A retrospective study was performed to document the radiological appearances of newly diagnosed pulmonary and extrapulmonary tuberculosis and its relationship with CD4+ T-lymphocyte count in patients with human immunodeficiency virus (HIV) co-infection.
Patients were hospitalized between 2007 and 2012 in Clinic for Infective and Tropical Diseases of Clinical Centre of Serbia inBelgrade.
Study included 17 patient,
12 males and 5 females with their age ranging from 21 years to 52 years,
who had 31 independent episode of tuberculosis.
Information on demography,
history,
signs and symptoms of tuberculosis and imaging results was collected by review of medical records.
Patients treated in ambulant conditions did not enter the study.
HIV serological status was assessed by enzyme-linked immunoassay (ELISA) methods and Western blot.
The diagnosis of tuberculosis was based either on a positive Ziehl-Neelsen staining of a first morning sputum or liquor specimen,
or positive culture of sputum or other specimen on Lowenstein-Jensen medium (together with sensitivity to antibiotics),
or the combination of both a clinical presentation and a chest radiograph or other needed imaging method for both pulmonal and extrapulmonal tuberculosis or response to antitubercular chemotherapy.
In some cases Mycobacterium tuberculosis was proved by hybridisation reaction,
MGIT and PCR.
A posteroanterior chest radiograph was taken of every subject,
as well as abdomen ultrasonography,
blood analysis,
biochemical analysis of serum and liquor,
microbiological analysis of sputum,
liquor,
blood,
urine and feces,
and number of CD4 and CD8 lymphocytes in μL and CD4/CD8 ratio.
If it was needed,
CT,
MRI,
biopsy of lymph node or bone marrow,
bronchoscopy,
oesophagogastroduodenoscopy or colonoscopy and histology examination and culture of specimen were added to protocol.
Most patients were also tested for hepatitis B and C co-infection,
Toxoplasma gondii,
Treponema palidum (sexually transmitted diseases),
as well as other suspected opportunistic infections if needed (such as Criptococcus neoformans,
Candida sp.,
Microsporidiosis,
Hystoplasmosis). In this report only diversity in radiology findings are presented.
Only one patient had typical radiography of lung postprimary tuberculosis,
while all other patients had atypical chest radiography findings,
no matter what was the level of their immunodeficiency.
Three cases of tuberculosis had normal lung radiography and all three had number of CD4 cells under 200/μL.
The commonest form of extrapulmonary manifestation in our study was lymphadenopathy,
thoracal,
cervical or abdominal.
Lymphadenopathies,
enlargement of liver or spleen,
focal lesions in spleen and pathologic findings in brain were seen more frequently in patient with severe immunodeficiency.
After HAART introduction four cases had symptoms of IRIS,
and among them only one patient had number of CD4 cells above 200/μL (exactly 268/μL).
Cultivation of sputum smear in two patients found Mycobacterium avium intracelulare infection instead of Mycobacterium tuberculosis,
and one patient had multidrug resistant species of Mycobacterium tuberculosis.
Typical radiography of lung postprimary tuberculosis with parenchymal infiltration of right upper and apical lung field was seen in patient that had CD4 count above 200/μL.
Patient was 28 years old female,
use to be male,
so besides infiltrates in parenchyma,
we can see silicon implants in patient’s breast on chest radiography.
There were no abnormalities on abdominal ultrasound.
Two months after beginning of tuberculosis treatment patient (who also received HAART) was hospitalized again because of worsening of symptoms and radiology findings,
defined as IRIS.
On chest x-ray (figure no.
1),
we could see spreading of infiltrates that were localised now in apical,
upper and medial lung field.
CT was also done and it showed infiltrative tumour-like lesion,
irregular in shape,
with spiculated margins situated in posterior segment of right upper lobe,
with extension to superior segment of right lower lobe,
4,6x3,5x5,6mm in size,
without enlargement of mediastinal lymph nodes,
with several axillar lymph nodes size up to 1cm.
Abdominal ultrasound was still without pathologic changes.
Treatment of tuberculosis was continued.
Fig. 24
References: Clinic for Infective and Tropical Diseases, Clinical Centre of Serbia, Belgrade, RS
Other patients had atypical presentation of pulmonal tuberculosis,
extrapulmonal tuberculosis or combination of both.
Atypical pulmonal tuberculosis was presented on chest x-ray as infiltration of right middle lung field (figure no.
2) in male patient,
age 31,
besides his high CD4 count level (630/μL),
or parenchymal infiltration of left parahilar region (figure no.
3) in also male patient,
age 27,
that had CD4 count 116/μL.
Fig. 25
References: Clinic for Infective and Tropical Diseases, Clinical Centre of Serbia, Belgrade, RS
Fig. 26
References: Clinic for Infective and Tropical Diseases, Clinical Centre of Serbia, Belgrade, RS
It was also presented as left basal parenchymal infiltration on chest x-ray (figure no.
4) in male patient,
age 37,
with CD4 count 262/μL,
and as massive bilateral infiltrations (figure no.
5) in male patient,
age 30,
with no data about CD4 count at the moment of hospitalization.
Fig. 27
References: Clinic for Infective and Tropical Diseases, Clinical Centre of Serbia, Belgrade, RS
Fig. 28
References: Clinic for Infective and Tropical Diseases, Clinical Centre of Serbia, Belgrade, RS
Female patient,
age 52,
with unknown CD4 count in patient chart had bilateral infiltration in parahilar localisation in combination with bilateral pleural effusion on chest radiography findings (figure no.
6) and another female patient,
age 39,
with CD4 count 21/μL,
had bilateral miliary pattern of infiltration,
(confirmed by CT of thorax) with pneumothorax as later complication (figure no.
7).
Fig. 29
References: Clinic for Infective and Tropical Diseases, Clinical Centre of Serbia, Belgrade, RS
Fig. 30
References: Clinic for Infective and Tropical Diseases, Clinical Centre of Serbia, Belgrade, RS
Male patient,
with heroin and alcohol abuses,
and chronic hepatitis type B and C,
age 35,
CD4 count 214/μL had radiology findings that included parenchimal consolidation as in pneumonia in right parahilar region but with abscess.
It was confirmed on CT of the thorax that found parenchimal consolidation in right lung near hilus with lateral extension,
located in anterior segment of upper lobe,
with abscess cavum 4,5cm in size and 18mm wall thickness,
two smaller cavitations and enlargement of hilar lymph nodes.
(Figure no.
8).
These cases of tuberculosis had no signs of extrapulmonal tuberculosis on clinical examination and performed abdominal ultrasonography.
Fig. 31
References: Clinic for Infective and Tropical Diseases, Clinical Centre of Serbia, Belgrade, RS
Combination of atypical pulmonal and extraplmonal tuberculosis was found in male patient,
age 49 that had CD4 count 32/μL and chest x-ray with massive bilateral infiltrations mostly on lower lung fields.
CT was indicated and it had zone of infiltration of right lung in perihilar and basal region,
with nodal lesion in anterior segment of right upper lobus 15mm in size that had central excavation zone,
and another nodal lesion beside the first one,
13mm in size and with blured margins.
Nodal lesions were also in laterobasal region of right lung 7mm in size,
in apical region of the left lung,
paramediastinal in localisation and 15mm in size,
and also in left lung,
in posterobasal region 10mm in size.
There were also large mass of increased lymph nodes in right hilus,
and enlargement of lymph nodes localised in paratracheal (19 mm),
left prevascular (13-20 mm) and subcarineal (25 mm) area.
Abdominal ultrasound had hepatomegalia with no other findings (figure no.
9).
Fig. 32
References: Clinic for Infective and Tropical Diseases, Clinical Centre of Serbia, Belgrade, RS
Next patient with pulmonal and extrapulmonal tuberculosis was male,
age 23,
and CD4 count 18/μL.
Chest x-ray was done and abdomen ultrasonography.
They found enlargement of left hilus and infiltration of lung parenhim near that hilus,
with enlargement of lymph nodes in liver hilus (10 mm in size) and retroperitoneum as well as hepatosplenomegalia (figure no.
10).
Fig. 33
References: Clinic for Infective and Tropical Diseases, Clinical Centre of Serbia, Belgrade, RS
Abdominal lymphadenopathia was found on ultrasound in female patient,
35 years old,
five years living with HIV,
three years without HAART (at her own decision),
with CD4 count only 3/μL.
She came to hospital with chest x-ray that had left side pneumonia with cavitation.
Infiltration was in both upper and lower lobe with ring shadows that had thick wall,
located in region of second and forth intervertebral space (Figure no.
11).
Fig. 34
References: Clinic for Infective and Tropical Diseases, Clinical Centre of Serbia, Belgrade, RS
Another case of atypical pulmonal tuberculosis that could be misdiagnosed was found in male patient,
21 years old,
with CD4 count that was 50/μL.
He had interstitial pattern of diffuse infiltration on chest x-ray.
CT of the thorax was done and it showed discreet shadows in parenchymal window like “milky glass”,
located in upper lobes bilateral,
more on left side,
which can be seen in vascular lesions and viral pneumonia.
There was no enlargement of thoracic lymph nodes or changes on pleura.
Hepatosplenomegalia was also found on abdominal ultrasound as manifestation of extrapulmonal tuberculosis (figure no.
12).
Fig. 35
References: Clinic for Infective and Tropical Diseases, Clinical Centre of Serbia, Belgrade, RS
Female patient,
33 years old,
with CD4 count that was 56/μL had infiltration of basal part of left lung with small pleural effusion because of pleuropneumonia on chest x-ray,
comfirmed by CT (figure no.
13).
Splenomegalia with hypoechogen lesions 0,4 – 1,1 cm in size and retroperitoneal lymphadenopathy (parapancreatic 2 cm in size,
at least two with central necrosis,
and in hepatic hilus 11 mm in size) were seen on abdominal ultrasound and CT of the abdomen (figure no.
14).
The same patient was received to hospital again two weeks after initiation of HAARRT because of symptoms of IRIS,
with CD4 count 22/μL and progression of findings showed on chest x-ray.
Fig. 36
References: Clinic for Infective and Tropical Diseases, Clinical Centre of Serbia, Belgrade, RS
Fig. 37
References: Clinic for Infective and Tropical Diseases, Clinical Centre of Serbia, Belgrade, RS
One case of multiresistant tuberculosis was found in male patient with age 47,
and CD4 count 34/μL that had chest x-ray showing bilateral pulmonal infiltrates and abdomen ultrasound with enlargement of lymph nodes around portal vein and abdominal aorta,
1cm in size.
Next year he left HAART and came with CD4 count,
which was 97/μL.
Chest x-ray had sequels from tuberculosis and abdominal ultrasound was normal.
He was treated in the next few years for tuberculosis and came with resistance to antituberculotic drugs.
In next few years his lung was destroyed and CT that was done showed big cavity in whole right upper lobe,
with thick walls,
as well as cavity in apicoposterior segment of left upper lobe that has soft tissue mass,
40x25mm in size and air.
Lungs were fibrocystic.
Upper parts of pleura were thick,
and mediastinum was dislocated to the right.
CD4 count was 371/μL (figure no.
15).
Fig. 38
References: Clinic for Infective and Tropical Diseases, Clinical Centre of Serbia, Belgrade, RS
Fig. 39
References: Clinic for Infective and Tropical Diseases, Clinical Centre of Serbia, Belgrade, RS
Only extrapulmonal tuberculosis was confirmed in male patient,
40 years old,
who came to hospital with CD4 count 14/μL and with normal chest x-ray.
He received HAART and after one month he came with symptoms of IRIS.
CD4 count was 64/μL and radiography of patient’s lung was normal,
but CT of abdomen had hepatosplenomegalia,
with lacunar low attenuated multifocal lesion on spleen,
and enlargement of retroperitoneal lymph nodes,
paraaortal,
infrarenal,
nodes near both a.
iliaca communis,
and the biggest one in interaortocaval region 2 cm in size (figure no.
16).
Inchomogen lesion in right m.
psoas was haemorrhage because of haemophilia that patient had.
His next hospitalization was three months later because of fistulization of neck lymph node and fever when abdomen ultrasound was done and showed hepatosplenomegalia and enlargement of retroperitoneal lymph nodes that had signs of central necrosis.
TB lymphadenitis was treated in male patient,
age 23,
with CD4 count 39/μL,
and enlargement of neck lymph nodes.
The same patient came five years later with CD4 count below 200/μL and abdominal ultrasound that found infraumbilical soft tissue mass,
hypo to unechogen,
which consists of aggregate of increased lymph nodes,
three at least,
30 mm,
20 mm and 21 mm in size.
Fig. 40
References: Clinic for Infective and Tropical Diseases, Clinical Centre of Serbia, Belgrade, RS
There were two cases of neurotuberculosis.
First case was male patient with age 24 and CD4 count 76/μL,
who had also splenomegalia on abdominal ultrasound and normal chest x-ray.
His findings of endocranium CT were: interstitial oedema next to the frontal and occipital horn of lateral brain ventricle that was,
as well as al other brain ventricles,
normal in size.
Brain sulcuses on the left frontotemporoparietal region were smaller,
and there was oval low attenuated lesion on the left parietal and periventricular region without compressive effect.
After application of intravenous contrast,
meningeal opacification of left frontotemporoparietal region was found.
All described findings correspond to localised meningoencephalitis (figure no.
17).
Fig. 41
References: Clinic for Infective and Tropical Diseases, Clinical Centre of Serbia, Belgrade, RS
Another case of neurotuberculosis,
also with splenomegalia on abdominal ultrasound and normal chest x-ray was in male patient,
age 25,
and with CD4 count 169/μL.
CT findings were left temporoparietal focal encephalitis and on NMR zone of encephalomalacia in left parietooccipitial region as sequel of tuberculosis and brain infarct in zone of arteria cerebri media,
with regression of focal lesion (tuberculoma) and glyosis as TB sequel on the right,
without acute lesions (figure no.
18).
Fig. 42
References: Clinic for Infective and Tropical Diseases, Clinical Centre of Serbia, Belgrade, RS
Two patients had sputum culture positive for Mycobacterium avium intracellulare.
First one had only pulmonal pathology.
It was male,
age 36,
without CD4 count in the chart.
First lung radiography was normal but after beginning of HAART,
progression of bilateral parenchymal infiltrate and appearance of cavitations,
more at the left side of lung,
was seen.ThoraxCTwas done and showed bilateral bizarre consolidation of parenchyma,
more expressed in subpleural and basal region,
with gas inclusion in mediastinum and subcutan region of neck and right axilla (figure no.
19).ControlCTwas done after two months of therapy and showed reduction of lesions.
Bronchoscopia was done and findings were bronchitis chronica.
Antituberculotic drugs were introduced ex iuvantibus.
Fig. 43
References: Clinic for Infective and Tropical Diseases, Clinical Centre of Serbia, Belgrade, RS
Another Mycobacterium avium intracellularae positive patient was male,
age 42,
who started with HAART and came back again because of IRIS symptoms with CD4 count 44/μL.
CT of the thorax was done and findings were massive lymphadenopathy in all lymph groups,
especially in paratracheal (33 mm in size) and hilar (30 mm in size) group.
Bilateral zones of consolidation in pulmonal parenchyma,
mostly in right upper lobe and parahilar region like pneumonitis,
were seen.
Besides pulmonal changes his abdominal ultrasound showed hepatosplenomegalia and rectosigmoidoscopia was also done with no changes of intestinal mucosa.
Antituberculotic treatment was introduced ex iuvantibus (figure no.
20).
Fig. 44
References: Clinic for Infective and Tropical Diseases, Clinical Centre of Serbia, Belgrade, RS