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tuberculosis viral infections mediastinum radiology

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Information about tuberculosis viral infections mediastinum radiology
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Published on March 3, 2014

Author: saketjain543

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tuberculosis viral infections mediastinum radiology
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Dr Saket Kumar Jain (Resident) Dept. Of Radio-Diagnosis MGM HOSPITAL

 Two types – primary and post primary  Patients who develop disease after initial exposure are considered to have primary TB .  Primary site of infection in the lungs is called the Ghon focus.  The combination of the Ghon’s focus and affected lymph nodes is known as the primary complex .  “ Ranke complex ”

Patterns Parenchymal Primary Post-primary Self limiting progressive dense, homogeneous parenchyma consolidation in any lobe patchy, poorly defined consolidation, particularly in the apical and posterior segments of the upper lobes however, predominance in the lower and middle lobes is suggestive of the disease, especially in adults in majority- more than one pulmonary segment is involved, with bilateral disease seen in one-third to two-thirds of cases. appearance is often indistinguishable from that of bacterial pneumonia

Cavitations' primary Post primary Rare Cavitation, the hallmark of postprimary tuberculosis typically have thick, irregular walls, which become smooth and thin with successful treatment Are multiple Lymphadenopathy is seen in up to 96% of children and 43% of adults typically unilateral and right sided, involving the hilum and right paratracheal region although it is bilateral in about one-third of cases it can be the sole radiographic finding more common in infants and decreases in frequency with age seen in only about 5% of patient

Pleural effusion Primary Post primary seen in approximately one-fourth of patients seen in approximately 18% of patients with postprimary tuberculosis often the sole manifestation of tuberculosis usually small and associated with parenchymal disease very uncommon finding in infants & is usually unilateral effusions are typically septated

Ranke complex

Parenchymal primary tuberculosis in an adult.

 Widespread hematogenous dissemination of Mycobacterium Tuberculosis  So named because the nodules are the size of millet seeds (1mm to 3 mm)  Diffuse, random distribution  Takes weeks between the time of dissemination and the radiographic appearance of disease  When first visible, they measure about 1 mm in size; they can grow to 2-3mm if left untreated

 No matter what form of TB the patient has, it tends to look like 1° TB  Hilar and mediastinal adenopathy are common  Cavitation is less common  There is no predilection for the apices  Atypical mycobacterium( MAI - mycobacterium aviumintracellulare) is more common in HIV than Mycobacterium Tuberculosis

SARCOIDOSIS HISTOPLASMOSIS

 Consolidation - ? acute pneumonia .  The term consolidation does not imply any particular aetiology or pathology .  Acute pneumonia is the commonest cause but not the only cause of consolidation --- ( other causes include chronic pneumonia, pulmonary oedema and neoplasm)

 what is consolidation ? Refers to fluid in the airspaces of the lung Consolidation may be complete or incomplete The distribution of the consolidation can vary widely. A consolidation could be described as “patchy”, “homogenous”, or generalized”. A consolidation may be described as focal or by the lobe or segment of lobe affected

Batwing sign Pulonary edema (especially cardiogenic) pneumonia

Air bronchogram refers to the phenomenon of air-filled bronchi (dark) being made visible by the opacification of surrounding alveoli (grey - white).

 Micro-organisms responsible may enter the lung by three potential routes:  via the tracheobronchial tree  via the pulmonary vasculature  via direct spread from infection in the mediastinum, chest wall, or upper abdomen

INFLUENZA PARAINFLUENZA Outbreaks in winter Risk in DM, Elderly, IC In winter Self limited Dry cough, headache, myalgia, fever, croup and otitis media Croup , coughing , dyspnea , wheezing , tonsilitis, pharyngitis Superadded bact inf. Can occur In children with croup may show subglottic tracheal narowing so called STEEPLE sign Multifocal patchy consolidation may be uni/bilateral Multifocal patchy consolidation may be uni/bilateral Plerual effusion uncommon

Influenza

RSV MEASLES (RUBEOLA) Winter & spring Imp. Cause of both URTI &LRTI in infants & young children Year round In children-URTI- pharyngitis, rhinitis, otitis media Fever, myalgia, headache, conjuctivitis cough LRTI- coughing, dyspnea, wheezing, intercoastal retraction Rhinorrhea followed by skin rash Perihilar linear opacities , bronchial wall thickening, patchy areas of consolidation B/L patchy air space consolidation associated in perihilar In children-may be lymph node enlargement

RSV Measles

HERPES SIMPLEX-1 Affects oral cavity ,LRTI occurs if organism is transported into trachea & bronchi They are severly immunocompromised Multifocal consolidation due to bronchopneumonia • Herpes simplex – 2 – acquired during child birth

Varicella zoster virus – pneumonia presents as high fever rapidly followed by skin rash Appear as diffuse small nodules in the range of 5-10 mm that progress to air space consolidation rather rapidly Hilar lymphadenopathy is common Pleural effusion is rare

 It is the central compartment of the thoracic cavity

Superior mediastinum contents "BATS & TENT": Brachiocephalic veins Arch of aorta Thymus Superior vena cava Trachea Esophagus Nerves (vagus & phrenic) Thoracic duct Anterior mediastinum 3 ; T’s Thymus Thyroid Thoracic aorta Middle mediastinum Heart surrounded by the pericardium great vessels : ascending aorta superior vena cava pulmonary trunk Trachea bifurcation Posterior mediastinum: contents “DATES”: Descending aorta Azygos and hemiazygous veins Thoracic duct Esophagus Sympathetic trunk/ganglia

Felsons method of division -  Anterior,  Middle,  Posterior.

 RADIOLOGY • Plain chest x-ray. • CT of the chest ( procedure of choice for mediastinal masses ) • MRI (may enhance the diagnostic abilities of chest CT) ▪ FNA or needle biopsy with CT guidance .

 A normal thymus is visible in 50% of pediatric age group of 0– 2 years of age.  The size and shape of the thymus are highly variable  The thymus is seen as a triangular sail (thymic sail sign) frequently towards the right of the mediastinum. It has no mass effect on vascular structures or airway.

THYMIC SAIL SIGN

 The most common neoplasm of the anterosuperior compartment  Radiograph: small, well-circumscribed mass or as a bulky lobulated mass confluent with adjacent mediastinal structures  Symptoms: • chest pain • dyspnea • hemoptysis • cough • superior vena cava syndrome • systemic syndromes caused by immunologic mechanisms

 Enlarged thyroid usually are considered retrosternal (also referred to as mediastinal, intrathoracic, or substernal) when more than 50% of the thyroid parenchyma is located below the sternal notch  Presentation - Substernal Goiters Asymptomatic Choking sensation, particularly in supine position Vague chest pain or heaviness Respiratory • Dyspnoea • Orthopnea • Cough • Respiratory distress/insufficiency • Airway obstruction Neural •Hoarseness •Hemidiaphragm elevation Esophageal •Dysphagia •Odynophagia

       The mediastinum is commonly involved in lymphoma, either as part of disseminated disease or less commonly as the site of primary involvement. Symptoms retrosternal chest pain SVC Compression with SVC SYNDROME dyspnoea Cough PLAIN FILM A soft tissue mass may be clearly visible, or more frequently the mediastinum is widened, and the retrosternal space is obscured.

 This is a broad term used to encompass a number of congenital mediastinal cysts derived from the embryological foregut.  They include bronchogenic, esophageal duplication and neuroenteric cysts .  Bronchogenic cysts are the most common.

Bronchogenic cyst Esophageal Duplication Cyst

Neurenteric cysts

These are congenital out-pouchings from the parietal pericardium

A hiatus hernia occurs where there is herniation of stomach through the esophageal hiatus of the diaphragm Two types: Sliding(99%) Rolling/paraoesophageal(1%)

Any cranial nerve may be involved, except CNI and CN2 which lack sheaths composed of schwann cells CN VIII (acoustic neuroma) most commonly the superior portion of vestibular nerve (most common) CN V (2nd most common) CN VII (3rd most common) Clinical presentation Presentation depends on location of the tumor.

 Pneumomediastinum is the presence of extra luminal gas within the mediastinum. Gas may come from lungs, trachea, central bronchi, esophagus, and the neck or abdomen. “Continuous diaphragm sign” of pneumomediastinum

spinnaker sign (also known as the angel wing sign)

TUBERCULOSIS VERY COMMON – HIGH INDEX OF SUSPICIONCLINICAL PRESENTATION Its easy to diagnose consolidation but difficult to interpret it , correlation with clinical symptoms is the key point MEDIASTINUM - To diagnose a pathology , very difficult - complete work-up HISTORY , X-RAY + further investigation

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