side
• The younger the child, the higher incidence
• Can cause compression
• Lateral view for confirmation
• Hilar adenopathy has a specificity of 36 on CXR

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PROGRESSIVE TB LYMPH NODE DISEASE
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TRACHEOBRONCHIAL TUBERCULOSIS IN CHILDREN

• Tracheobronchial tuberculosis is not uncommon
• Presents with barking cough, sputum production,
  hemoptysis and dyspnea
• Usually a result of compression by an enlarged
  lymph node
• Radiographic imaging
  
  
• - Hyperaeration
  
• - Segmental or subsegmental atelectasis
  
• - Collapse / consolidation
• CT with 3D and MPR
• - Highly accurate
• - Severe narrowing, small airways dz, lung,
  lymph node, pleura, and bone disease

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ACTIVELY CASEATING TYPE OF TRACHEOBRONCHIAL TB
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Laya, Concepcion, et al. Tracheobronchial TB.
St. Lukes Journal of Medicine July 2011
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PLEURAL DISEASE

• Well recognized manifestation of TB in children
• Pleural effusions, thickening and calcification
• Pleural effusions are usually unilateral and may
  vary in size
• Maybe serous, proteinaceous, bloody or purulent

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PLEURAL AND PERICARDIAL DISEASE
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MILIARY PATTERN

• A consequence of primary or post primary disease
• Hematogenous dissemination, initially
  interstitium and ultimately involving the
  airspaces
• Nodules measuring 2-3 mm in diameter
• More in lower lung zones because of greater blood
  flow
• Clearing is usually from 7 to 22 months after tx
• Perhaps the only radiographic finding that maybe
  highly suggestive of tuberculosis in infants and
  children

How CH. Tuberculosis in Infancy and Childhood.
10 65
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MILIARY TUBERCULOSIS
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CONGENITAL TUBERCULOSIS

• Unusual but well described clinical entity
• Results from clinical spread across placenta
• Fetal ingestion or aspiration of infected
  amniotic fluid
• Clinical manifestation is nonspecific
• Importance of clinical suspicion and imaging
• Imaging manifestation is disseminated /miliary
  pattern

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POST-PRIMARY TUBERCULOSIS

• After dormancy, organism are able to reactivate
  and proliferate leading to post primary
• Consolidation involving the upper lobes due to
  decreased lymph flow
• Cavitation usually seen in consolidated lung
  
• Often associated with significant fibrosis
• Lack of lymphadenopathy
• Most common form of disease in adults and older
  children

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POST PRIMARY OR REACTIVATION TB
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POST PRIMARY TUBERCULOSIS
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DESTRUCTIVE LUNG SEQUELAE OF TB
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TB INFECTION PRIMARY INFECTION
LATENT TB INFECTION
PRIMARY PROGRESSIVE TB DISEASE
REACTIVATION USUALLY LUNG APICES OR EXTRAPULMONARY
1. PULMONARY 2. EXTRAPULMONARY 3. DISSEMINATED
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IMPORTANT CONSIDERATIONS

• Primary infection normal, LN, primary complex
• Chest abnormalities are slow to resolve
• Fibrosis and atelectasis can occur in the
  presence of active disease
• Overlap of radiographic manifestations of primary
  and post-primary TB
• Presence or absence of the primary disease cannot
  be conclusively determined from the chest film
  alone
• No pathognomonic radiographic findings in
  childhood tuberculosis

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TUBERCULOSIS CAN AFFECT VIRTUALLY ANY ORGAN
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ABDOMINAL TUBERCULOSIS

• Genitourinary TB is commonly encountered
• Intestinal involvement in 55-90 of fatal cases
• Hepatobiliary, lymphadenopathy and peritonitis
• A minority of patients ( lt50) with abdominal TB
  have abnormal chest radiographic findings
• Clinical symptoms are diverse and non-specific
• Clinical presentation does not correlate with the
  severity and extent of imaging findings

Laya and Zamora. AOSPR 2008, St. Lukes Journal
of Medicine July 2011
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GENITOURINARY TUBERCULOSIS
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HEPATOSPLENIC TUBERCULOSIS

• Hematogenous dissemination
• Imaging appearance
• Micronodular
• Macronodular
• Mass like
• May contain calcifications
• DDX neoplasm, abscess, fungal infections

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HEPATO-SPLENIC TUBERCULOSIS
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GASTROINTESTINAL TB

• Routes
• - Ingestion of the tubercle bacilli
• - Direct extension from an adjacent infected
  organ
• - Hematogenous spread
• Presentation abdominal pain, weight loss,
  anemia, and fever with night sweats, obstruction,
  palpable mass RLQ
• - Hemorrhage, perforation, and malabsorption
• Ileocecal involvement in 80 90
• Imaging Inflammation causing mucosal thickening
  and irregularity, luminal narrowing, and
  obstruction
• DDx amebiasis, crohns disease, ileocecal
  malignancy

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ILEOCECAL TUBERCULOSIS OR TB TERMINAL ILEITIS
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TB LYMPHADENOPATHY

• Most common abdominal manifestation
• Mesenteric, omental, and peripancreatic locations
  
• Large, multiple, peripheral enhancement with
  central areas of low attenuation
• Common among children, supraclavicular and
  cervical lymph nodes
• Ddx metastases, Whipple disease, lymphoma, MAI

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TB PERITONITIS

• Diffuse or focal inflammatory reaction
• Associated with widespread abdominal TB
• Types
• - Wet type large viscous ascitis
• - Dry or plastic caseous nodules, fibrous
  reaction and dense adhesions
• - Fibrotic fixed omental masses, matted bowel

WET
DRY
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MUSCULOSKELETAL TB

• Skeletal involvement occurs in 1-3
• - Spondylitis, arthritis, osteomyelitis
• Hematogenous spread, direct invasion
• Children are more prone than adults
• Concurrent intrathoracic TB present in lt 50
• Associated soft tissue abscess
• Arthritis 25 of cases, usually monoarticular
• - Phemister triad, Hips and knees
• Oseomyelitis unifocal or multifocal
• - Cystic, infiltrative, erosive, spina ventosa

Laya and Geslani. St. Lukes Journal of Medicine
July 2011
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TUBERCULOUS ARTHRITIS
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TUBERCULOUS ARTHRITIS
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CYSTIC TB OSTEOMYELITIS
EROSIVE TB OSTEOMYELITIS
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TUBERCULOUS SPONDYLITIS (POTTS DISEASE)

• Spine is most common site of bone involvement
• Usually upper lumbar (L1) and lower thoracic
• More than one vertebral body are typically
  affected
• Begins in the anterior part of the vertebral body
  adjacent to endplates, spreads to into the disk
  space
• Leads to vertebral collapse - Gibbus deformity
• Paraspinal involvement usually the psoas
• DDX pyogenic vertebral osteomyelitis,
  metastasis, primary neoplasm (lymphoma, myeloma)

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CNS TUBERCULOSIS

• Hematogenous dissemination to brain and meninges
• Becomes clinically apparent 6 months after
  infection
• Gelatinous exudate fills the meninges along the
  basal cisterns and along the walls of the
  meningeal vessels
• - Vasculitis causing infarcts (50)
• - Communicating hydrocephalus (50-77)
• Abnormal meningeal enhancement typically more
  pronounced in the basal cisterns
• Other manifestations tuberculoma, cerebritis,
  abscess, miliary pattern, subdural epyema and
  atrophy

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DENSE BASAL CISTERN SIGN
TUBERCULOUS MENINGITIS
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CT MANIFESTATIONS OF CNS TUBERCULOSIS
Laya and Paguia. AOSPR 2008, St. Lukes Journal
of Medicine July 2011
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CONCLUSION

• Tuberculosis is a global health concern
• TB affects virtually every organ in the body
• Childhood TB diagnosis and management could be
  challenging
• Medical imaging plays a very important role
• Imaging manifestations are quite diverse
• Familiarization with the spectrum of imaging
  abnormalities
• Clinico-radiologic approach

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REFERENCES

• 1. De Villiers RV, Andronikou S, Van de
  Westhuizen S. Specificity of chest radiographs in
  the diagnosis of paediatric pulmonary TB and the
  value of additional high-kilovolt radiographs.
  Australas Radiol. 2004 Jun 48(2) 148-53
• 2. Kashyap S, Mohapatra PR, Saini V.
  Endobronchial Tuberculosis. Indian J chest Dis
  Allied Sci. 2003 45247-256
• 3. Harisinghani, M.G., Mcloud, T.C., Shepard,
  J.O., et al. Tuberculosis From Head to Toe.
  Radiographics. 2000 Mar-Apr20(2)449-70 quiz
  528-9, 532
• 4. Andronikou S, Wiesenthaler N, Smith B, Douis
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  paediatric tuberculous meningitis. Pediatr
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• 5. Balthazar E, Gordon R, Hulnick D. Ileocecal
  tuberculosis CT and radiologic evaluation.
  American Journal of Roentgenology. 1990 Mar 154
  499-503
• 6. Andronikou S, Wieselthaler N. Modern imaging
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  nervous system and abdominal tuberculosis.
  Pediatr Radiol 2004 34 861-875
• 7. Teo, H.E.L., Peh, WC.G. (2004) Skeletal
  Tuberculosis in Children. Pediatric Radiology
  34 853-860
• 8. Przybojewski S, et al. Objective CT criteria
  to determine the presence of abnormal enhancement
  in children with suspected tuberculous
  meningitis. Pediatrr Radiol (2006) 36 687-696.

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REFERENCES

• 9. Burill, J et al. Tuberculosis A Radiologic
  Review. Radiographics (2007) 271255-1273.
• 10. Laya BF. Thoracic Tuberculosis in Children
  Pitfalls and Dilemma in Chest Radiograph
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  Computed Tomography with Multiplanar Reformation
  and 3D-Volume Rendering Technique in correlation
  with Fiberoptic Tracheobronchoscopy for Thoracic
  Evaluation of Children with Primary Progressive
  Tuberculosis and Tracheobronchial Involvement.
  St. Lukes Journal of Medicine Special Edition,
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• 12. Global Tuberculosis Report 2012, Word Health
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• 13. Ann Leung. Pulmonary Tuberculosis The
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• 14. Andronikou S, Smith B, Hatherhill M, Douis H,
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