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426 Chapter 11 Infectious Diseases and Tropical Medicine
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11.13
TB reactivation : a situation where an old latent TB
infection gets reactivated into an acute disease, and
mostly occurs in patients with low immunity, such as
HIV patients, diabetics or children. TB reactivation
occurs in the lung apices; it is thought that this location is preferred by the bacilli due to the high oxygen
tension or the low lymph fl ow at the lung apices.
Cavity formation in the lung apices is seen in up to
40% of reactivation TB patients.
Signs on Chest Radiographs
Primary TB presents with a pneumonic patch in the middle or
lower lobes, with ipsilateral hilar lymphadenopathy
(Fig. 11.13.1 ). When the TB pneumonic patch regresses and
calcifi es, it results in Ghon Lesion.
Ranke’s complex : Ghon lesion with ipsilateral calcifi ed hilar
lymphadenopathy.
Tuberculoma : a round, smoothly circumscribed pulmonary
nodule (<3 cm) that usually contains central calcifi cation. It is
seen at the common areas of TB infection (upper lobes and
apical segment of lower lobes). The main diff erential
diagnosis of tuberculoma is “pulmonary hamartoma,” which
has the same tuberculoma features, central popcorn
calcifi cations, and occurs anywhere within the lungs.
Tuberculoma is diagnosed by its features and locations.
Apical fi brosis (Simon’s focus) : old TB in the lung apices may
results in chronic granulomatous reaction that causes lung
fi brosis (Fig. 11.13.2 ). The term “old TB” should be used with
caution, as the TB may be chronic but still active. “Stable TB
disease” requires 6 months of unchanged radiological features
to be acclaimed.
TB reactivation is classically seen as lung apices cavitary
lesions (40%) or noncavitary lung infi ltration (4–9%). A TB
cavity tends to have thick irregular walls (Fig. 11.13.3 ), and
air–fl uid level may be seen (9–21%). Superimposed infection
of the cavity with fungi can result in fungal ball (mycetoma/
aspergilloma) within the cavity (halo sign).
Cicatrization atelectasis : atelectasis of the upper lobes due to
previous fi brosis from TB infection, with retraction of the
hilum upward.
Bronchiectasis may occur in up to 87% of patients due to
bronchial wall and parenchymal destruction. Bronchiectasis is
seen as focally dilated bronchi with honeycomb, cystic
interstitial pattern.
Broncholithiasis is an uncommon complication of TB
characterized by the presence of calcifi ed materials within the
bronchial tree.
Pleural calcifi cation is often seen unilaterally, especially with
previous empyema.
Fig. 11.13.1. Posteroanterior plain chest radiograph in a patient
with primary TB shows a pneumonic patch in the right middle
lung zone ( arrowhead ) with ipsilateral lymphadenopathy
Fig. 11.13.4. Axial lung window HRCT in a patient with TB
shows apical left mycetoma with a halo sign ( arrowhead ) and
marked bronchiectasis in the right lung ( arrow )
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Fig. 11.13.3. Posteroanterior plain chest radiograph shows right
Fig. 11.13.2. Posteroanterior plain chest radiograph in a TB
patient shows right apical fi brosis (Simon’s focus)
apical TB cavity
Signs on HRCT
Mycetoma is seen as a fungal ball within a TB cavity at the
lung apices in up to 55% of patients ( halo sign ) (Fig. 11.13.4 ).
Tree - in - bud appearance represents terminal bronchiole
impaction with mucus, pus, or fl uid, resulting in enhanced
appearance of the normal branching bronchial tree that is
normally invisible (Fig. 11.13.5 ). It is seen in diseases that
aff ect the peripheral airways and cause material plugs
deposition within them, such as TB, cystic fi brosis, and
panbronchiolitis.
Fig. 11.13.5. Axial lung window HRCT in a patient with TB
shows peripheral tree-in-bud appearance ( arrowheads )
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Chyliform (lymphatic) pleural effusion may occur
in TB, with deposition of cholesterol within the pleural
space. Fat-fl uid or fat calcium level with calcifi ed pleural margins may be seen on CT.
Empyema necessitates is a rare situation that arises
when the empyema spontaneously discharge through
the parietal pleura into the chest wall, forming a subcutaneous abscess.
Signs on Chest Radiograph and HRCT
Fig. 11.13.6. Axial postcontrast chest CT illustration demonstrates a mass of TB associated with dilated pulmonary vessels
representing Rasmussen pulmonary aneurysm ( arrowhead )
Signs on CT
Rasmussen pulmonary aneurysm is a rare phenomenon character-
ized by dilatation and weakening of the peripheral pulmonary
artery wall from an adjacent TB cavity (Fig. 11.13.6 ). It is seen in up
to 5% of patients, and it may cause life-threatening hemoptysis. It
is detected as TB infl ammatory reaction or cavitary mass, with
dilatation of the peripheral pulmonary artery adjacent to it.
Pleural TB
Pleural TB is the most common extra-pulmonary manifestation of primary or reactivation TB, and it can
alone be the only manifestation of primary TB.
The pleural fl uid often contains granulomata and a
few organisms. When the fl uid contains pus, high protein content (>3 g/dL), and a large number of organisms, it is called “ empyema .” Tuberculous empyema
can be rarely caused by spinal TB draining into the
pleural space via a sinus.
Patients with pleural TB present with pain during
deep inspiration (pleuritic pain), fever, weight loss,
and anorexia.
On plain radiograph, pleural eff usion is seen as loss of the
posterior and lateral costo-phrenic angles along with
meniscus sign.
Pleura thickening on CT is confi rmed when the pleura is >2
mm in width.
When the empyema calcifi es, the CT scan shows empyema
with calcifi ed edges, a clinical condition called “ fi brothorax ”
(Fig. 11.13.7 ).
Empyema necessitates is detected as thickened pleural
eff usion with abscess formation that opens into the chest wall
(Fig. 11.13.8 ).
Fig. 11.13.7. Axial chest CT illustration demonstrates fi brothorax ( arrowheads )
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Fig. 11.13.9. Posteroanterior plain chest radiograph in a patient
with miliary TB shows bilateral diffuse nodules in the lung fi elds
representing miliary TB
Signs on Chest Radiograph
Fig. 11.13.8. Posteroanterior plain chest radiograph in a patient
with old TB and chronic empyema that transformed into a lung
abscess shows a huge right lung abscess ( arrowhead ) and bron-
chiectasis ( arrow ). The patient needed several pleural taps, and the
abscess was beginning to open into the right lateral chest wall
Miliary TB is seen as bilateral symmetrical interstitial nodular
pattern (Fig. 11.13.9 ). Absence of miliary pattern on chest
radiograph does not rule out miliary TB.
Bilateral pleural eff usion may occur.
Miliary TB
Hematogenous spread of TB can be in small numbers
causing no harm, moderate amount affecting one or
two organs (isolated-organ TB), or in a diffuse large
amount (miliary TB). In 5% of primary TB patients,
the infection is not contained within an organ, and is
disseminated into the blood stream and the lymphatic
system, resulting in miliary TB. The term “miliary” is
given because the disseminated lesions (granulomas)
are round and small, mimicking numerous millet seeds.
Miliary TB in HIV patients arises when the CD4 count
is <300/mL.
Miliary TB is divided into acute miliary TB or cryptic miliary TB. Acute miliary TB may be associated
with hyponatremia, inappropriate secretion of antidiuretic hormone, or adrenal insuffi ciency. Cryptic
miliary TB is characterized by silent TB foci that seed
bacilli into the blood stream from time to time; TB foci
may be located within the lungs, kidneys, or lymph
nodes.
Signs on HRCT
Miliar y TB shows multiple, bilateral small nodules (<3 cm in
size) randomly distributed through the lungs (Fig. 11.13.10 ).
Fig. 11.13.10. Axial lung-window HRCT in the same patient of
fi gure 11.13.19 shows the multiple nodular interstitial pattern of
miliary TB
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Abdominal TB
Abdominal TB invades the abdomen, peritoneum, and
pancreato-biliary system via hematogenous spread
from a primary lung or reactivation TB, or from swallowing infected milk. Although any structure can be
involved, the ileocecal valve is the most frequently
affected by granulomas, fi brosis and later scarring.
Patients may present with fever, weight loss, diarrhea, and abdominal pain and distension. Duodenal TB
may results in dyspepsia, while rectal TB may results
in constipation (30%) and passing fresh blood (hematochezia). Fistula-in-ano may arise due to anal TB.
The chest radiograph may be normal in patients with
abdominal TB in up to 60% of cases.
TB peritonitis may develop causing ascites, and
omental and peritoneal thickening. TB peritonitis is
divided into three forms: wet, fi brotic, and dry. Wet peritonitis is characterized by a large amount of viscous
ascetic fl uid (90% of cases). Fibrotic peritonitis is characterized by large omental masses and intestinal adhesions,
causing the omentum to form a hard mass on palpation.
Dry or plastic peritonitis is characterized by fi brous peritoneal reaction, dens adhesions, and caseous nodules.
Diff erential Diagnoses and Related Diseases
Bauhin’s ileocecal valve syndrome is a rare sporadic
disease characterized by hypertrophic ileocecal valve
in the absence of intestinal pathology. Patients classically present with vague abdominal pain, nausea,
vomiting, diarrhea or constipation, and even active
bleeding or melena. Differential diagnoses include
TB, lymphoma, adenocarcinoma, and infl ammatory
bowel diseases.
Nonreactive TB is a rare form of TB characterized by
the formation large abscesses with large quantities of
bacilli without granulomata. The abscesses may
develop in the liver, lungs, or kidneys. Patients often
present with fever, sepsis syndrome, and splenomegaly. This form of TB has been associated with
AIDS, lymphoma, chronic steroid users, diabetics,
and patients with hematological disorders.
Signs on Barium enteroclysis and Enema
Ileocecal valve deformity, ulceration, and fi brosis. Wide
gaping between the valve and the narrowed terminal ileum is
called “ Fleischner sign .”
Coned cecum is a deformity of the cecum into a cone-shaped
structure due to prolonged infection and infl ammation.
Conical cecum with a widely open ileocecal valve and fi xed
terminal ileum is called “ Stierlin’s sign .”
Signs on CT
Thickened peritoneum may be seen as a tiny nodules or a
thick nodular line surrounding the viscera beneath the
abdominal walls, with marked enhancement after contrast
injection.
Irregular or focal omental thickening ( omental cake sign ).
TB ascetic fl uid with septations is seen in 30–100% of cases.
The fl uid typically has attenuation between 25 and 45 HU,
which may refl ect its exodative nature.
Retroperitoneal (e.g., parao-aortic) nodes enlargement.
Intestinal adhesions are identifi ed on CT as intestinal loops
sticking to the abdominal wall.
In Bauhin’s ileocecal valve syndrome , the CT show hypertrophic
ileocecal valve with dilated small bowel loops proximally. The
absence of abnormal contrast enhancement, pathologic
intestinal manifestations, and iliocecal mass are supportive
signs that assist in establishing the diagnosis. Defi nite
diagnosis requires colonic biopsy that typically shows
hypertrophic muscularis layer with absence of infl ammatory
or malignant changes.
Hepatic TB
Hepatic TB is seen as a part of miliary TB, and is characterized by hepatomegaly and liver failure. The bacilli
reach the liver via hematogenous spread through the
hepatic artery. TB can be one of the causes of hepatic
peliosis.
Hepatic peliosis is a pathological condition charac-
terized by segmentally or focally dilated liver sinusoids,
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with or without macroscopically visible blood-fi lled
cysts formation, with no preferential location in the liver.
The blood-fi lled cysts can be lined by hepatocytes
(parenchymal type) or lined by endothelium, and are
based on aneurysmal dilatation of the central vein (phlebectatic type). Hepatic peliosis is caused by chronic
wasting diseases like TB and malignancies, and it is also
reported in long-term abuse of anabolic steroids or prolonged oral contraceptive use. Hepatic peliosis can be
asymptomatic or causes liver failure, portal hypertension, or fatal intra-abdominal bleeding. Peliosis may also
occur in the spleen, bone marrow, and lymph nodes.
Signs on CT
Liver tuberculomas are abscesses that are seen on CT as
multiple, scattered, hypodense lesions through the liver, 1–3
cm in size (Fig. 11.13.11 ).
Large abscesses show ring enhancement after contrast
injection.
Hepatic peliosis has nonspecifi c features, and most reported
features are variable. Histopathology is the defi nite
diagnosing method. The most constant reported features are
hypodense liver lesions that do not show mass eff ect over the
adjacent vessels. The masses show a variable degree of
enhancement, depending on the connection with the normal
liver sinosoids. These masses represent areas of hepatic
necrosis with internal hemorrhagic cysts formation.
Central Nervous System TB
Intracranial TB can occur without evidence of pulmonary TB. It occurs in 10% of AIDS patients. Up to
60% of patients with intracranial TB are younger than
20 years.
TB of the central nervous system may occur in the
form of meningitis (often in children), abscess, tuberculomas, or spinal cord disease. Patients may present with
seizures, cognitive changes, or neurological defi cits.
Signs on CT and MRI
Tuberculous meningitis : there is thickening and enhancement
of the meninges after contrast injection, along with signs of
hydrocephalus due to basal meninges obstruction.
Tuberculous meningitis usually occurs due to rupture of
parenchymal granuloma into the subarachnoid space.
Meningeal enhancement may persist for years after successful
TB therapy.
Tuberculomas : seen as multiple nodular, ring enhancing
lesions (<1 cm). Only active tuberculomas enhance with
contrast, while nonactive tuberculomas will not enhance.
Tuberculoma may show mass eff ect over the adjacent brain
parenchyma.
Tuberculous Abscess : seen as a hypodense area surrounded by
edema and uniform ring enhancement postcontrast injection
(Fig. 11.13.12 ).
Fig. 11.13.11. Axial abdominal-enhanced CT shows multiple
hypodense lesions in a patient with liver TB representing tuberculomas ( arrowheads )
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11.13
Fig. 11.13.12. Axial postcontrast CT image show multiple tuberculous abscesses in a patient with disseminated TB ( arrowheads )
Genitourinary TB
Renal TB commonly occurs due to hematogenous
spread of M. tuberculosis from adjacent primary focus,
usually from the lungs. The urinary tract is infected in
15% of patients.
In the kidneys, there are papillary lesions forming
multiple granulomas, and irregular renal cavities that
may communicate with the calyces.
Patients classically present with burning micturation, frequent urination due to contracted bladder
(29%), renal colic (13%), and (uncommonly) hematospermia. Patients with TB urinary symptoms do not
respond to the usual antibiotics.
Epididymitis in males and tubo-ovarian abscess and
infertility in females may be seen when the genital
organs are infected with TB.
Fig. 11.13.13. Plain abdominal radiograph shows unilateral left
renal parenchymal calcifi cation in a patient with TB
Signs on IVU
There are strictures of the calyces and calcifi cations within the
renal parenchyma (Classic) (Fig. 11.13.13 ).
The presence of psoas abscess supports the diagnosis of renal
TB.
Ureteral strictures may present at the infundibulum, the
ureteropelvic junction, or the distal ureters (saw tooth
appearance). The ureter may become a straight rigid tube,
known as “ pipestem ureter .”
End-stage renal TB results in a small, shrunk, and fi brotic
kidney with poor function and parenchymal calcifi cations
(putty kidney).
Signs on CT
Calcifi cations within the renal parenchyma are seen in up to
50% of cases.
Fibrotic strictures of the infundibulum, renal pelvis, and
ureters (diagnostic).
Putty kidney is a term used to describe end-stage TB kidney,
characterized by a shrunken kidney with extensive calcifi cation that is associated with autonephrectomy (Fig. 11.13.14 ).
Phantom calyx is a kidney in which no collecting system
element can be identifi ed.
Thimble bladder is a very small bladder with reduced capacity
due to thick extensive calcifi cation of the bladder wall.
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affected. Patients present with progressive pain, swelling of the affected joint with loss of function due to
septic arthritis, and synovial pannus formation.
Spina ventosa is a term used to describe a form of TB
osteomyelitis where there is underlying bone destruction, overlying periosteal thickening, and fusiform
expansion of the bone. Very rarely, TB osteomyelitis
can result after vaccination with Bacille-CalmetteGuérin (BCG) vaccine ( BCG osteomyelitis ). BCG vac-
cine is used for preventing TB in many areas of the
world, and it is composed of a live attenuated strain of
Mycobacterium bovis . BCG osteomyelitis usually arises
in infants and children with low immunity, with a very
low incidence (1 or 2 per several million vaccine recipi-
Fig. 11.13.14. Axial postcontrast abdominal CT illustration demonstrates right putty kidney
ents). Symptoms arise during a period ranging from a
few months to 5 years postvaccination. The lesions
occur in the epiphysis and metaphysis, and may cross
the growth plate. BCG osteomyelitis is radiographically identical to TB osteomyelitis. Diagnosis requires
Musculoskeletal TB
culture of the BCG strain for conformation.
Musculoskeletal TB is an uncommon condition that
occurs in 1–3% of patients. M. tuberculosis often infects
the musculoskeletal system via hematogenous spread.
Any bone can be affected, but the spine, hip, and
knee are commonly affected, usually in young patients.
Spinal TB is called “ Pott’s disease ,” and it often affects
the thoracic spine (50% of cases). Pott’s disease is
characterized by kyphosis, cold abscess, and paraplegia. Cold abscess is a localized caseous collection that
can be seen in the lymph nodes, TB of joints, and in
Pott’s disease. In Pott’s disease, it occurs due to collapsed TB-infected vertebra with pus released into the
adjacent paraspinal compartments. It can be seen as a
retropharyngeal abscess (cervical Pott’s disease), retrocardial abscess (thoracic Pott’s disease), and psoas
abscess (lumbar Pott’s disease).
Patients often present with progressive focal back
pain and muscle spasm. Neurological defi cits, cauda
equine compression syndrome, and paraplegia due to
cord compression are uncommon neurological complications of Pott’s disease. Paraplegia occurs in Pott’s
disease (10% of cases) due to cord compression from a
collapsed vertebra or due to spinal cord infarction from
closed vessels due to endarteritis obliterans.
Tuberculous arthritis commonly affects one joint
(monoarthritis). The hip or the knee joint is frequently
Diff erential Diagnoses and Related Diseases
Mycobacterium marinum fl exor tenosynovitis : M. mari-
num is an atypical mycobacterial infection that inhabits
saltwater fi sh and swimming pools. Patients are often
infected with M. marinum after abrasions or puncture to
the hand while working with aquariums. Lesions start to
appear 2–4 weeks after inoculation in the form of focal
tenosynovitis of the hand, usually with lymphadenopathy in the ipsilateral arm. Diagnosis is often delayed for
months due to lack of clinical suspicion, and is often
mistaken for rheumatoid arthritis or gout arthropathy.
Diagnosis is usually diffi cult and requires open surgical
biopsy of the synovium with histological examination.
Ziehl-Nielson stain is often negative, and diagnosis is
established by modifi ed AFB (Fite) stain, which will
stain the M. marinum . On MRI, there is fl exor tenosyno-
vitis with hypertrophied synovium und contrast enhancement similar to the image seen in chronic granulomatous
diseases. Unlike acute purulent tenosynovitis, the bone
and the underlying muscles are rarely affected (characteristic fi nding). Tenosynovitis with normal muscle and
bone marrow signal on postcontrast MRI in a fi sherman or a patient dealing with aquariums should bring
M. marinum tenosynovitis to mind.
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Signs on Radiograph
Vertebral end plate irregularities with decreased high of the
disk intervertebral space (Fig. 11.13.15 ). In contrast to Pott’s
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disease, metastases destroy the vertebral bodies and spare
the disc spaces, while in Pott’s diseases both vertebral body
destruction and intervertebral disc space reduction are found.
Step-off kyphosis : there is loss of the anterior vertebral
endplates with herniation of the intervertebral disk into the
vertebral bodies, causing kyphosis.
Gibbus deformity is referred to as destruction of multiple
thoracic vertebrae, causing angular kyphosis.
Paraspinal (cold abscess) and psoas abscesses may develop
due to extension of the infection to the nearby structures.
The aff ected joint in tuberculous arthritis shows soft-tissue
mass swelling with loss of the joint surface defi nition
(Fig. 11.13.16 ). Articular cartilage destruction and erosion are
commonly seen.
Phemister’s triad : juxta-articular osteoporosis, gradual
joint-space narrowing, and peripheral osseous erosions. It
suggests TB arthritis, but is not specifi c.
Spina ventosa is typically seen in the short bones of the hands
and feet as cyst-like cavities with expansion of the diaphyses
and soft-tissue swelling ( TB dactylitis ) .
Fig. 11.13.16. Plain radiograph of the ankle in a young patient
with tuberculous arthritis shows lateral ankle soft-tissue swelling with bone destruction of the distal fi bular epiphysis and the
metatarsal bones, suggesting osteomyelitis ( arrowheads )
Fig. 11.13.15. Lateral plain radiograph of the thoracic spine in a
patient with thoracic Pott’s disease shows destruction of the vertebral body and narrowing of the intervertebral disc space ( arrows )
Signs on CT
Psoas abscess is seen as an enlarged psoas muscle with a
hypodense center due to abscess formation (Fig. 11.13.17 ).
Rim enhancement after contrast injection is typically seen.
Paraspinal cold abscess is detected as abnormal fl uid
collection adjacent to vertebral destruction (Fig. 11.13.18 ).
Borrowing abscess is a pathological situation characterized by
tracts (sinuses) linking the infected vertebra with the
peritoneal cavity. There may also be sinuses linking the
infected vertebra with the muscles or the skin.
Formation of an epidural abscess is the most feared
complication of Pott’s disease, and it develops in 10–47% of
patients.
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Tuberculous pericarditis that may lead to constrictive pericarditis may occur due to invasion of the pericardium from the adjacent tuberculous hilar lympha
denitis. It is a rare complication that may occur in 1%
of cases. Also, direct bacilli invasion of the mediastinum from the adjacent hilar tuberculous lymphadenopathy may result in infl ammation of the mediastinal
structures (mediastinitis).
Signs on Sonography and PD
Fig. 11.13.17. Axial pelvic CT in a patient with Pott’s disease
shows a large right psoas abscess ( arrowhead ), which drains into
both gluteal muscles ( arrows )
Fig. 11.13.18. Axial nonenhanced vertebral CT shows vertebral
destruction in a patient with Pott’s disease, with left paraspinal
cold abscess formation ( arrowheads )
TB cervical lymphadenopathy shows diff erent fl ow pattern
signals on power Doppler sonography. The most frequent
pattern is hilar fl ow, in which the fl ow signal branches from
the hilus radially. The second pattern is peripheral , where the
signal is spotted fl owing along the periphery of the enlarged
node. A mixed pattern between the hilar and the peripheral
can be seen.
Avascular nodes with no fl ow signal on PD may be seen, and
attributed to caseous necrosis within the nodes.
Signs on CT
Enlarged, circular nodes with a mean size of 20 mm.
Calcifi cation may be seen.
Center caseation of the nodes is seen as low-attenuated
center of the enlarged nodes (Fig. 11.13.19 ).
After contrast administration, enhancement can be peripheral
(characteristic of TB lymphadenopathy), homogeneous, or
homogeneous mixed with peripheral enhancement.
Tuberculous Lymphadenitis
Tuberculous lymphadenitis is a common cause of
lymphadenopathy in primary TB patients. It may occur
in the pulmonary hilar nodes, cervical lymph nodes
(called scrofula ), the mesenteric nodes, the para-aortic
nodes, the axillary and the inguinal nodes. Tabes mes-
enterica is a term used to describe primary TB lymphadenopathy of the mesentery.
Nodal infection arises from hematogenous or lymphatic TB dissemination. Clinical presentation depends on
the lymph nodes affected. The affected nodes may erode
into the adjacent organs, resulting in draining sinuses.
Fig. 11.13.19. Axial abdominal postcontrast CT in a patient
with TB shows enlarged para-aortic lymph nodes with a
hypodense center ( arrowheads )
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