1. TB
Dr. Hytham Nafady

3. Pulmonary
TB

4. TB or not TB that is the question
Chest
Doctor

6. Pathology of Primary T.B.

7. Pathology of post-primary T.B.

8. Radiological manifestations of TB
TB
Parenchymal TB
Mediastinal TB
Airway TB
Vascular TB
Pleural TB
Chest wall TB

9. Parenchymal TB
• TB pneumonia.
• Cavitary TB.
• Tuberculoma.
• Miliary TB.

10. Parenchymal TB
TB pneumonia
Cavitary TB
Tuberculoma
Miliary TB
1ry
Post-1ry
Post-1ry
1ry
Post-1ry
1ry
Post-1ry

11. Complications of
parenchymal TB
Fibrosis Cavitation
Endo-bronchial
spread
Aspergilloma
Bronchogenic
carcinoma

12. Tuberculoma
Pathogenesis:
• Localized parenchymal TB with alternating activation and
healing.
• it may occur in the setting of 1ry and post-1ry TB.
Location:
Right upper lobe (but can occur in any other lobe).
Radiological manifestations:
• Rounded nodule with well defined margins.
• 0.5 - 4cm in diameter
• Usually single but may be multiple.
• +/- calcification.
• +/- cavitation.
• +/- satellite nodules.

13. nodule
nodule
nodule
DD: Nodule
1. Tuberculoma
2. Hamartoma
3. Metastases
4. Hydatid
Tuberculoma

14. TB pneumonia

15. 1ry TB pneumonia Post-1ry TB pneumonia
Children Adult
Segmental or lobar
consolidation.
Patchy & nodular opacities
which may be bilateral
Involve any part of the lung. apico-posterior segment of
UL.
Superior segment of LL.
Associated with
lymphadenopathy.
Not associated with
lymphadenopathy.
Healing is complete without
any sequelae.
Healing by fibrosis.
Caviatation.
Or both.

16. 1ry TB pneumonia with
lympadenopathy

17. Miliary TB
Etiology:
• It results from hematogenous dissemination of
infection from pulmonary nidus.
• It can be 1ry or post-1ry TB.
Location:
Randomly distributed with mild basilar predominance.
Radiology:
CXR: miliary shadows (nodules < 2mm).
CT: sharply defined miliary shadows (nodules < 2mm).
Association:
TB chronic lesions
Consolidation, cavitation or calcified LN.

18. Millet seeds (‫الدخن‬ ‫)بذور‬
The term miliary is derived from the radiographic picture
of diffuse discrete nodular shadows about the size of
millet seeds = 2mm.

19. Random distribution

23. Sarcoidosis

25. Thyroid metastases
(snow storm)

26. Thyroid metastases
(snow storm)

27. 2ry hemosiderosis (MS)

28. Airway lesions of TB
• Endobronchial tuberculosis.
• Bronchiectasis.
• Broncho-stenosis.
• Broncholithiasis.

29. Endobronchial TB
Pathogenesis:
• Cavitation & communication with bronchial tree
Location:
• Lower dependent lung zones, distant from the
original cavity.
Radiological manifestations:
• X-ray:
• Micro-nodules with lobar or segmental distribution.
• CT:
• Tree in bud opacities.
Association:
• Cavitation.

30. Tree in bud opacities

32. Bronchiectasis
• Irreversible dilatation of the cartilage containing airways.
Pathogenesis:
• Cicatricial bronchiectasis:
Due to endobronchial TB & subsequent fibrosis.
• Traction bronchiectasis:
Due to pulmonary TB & subsequent fibrosis.
Location:
• Unilateral apical bronchiectasis is highly suspicious of TB.
Radiological manifestations:
• Dilated bronchi.
• Bronchocele (dilated bronchi filled with mucus with branching
tubular opacities giving finger in glove appearance).

33. TB bronchiectasis

34. Broncho-stenosis
Pathogenesis::
• Endobronchial TB.
• Extrinsic pressure from enlarged peribronchial TB.
Location:
• Central air ways.
CT:
• Active stage:
Irregular luminal narrowing with wall thickening,
enhancement & enlarged adjacent lymph nodes.
• Fibrotic stage:
Concentric narrowing, uniform thickening with involvement of
a long segment.

35. • Lymphadenopathy with partial obstruction of the left
main bronchus resulting in obstructive emphysema of
the left lung. Bronchoscopy and biopsy revealed T.B.

36. DD of broncho-stenosis
Endobronchial TB Bronchogenic carcinoma
Double obstructive lesions Low density mass at the
obstructive site.
Multiple bronchial wall
calcifications
Sever distortion of the
bronchi

37. Broncholithiasis
• Presence of calcified or ossified material
within the lumen of the tracheo-bronchial
tree.
Pathogenesis:
• Erosion of bronchial wall by calcified
peribronchial lymph node.
CT:
• Calcified lymph node with findings of
bronchial obstruction.

39. Vascular TB
• Hypertrophy of bronchial vessels.
• Rasmussen aneurysm.

40. Hypertrophy of bronchial arteries
Pathogenesis:
• Due to vasculitis.
C.P:
• Hemoptysis.
Location:
• Peribronchial.
CT:
• Peribronchial rounded & tubular densities similar to
enlarged lymph nodes.
• It may protrude into the lumen of the ectatic bronchi.

42. Rasmussen aneurysm
Pathogenesis:
• Vasculitis of a pulmonary artery within a
tuberculous cavity.
Location:
• Within a tuberculous cavity.
CT:
• Rounded enhancing lesions within a
tuberculous cavity.
• It may cause life threatening hemoptysis.

44. Medically treated aneurysms
Rasmussen aneurysm Pulmonary
pseudoaneurysm in Behcet
syndrome
Anti-tuberculous therapy Corticosteroid therapy

45. Mediastinal TB
• TB Lymphadenopathy.
• TB pericarditis.
• Esophageal TB.
• Fibrosing mediastinitis.

46. TB lymphadenopathy
• Is the hall mark of primary T.B.
• Its incidence decreases with age.
Pathogenesis:
• Formation of tuberculous caseating granulomas in the lymph
nodes.
Location:
• Right paratracheal and hilar lymph nodes.
CT:
• Central low attenuation.
• Peripheral rim enhancement.
• Obliteration of the perinodal fat.
• Usually nodal size doesn’t exceed 2 cm.
Association:
Parenchymal involvement.

47. TB Lymphadenopathy

48. Sequelae of
TB lympadenopathy
Healing Complications
Fibrosis Calcification
Compression of
adjacent bronchus
Extranodal
extension

49. DD of lymphadenopathy
• 1- Metastases
• 2- Lymphoma
• 3- other infections e.g. histoplasmosis &
varicella.
• 4- Sarcoidosis

51. Esophageal TB
Pathogenesis:
• Extension from adjacent lymph nodes.
Location:
• subcarinal region (due to anatomic proximity of
the esophagus to lymph nodes).
Radiological manifestations:
• Traction diverticula (triangular in shape).
• Esophago-mediastinal or esophago-bronchial
fistula, manifested as (pneumomediastinum).
• Esophagobronchopleural fistula:

52. Esophageal traction diverticulum
• Triangular or tent shaped.
• Wide neck.
• It empties when the
esophagus is collapsed
as it contains all layers.
• Calcified mediastinal LN
adjacent to the
diverticulum.

53. Esophageal diverticulum
Traction diverticulum Pulsion diverticulum

54. Esophago-mediasinal fistula

55. Esophago-broncho-pleural fistula

56. Pericardial tuberculosis
Pathogenesis:
• Extension from adjacent lymph nodes due to close
anatomic proximity of the lymph nodes & posterior
pericardial sac.
Location:
Radiological manifestsions:
• Pericardial effusion:
• Constrictive pericarditis
– Pericardial thickening > 4 mm.
– Pericardial calcification.
Association:
• Lymphadenopathy.

58. Fibrosing mediastinitis
• N.B: the most common cause of mediastinitis is
histoplasmosis.
Pathogenesis:
• TB lymphadenitis with reactive fibrous changes.
Radiological manifestations:
Plain x-ray:
• Mediastinal widening or localized mass.
CT:
• Mediastinal or hilar mass with or without calcification.
• Diffuse obliteration of mediastinal fat.
• Tracheo-bronchial narrowing.
• Vascular encasement.

60. Pleural manifestations of TB
• Pleural effusion.
• Chronic TB empyema.
• Fibrothorax.
• Broncho-pleural fistula.
• Pneumothorax.
• Malignancy associated with chronic empyema.
Pleural TB

61. TB empyema
• Persistent purulent pleural fluid containing TB bacilli.
Pathogenesis:
• Rupture of subpleural cavity.
• Hematogeneous dissemination.
• Direct extension from infected lymph nodes.
Location:
• almost always unilateral.
Radiological manifestations:
• Plain x-ray:
• CT:
• L oculated fluid collection.
• Pleural thickening.
• Pleural calcification.
• Extrapleural fat proliferation.
• Milk of calcium with calcium / fluid level.
• Pseudochylous effusion with fat / fluid level.
• Associated pulmonary TB (subpleural cavitation)

62. TB empyema
Proliferation of extra-pleural fat

63. TB empyema with subpleural cavity

64. TB empyema with milk of calcium
Ca / fluid level

65. TB empyema with pseudochylus effusion
Fat / fluid level

66. DD of pleural calcification
• TB (usually unilateral).
• Old hemothorax (usually unilateral).
• Asbestosis (usually bilateral).

67. Pleural manifestations of TB
• Empyema necessitans.
• Pott’s disease of the dorsal verebrae.
• Sternum
• Rib.
• Sternoclavicular joint.
Chest wall TB

68. Empyema necessitans

69. Extra-pulmonary TB

70. Skeletal TB
• TB spondylitis.
• TB arthritis.
• TB osteomyelitis.

71. TB spondylitis TB arthritis TB osteomyelitis
50% of skeletal
TB
34% of skeletal
TB
16% of skeletal
TB
Any age Middle age &
elderly
Children < 5 y
(rare in adults)
Thoraco-lumbar
region
Large weight
bearing joints
Any bone can be
affected.
Paradiscal type.
Central type.
Anterior type.
Appendicial type.
Mono-articular. Metaphyseal.

72. TB spondylitis TB arthritis TB osteomyelitis
Hematogeneous
spread (Batson
venous plexus).
Trans-
cartilagenous
spread into disc
material.
Subligamentous
spread (beneath
anterior
longitudinal
ligament)
Hematogeneous
spread
Transphyseal
spread to the
epiphysis (on the
contrary to
pyogenic
osteomyelitis).

73. Tuberculous
spondylitis
Pyogenic
spondylitis
Early preservation of the
disc space.
Early & sever narrowing
of the disc space.
Absent reactive sclerosis Reactive sclerosis.
Marginal calcification of
psoas abscess.
No calcification
Skip lesions No skip lesions

74. Tuberculous arthritis Pyogenic arthritis
Gradual narrowing of the
joint space.
Early & sever narrowing
of the joint space.
Peripheral bone
erosions.
Central bone erosions.
Fibrous ankylosis Bony ankylosis.
Kissing sequestra

75. Phemister triad
• Periarticular
osteopenia.
• Marginal bone
erosions.
• Gradual narrowing of
the joint space.
DD: Rheumatid arthritis.
(polyarticular).

76. Tuberculous
osteomyelitis
Pyogenic
osteomyelitis
Transphyseal spread. No transphyseal spread.
Little or no periosteal reaction. Periosteal reaction.
Little or no surrounding sclerosis Surrounding sclerosis.

77. Special forms of TB
osteomyelitis
• TB dactylitis.
• Cystic TB.

78. TB dactylitis
Spina ventosa
• Spina = sail.
• Ventosa = expanded with air
Ventosas

79. Cystic TB

80. TB spondylitis
1. Maginal Paradiscal (commonest).
2. Central.
3. Anterior (subperisteal).
4. Posterior (appendiceal).

81. Marginal (paradiscal) TB spondylitis
Plain x ray:
• Disc space narrowing:
• Due to involvement of the disc material.
MRI:
• Abnormal bone marrow signal along
adjacent vertebral end plates.
• Disc space narrowing.

83. Anterior (subperiosteal) lesion
Plain x-ray:
• Anterior scalloping (gouge effect):
• Due to stripping of the periosteum and ALL 
ischemia & pressure necrosis of the anterior
vertebral body.
MRI:
• Subligamentous abscess.
• Preservation of the discs.
• Abnormal signal involving multiple vertebral
segments.

85. Gouge
• Is a special type of chisel

86. Central lesion
• Centered on the vertebral body.
• Disc is not involved.
• Spread of infection through Baston’s venous
plexus.
Plain x-ray:
• Central rarefaction.
• +/- Vertebral collapse (vertebra plana).
MRI:
• abnormal signal along the vertebral body with
preservation of the disc material.
• DD with metastasis, lymphoma & eosinophilic
granuloma.

88. Posterior (appendicial) type
• Isolated infection of the pedicles, lamina,
transverse processes & spinous process.
• Erosive lesions with paravertebral
abscess.

90. Skip lesions
• Involvement of non contiguous vertebrae.

91. Paravertebral abscess

92. • Located at a some distance below the
original lesion due to gravitation along the
fascial planes.
• Calcifications are pathognomonic.

93. Angular kyphotic deformity
gibbus deformity

94. CNS
TB meningitis:
• Leptomeningeal thickening &
enhancement along the basal cisterns.
Parenchymal tuberculoma:
• Multiple ring enhancing lesions.

105. Gastrointestinal TB
• Most common location is
ileocecal junction.
• Hypertrophy of ileocecal
valve (Flischner sign).
• Cone shaped cecum
(normally the cecum is
purse shaped).
• Pulled up cecum (fibrosis).
• DD: Crohn’s disease.

106. Ileocecal TB
• Pulled cecum.
• Narrowed
terminal ileum

107. Ileocecal TB

108. Ileocecal TB

109. DD of Coned cecum
• Crohn's - TI involved more than cecum
• TB - colon involvement greater than TI; usually have
pulmonary TB; no reflux from cecum to TI
• Amebiasis - cecum involved in 90% of chronic
amebiasis; TI normal; ileocecal valve fixed in open
position
• UC - backwash ileitis occurs 10% of time through gaping
ileocecal valve
• Actinomycosis - uncommon may simulate appendicitis,
palpable abdominal masses and draining fistulas
• Typhlitis - necrotizing process of multifactorial origin
involving predominantly the right colon; most common in
children with leukemia; typically begins 1-2 weeks
following chemotherapy
- may also occur in adults with hematologic malignancy
- there is bowel wall thickening, mucosal ulceration,
intramural hemorrhage and necrosis

110. TB peritonitis
Pathology:
• Direct haematogenous spread,
• Rupture of a tuberculous intra-abdominal
lymph node.
Types:
• Wet type (commonest).
• Dry type.
• Fibrotic type.

111. Wet TB peritonitis
• Exudative high attenuation ascites.
• May be free or loculated.
• Measurement of ascitic fluid adenosine
deaminase level is diagnostic.

114. Dry type
• Matted small bowel loops.

115. Fibrotic type
• Omental & mesenteric caking

116. Scrofula = breeding sows

117. Cervical TB lymphadenopathy
scrofula
US:
• Nodal matting.
• Surrounding soft tissue edema is less marked than
would be expected given the size of the collections.
Duplex:
• Prominent hilar vascularity (on the contrary of
malignant LN which show prominent peripheral
vascularity).
US guided FNAC:
• Has 92% sensitivity & 97% specificity.

121. Genitourinary TB

122. Renal size
• Diffusely enlarged (T.B pyonephrosis from
ureteric stricture).
• Focally enlarged with displacement of
adjacent calyces (tuberculoma).
• Shrunken kidney small scarred non
functioning kidney with dystrophic
calcification (putty kidney).
• May be normal size.

123. Renal papillae
• Papillary irregularity (moth eaten calyces)
earliest sign.
• Irregular papillary surface due erosions.
• Papillary necrosis (blunted dilated
calyces).
• Parenchymal cavities communicating with
collecting system.

124. Parenchymal calcifications
• Amorphous.
• Punctate.
• Confluent calcifications.
• Cumulus cloud opacity:
• Due to calcification in caseous material in
caverno-caseous type.
• Complete cast of calcification (putty
kidney) end stage renal TB
(autonephrectomized kidney).

125. Putty kidney

126. Collecting system
Uneven caliectasis:
unequal dilatation of renal
calyces due to varying
degree of stenoses.
Hydrocalicosis:
• dilated calyx due to
infundibular stenosis.
Phantom calyx:
• non opacified calyx due to
infundibular stenosis.

127. Renal pelvis
• Reduced capacity.
• Sharp kinking (Kerr kink).
• Mural thickening.

128. Ureter
• Spread:
• Direct spread from renal
involvement:
• Early:
• Multiple filling defects
(mucosal granulomas)
• Saw tooth ureter:
• Dilated ureter with irregular
contour & mucosal
ulcerations.

129. Late (fiborsis):
• Beaded ureter: alternating strictures &
dilatations.
• Cork screw ureter: alternating strictures
& dilatations with tortuousity.
• Pipe stem ureter: rigid, thick straight
ureter.

130. Bladder
• Thickened contracted low capacity urinary
bladder (thimble bladder).