Dr. Pepe’s Diploma Casebook – The art of interpretation – CASE 146 – SOLVED

Findings: PA radiograph shows convexity of the aortopulmonary window (A, white arrow) and increased opacity of the left hilum (A, red arrow). The lateral view shows a faint opacity projected over the middle third of the thoracic spine (B, circle) that was overlooked in the initial reading.
The convexity of the APW suggested mediastinal lymphadenopathy, and CT was performed.

Coronal enhanced CT shows an enlarged lymph node in the APW (A, arrow). Axial CT depicts enlarged lymph nodes in the left hilum (B, circle). Lung window demonstrates air-space disease in the apical segment of the LLL (C, arrow), which explains the posterior faint opacity in the lateral view.

Summary of CT findings:

– Unilateral enlarged hilar lymph nodes
– Lymph node in APW
– Air-space disease in the apical segment of LLL

The most significant finding is the presence of unilateral hilar lymph nodes which have a limited differential diagnosis: in the great majority of patients they are due either to lung carcinoma or active tuberculosis. As this particular patient is 27 y.o., carcinoma is unlikely. Therefore, our tentative diagnosis should be active TB, which is also supported by disease in the apical segment of the LLL, a common location for TB.

The patient was placed in isolation, bronchoscopy was performed, and Mycobacterium tuberculosis was found in the aspirate.

Final diagnosis: active tuberculosis

YOUNG PERSON + UNILATERAL ENLARGED HILAR LYMPH NODES + PULMONARY INFILTRATE IN APICAL SEGMENT OF LLL = ACTIVE TUBERCULOSIS

Active pulmonary tuberculosis is not uncommon, and the chest radiograph plays an important role in its detection. Findings that help to suspect TB in the plain film are:

Location of the parenchymal disease. Involvement of the apices or the apical segment of either lower lobe should raise the possibility of a tuberculous infiltrate, although TB can affect any area of the lung.

Cavitation. The presence of cavities within a pulmonary infiltrate suggest tuberculosis or necrotic pneumonia.

Visible lymphadenopathies. Tuberculous lymph nodes are usually unilateral and located in the hilum and homolateral mediastinum. In about one third of patients they are bilateral. In such cases, lymphoma and sarcoidosis, among others, should also be considered.

CT refines these parameters by discovering cavitation or lymphadenopathy that is not evident in the plain film. The presence of low-attenuation lymph nodes due to caseous necrosis is highly suggestive of TB, although it is not pathognomonic. Other conditions can also show these features. However, normal-density lymph nodes do not exclude TB, as was seen in the present case.

Below, I show a few nice images of active TB in which low-attenuation lymph nodes
suggested the correct diagnosis.

CASE 1

23-year-old woman with cough and low-grade fever. Chest radiographs shows air-space disease in the RLL (A and B, white arrows). There is obvious widening of the right paratracheal line (A, red arrow), indicating mediastinal lymphadenopathy.

Enhanced axial CT confirms the RLL disease which is non-specific (C, arrow). No cavitations are visible. The mediastinal window shows numerous enlarged lymph nodes, some with a hypodense center (D and E, arrows) and others with peripheral enhancement (ring sign) (F, arrows).

Abdominal CT also shows enlarged mesenteric lymph nodes with the ring sign (G and H, circles).

It is interesting to note that lower lobe TB occurs in only 5% of patients. In this particular case the diagnosis of TB was suggested by the CT appearance of the affected lymph nodes. Mycobacterium tuberculosis was recovered from sputum.

Final diagnosis: active TB

Dr. Pepe’s teaching points:

1. Think of TB in unilateral hilar adenopathy in a young person.

2. Low-density lymph nodes on CT are highly suggestive of active TB, although normal-density nodes do not exclude it.