Extra- pulmonary tuberculosis · los casos de afección del aparato digestivo. También son sitios...
Transcript of Extra- pulmonary tuberculosis · los casos de afección del aparato digestivo. También son sitios...
25Vol. 5 / Nº 14 - Septiembre 2016
Extra-pulmonary tuberculosisLuciana Sánchez, Federico Felder, Marcos Dellamea, María Paz García Kosinsky, Andrés Sáez, Mariano Volpacchio.
Pictorial essay
Resumen
La tuberculosis (TBC) continúa siendo un importante
problema de salud pública a nivel mundial y una causa
significativa de enfermedad y muerte en muchos
países. El incremento de la prevalencia en las últimas
décadas se debe al aumento en el número de pa-
cientes inmunocomprometidos, frecuentemente con
afección extra-pulmonar. Dado que puede compro-
meter cualquier parte del cuerpo humano, es una de
las entidades a tener en cuenta entre los diagnósticos
diferenciales, sea cual fuera el área afectada. Así, la
diversidad de los hallazgos radiológicos de la TBC
dificulta reconocer esta entidad y realizar su diagnós-
tico. El compromiso extra-pulmonar se presenta en el
sistema músculo esquelético y el área más afectada es
la columna vertebral. En el sistema nervioso central
adquiere varias formas que incluyen meningitis, tuber-
Abstract
Tuberculosis (TB) remains a major public health pro-
blem worldwide and a significant cause of illness and
death in many countries. The increasing prevalence in
recent decades is due to the increase in the number of
immunocompromised patients, often with extrapul-
monary conditions. Since it can involve any part of the
body, it is one of the entities to be considered in the
differential diagnosis, whatever the affected area is. The
diversity of radiological findings of TB makes it difficult
to recognize this entity and provide a diagnosis. Extra-
pulmonary involvement occurs in the musculoskeletal
system and the most affected area is the spine. In the
central nervous system, it acquires several forms inclu-
ding meningitis, tuberculoma, abscesses, cerebritis and
miliary spread of mycobacterium tuberculosis. Ileocecal
involvement is present in 80-90% of cases of gastroin-
Contact information:
Luciana Sánchez.
Hospital de Clínicas José de San Martín - Ciudad de Bs. As.
E-mail: [email protected]
Recibido: 10 de agosto de 2015 / Aceptado: 12 de noviembre de 2015
Received: August 10, 2015 / Accepted: November 12, 2015
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Sánchez L. et al.Extrapulmonary tuberculosis
culoma, abscesos, cerebritis y diseminación miliar. El
compromiso ileocecal está presente en el 80-90% de
los casos de afección del aparato digestivo. También
son sitios frecuentes de afección el aparato genitouri-
nario y el sistema linfático, en particular en los niños
con adenopatías cervicales o supraclaviculares. Otros
infrecuentes son mamas, laringe, glándulas suprarre-
nales y partes blandas. Nuestro objetivo es describir
las manifestaciones extra-pulmonares de la TBC y es-
tablecer los diagnósticos diferenciales con patologías
que presentan patrones similares en imágenes.
Palabras clave: Tuberculosis extrapulmonar, enferme-
dad de Pott, tuberculosis ileocecal, meningitis tuber-
culosa, tuberculosis peritoneal.
testinal conditions. Other common sites of involvement
are the genitourinary system and the lymphatic system,
particularly in children with cervical or supraclavicular
lymphadenopathy. Some less frequent sites are breasts,
the larynx, adrenal glands and soft tissues. Our purpose
is to describe extrapulmonary manifestations of TB and
establish differential diagnosis with other pathologies
with similar patterns in images.
Key words: Extrapulmonary tuberculosis, Pott disease,
ileocecal tuberculosis, meningitis, peritoneal tuberculosis.
IntroductionTuberculosis (TB) is generally associated with the in-
volvement of the respiratory system; however, it can
affect any organ. Its increasing prevalence is related
to the increase in the number of immunocompro-
mised patients and the resistance to pharmacologic
treatment. These determining factors make TB an
important entity that has to be taken into account
in the diagnosis, especially in developing countries.
This article presents the most frequent radiological
findings of extrapulmonary TB.
Musculoskeletal systemTB of the musculoskeletal system represents up to
35% of cases of extrapulmonary tuberculosis. Howe-
ver, only 1-3% of all cases of TB show this type of in-
volvement and less than 50% have evidence of con-
comitant active thoracic TB (1, 2). The most frequent
forms of presentation are spondylitis, arthritis, and
osteomyelitis. Bone conditions and joint destruction
cause a severe morbidity. Vertebral involvement cau-
ses severe neurological consequences (2).
Spondylitis (Pott disease)In the musculoskeletal system, the most affected site
by TB is the spine, and the most affected levels are
the lower dorsal region and the upper lumbar region.
Generally, it involves more than one vertebral body,
although isolated involvement of one vertebra can be
observed. It is believed that the process is a result of
homogeneous dissemination through venous plexus.
The infection starts in the anterior part of the verte-
bral body adjacent to the inferior plates, followed by
demineralization of the vertebral plate with a loss
of image definition and extension towards the ad-
jacent intervertebral disc. The alteration of the in-
ternal structure of the disk allows the dissemination
towards the contiguous vertebral segment, resulting
in the classical pattern of more than one vertebral
body with intervertebral disc involvement (Figures
1a and 1b). The infection can also extend towards
paravertebral tissue, creating muscle abscesses (Figu-
res 1c and 1d), including the psoas muscle (Figure
2). A delay in treatment can cause vertebral collapse
or anterior wedging of the vertebral body with for-
mation of a hump. As a consequence of treatment,
there can be ankylosis of the affected segment. The
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Extrapulmonary tuberculosisSánchez L. et al.
differential diagnosis includes metastatic disease,
pyogenic infection, brucellosis, mycosis, and sarcoi-
dosis. The main difference with metastasis lies in the
lack of frequency with which TB involves posterior
vertebral elements. In initial stages, it is difficult to
differentiate the involvement of pyogenic infection
due to TB and, therefore, it is essential to consider
the clinical evolution of the patient to differentiate
the conditions (3).
Arthritis The tuberculous arthritis is a monoarthritis that pro-
gresses slowly and compromises the joints that su-
pport weight, such as the hip and knees. The disse-
mination is produced from a focal point of diaphyseal
osteomyelitis that goes through the metaphysis and
opens towards the joint. With less frequency, it dis-
seminates hematogenously towards the synovial
membrane. Radiological findings are unspecific and
similar to other types of inflammatory or infectious
arthritis with osteopenia, synovitis, soft tissue in-
flammation, marginal erosion mainly at the synovial
insertion, partial destruction of the cartilage, and
decreased articular space in later stages. In young
patients, synovial compromise causes hyperemia and
epiphyseal overgrowth. The progression of the infec-
tion can cause bone sequestration. The final result is
fibrous ankylosis of the joint. The clinical presenta-
tion is insidious and causes pain, joint edemas and
a decrease in the range of movement. Diagnosis is
established due to clinical evolution, mild sclerosis
compared to other entities, limited periosteal reac-
tion and lack of alterations in the articular space in
later stages. The differential diagnosis includes pyo-
genic and fungal infection.
Osteomyelitis Extraspinal tuberculous osteomyelitis often appears with
local pain and can affect any bone, mainly the femur,
the shinbone or the bones of hands and feet. Generally,
it appears with osteolytic lesion and minimal sclerosis
at the level of metaphysis (Figure 3). Also, it can cause
bone destruction, bone sequestration and extension to
soft tissues. The involvement of adjacent structures can
lead to complications such as carpal tunnel syndrome,
tenosynovitis and facial paralysis (5). Tuberculous os-
teomyelitis without associated arthritis is not frequent.
Central Nervous SystemAround 5% of patients with TB have CNS compro-
mise, although this prevalence increases in immu-
nocompromised patients. Generally, dissemination
occurs hematogenously and can manifest itself
as a meningoencephalitis, communicating hydro-
cephalus, tuberculoma, tuberculous abscess or ce-
rebritis (1).
Meningoencephalitis Meningeal TB is the most common manifestation of
the central nervous system. Its early diagnosis is es-
sential due to the associated morbidity and mortality.
Dissemination can be hematogenously or through
direct extension of CSF. A typical finding is menin-
geal enhancement with intravenous contrast, more
marked in basal cisterns, cerebral convexity and Syl-
vian fissures (Figure 4). The most frequent complica-
tion is communicating hydrocephalus and ischemic
stroke due to vascular compression and occlusion of
small puncturing vessels (6) (Figure 5). Radiological
findings are unspecific and the differential diagnosis
is done with other infectious agents, sarcoidosis and
neoplastic involvement.
TuberculomaThe most frequent lesion of the cerebral parenchy-
ma is tuberculoma or tuberculous granuloma. It can
be isolated or multiple and its most frequent loca-
tion is frontal or parietal. They appear as nodules
or rounded masses of variable density in CT with
homogenous enhancement or ring enhancement af-
ter contrast administration (Figure 6). In some cases,
there is a target sign due to the presence of a central
calcification. The appearance in MRI depends on the
level of central caseous necrosis showing a hyper-
intense center in case of liquid content. Perilesional
edema is variable and generally less than the metas-
tatic lesions. Tuberculomas can be associated with
meningoencephalitis (7).
Tuberculous abscessTuberculous abscess are masses with a multilocula-
ted liquid center, heterogeneous enhancement af-
ter contrast administration, severe edema and mass
effect. The differential diagnosis includes other abs-
cesses of infectious origin.
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Sánchez L. et al.Extrapulmonary tuberculosis
Abdominal tuberculosis Gastrointestinal TBGastrointestinal compromise is rare and the ileocecal
region is the most affected (80-90%). Typically, it is
presented with concentric parietal thickening of the
cecum wall, terminal ileum and ileocecal valve (Figu-
re 7). It can cause a luminal stenosis with intestinal
occlusion, dilation of loops and appear with regional
mesenteric adenopathy. When the disease is advan-
ced, there can be deformity, stenosis, shortening or
retraction of the intestine. Differential diagnosis is
made with adenocarcinoma, intestinal inflammatory
diseases, amebiasis and Behçet’s disease (8).
Hepatosplenic TBThis form of presentation generally occurs in patients
with disseminated disease and can adopt a micro-
or macro-nodular pattern. The micro-nodular or mi-
liary form is seen in patients with miliary lung TB. It
appears with dispersed small nodules measuring less
than 2 mm. They can be seen with MRI but they may
not be seen with CT. Differential diagnosis is made
with metastasis, mycosis or sarcoidosis (Figure 8).
Macronodular form is rare and it is also called tuber-
culoma. It can be isolated or multiple, it measures
from 1 to 3 cm, it is hypodense in CT, hypointense in
T1 and hyperintense in T2. Enhancement is variable,
but most frequently marginal. Differential diagnosis
is made with metastasis, primary neoplasia or pyoge-
nic abscesses (9).
Peritoneal TBFrequently, peritoneal involvement is associated with
other types of gastrointestinal tuberculosis. Dissemi-
nation can be hematogenously or direct. The most
frequent form of presentation is with great amount
of free liquid or loculated viscous fluid, omental and
mesenteric multinodular thickening simulating a pe-
ritoneal carcinomatosis. There is also a fibrotic retrac-
table form with mesenteric thickening and intestinal
adhesions (10) (Figure 9).
Figure 1. Spondylitis due to TB. Images of the cervical rachis. MRI in T1 (A) and STIR (B). CT with contrast
(C and D). Hyperintense signal of bone marrow in C6, C7 and interverte-
bral disc in A and B (arrows). Large paravertebral collection (C) and lytic
involvement of vertebral bodies (D) (arrows).
A B
D
C
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Extrapulmonary tuberculosisSánchez L. et al.
Figure 2. CT of lumbar spine.Osteolytic lesion due to TB (A) and small abscess of the left psoas muscle (B) (arrows).
A
B
Figure 3. Tuberculous osteomyelitis in CT.Metaphyseal lytic lesion in the medial end of the left collarbone (A) with a collection of fluid (B) (arrows).
A B
Figure 4. Meningoencephalitis.Sagittal T1 with contrast (A) and FLAIR (B). There is meningeal enhancement and thickening in cerebral convexity
(A) and right parietal edema (B) (arrows).
A
B
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Sánchez L. et al.Extrapulmonary tuberculosis
Figure 5. Skull CT without contrast. Communicating hydrocephalus in patient with tuberculous
meningitis.
Figure 6. Skull CT with contrast in two patients with tuberculoma (A and B). Intraparenchymatous nodules with annular enhancement and scarce perilesional edema (arrows).
A
B
Figure 7. Abdominal CT with contrast in pa-tient with ileocecal TB. Concentric ileocecal parietal thickening and node with
necrotic center in the root of the mesenterium (arrows).
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Extrapulmonary tuberculosisSánchez L. et al.
Figure 8. Abdominal CT with contrast. Small hypodense images in the hepatic parenchyma in
patient with disseminated tuberculosis (arrows).
Figure 9. Abdominal CT without contrast. Patient with disseminated tuberculosis showing ascites
with multinodular peritoneal thickening.
Genitourinary systemRenal TBFrequently, renal compromise is unilateral in 75% of
patients in its initial presentation. It appears as a cor-
tical caseous lesion with destruction of the tissue. Ge-
nerally, it is self-limited. In other occasions, it evolves
progressively adopting the following patterns:
1- Nodular form: It is similar to tuberculoma in other
locations; however, it is rare (Figure 10).
2- Cavitary exudate/caseous form: It is the most fre-
quent and it is characterized by caseous necrosis and
a tendency to open towards the calyx or renal pelvis.
3- Mastic kidney: It represents the natural healing of
renal TB. It is also called retractable fibro-caseous
renal tuberculosis and corresponds to the destruc-
tion of the renal parenchyma after accumulation of
caseous material due to ureter obstruction of inflam-
matory origin.
Radiological findings include erosion of calyxes
that is evident in excretory phase, hydronephrosis
of irregular margins, filling defects due to caseous
material, and cavitation of the renal parenchyma. In
later stages, more than 50% of the cases present lobar
calcifications, scars and retractions (11).
Ureteral TBDilation and irregular appearance of urothelium are
the first signs of ureteral TBC. Ureteral dilation is cau-
sed mainly by an inflammation of the uretero-vesical
union due to urethritis or tuberculous cystitis. In later
stages there can be areas of stenosis, shortenings,
filling defects or calcifications (11) (Figure 11).
Vesical TBTuberculous cystitis in initial stages does not present
specific characteristics, although in later stages it can
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Sánchez L. et al.Extrapulmonary tuberculosis
be small, irregular and calcified. Differential diagno-
sis is made with schistosomiasis, actinic changes or
calcified carcinoma (11) (Figure 12).
Female genital TBFemale genital TB compromises the fallopian tubes
in 94% of the cases and can disseminate towards pe-
ritoneum, endometrium, ovaries, cervix, and vagina.
Patients have pelvic pain, present infertility and va-
ginal bleeding. Tubo-ovarian abscesses with intra- or
extra-peritoneal extension are suggestive of tubercu-
losis (12).
Male genital TBThe most affected organ by TB is the prostate. Ultra-
sound shows hypoechogenic areas with an irregular
pattern that predominates in the peripheral region.
Lesions are hypodense in CT, and they cannot be
differentiated with pyogenic prostatic abscesses or
neoplasia. To be able to do it, MRI is the most useful
means due to its high contrast definition (12).
Lymphatic systemAdenopathy is a frequent form of presentation in
extrapulmonary TB, especially at the cervical and
supracervical level in pediatric patients. CT shows
adenopathic conglomerates with hypodense cen-
ter due to caseous necrosis and marginal enhan-
cement with intravenous contrast injection (13)
(Figure 13).
Other rare forms of presentationAdrenal TB Generally, TB compromise is bilateral and asymme-
trical with diffuse enlargement of the glands, creating
big heterogeneous masses that are difficult to diffe-
rentiate from metastasis. After treatment, the glands
are stunted and there is diffuse calcification of them
(Figure 14).
Mammary TBIs a rare condition. Even though findings are uns-
pecific, it can be seen as a hypoechogenic mass of
abscesses in ultrasound with moving internal echoes
and posterior acoustic enhancement. In MRI, these
abscesses are hypointense in T1, hyperintense in T2
and have peripheral enhancement (2).
Laryngeal TB Radiological findings of laryngeal TB are thickening
of soft tissues with infiltration of pre-epiglottic and
para-laryngeal fatty space, which is impossible to
differentiate from other inflammatory or neoplastic
processes, such as lymphoma (14) (Figure 15).
Ocular TB It is an infrequent condition and can compromise
any component of the orbit. Habitual forms are chro-
nic anterior uveitis, choroiditis and sclerokeratitis.
However, choroidal tuberculoma is the best docu-
mented form of presentation (15) (Figure 16).
Cutaneous TBCutaneous presentation is not frequent and it is ge-
nerally associated with disseminated disease. Infec-
tion can occur due to direct inoculation, which is
rare, or hematogenously. Radiologically, they are
seen as subcutaneous lesions with soft tissue density
of unspecific aspect (16) (Figure 17).
Pancreatic TBIt is an atypical condition by TB and can simulate
a carcinoma, lymphoma, cystic neoplasia, pancrea-
titis or pseudocyst. It affects immunocompromised
patients and has multiple hypodense areas with mar-
ginal enhancement in the pancreatic parenchyma,
with a tendency to present central liquefaction (17)
(Figure 18).
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Extrapulmonary tuberculosisSánchez L. et al.
Figure 10. Abdominal CT with contrast. Small hypodense subcortical nodules in both kidneys
with alteration of the nephrogram in patient with disse-
minated hematogenous tuberculosis (arrow).
Figure 11. Abdominal CT with contrast.Coronal (A), sagittal (B) and axial (C) view. Left ure-
teral dilation with stenosis areas in the uretero-vesi-
cal union of tuberculous origin (arrows).
A
B
C
Figure 12. Abdominal CT with contrast. Consequence of tuberculous cystitis with retracted
bladder (arrow).
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Sánchez L. et al.Extrapulmonary tuberculosis
Figure 13. CT of three patients with adenitis due to TB. Cervical and supracervical location (A and B);
necrosis mediastinal location (C); and retro-
peritoneal location (D) (arrows).
A
B
C
D
Figure 14. Abdominal CT. A) Increase in the size of the left adrenal gland of tuberculous origin and B) adrenal calcifica-
tions due to TBC (arrows).
A
B
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Extrapulmonary tuberculosisSánchez L. et al.
Figure 15. Neck CT with contrast (A and B). Concentric laryngeal thickening with involvement of the pre-epiglottic space due to TB in a
pediatric patient (arrows).
A B
Figure 16. Orbits CT with contrast.Posterior focal thickening of the left ocu-
lar membranes with protrusion towards
the interior of the eyeball and enhan-
cement with contrast in a patient with
disseminated TB (arrows).
A B
C
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Sánchez L. et al.Extrapulmonary tuberculosis
Figure 17. Patient with HIV and disseminated tuberculosis. Multiple cutaneous/subcutaneous lesions that are visible in CT (A and B) (arrows).
A B
Figure 18. Abdominal CT without contrast (A), with contrast (B), oblique reconstruction (C) and late phase (D). HIV patient with disseminated TB and pancreatic involvement with two hypodense images,
necrotic center and marginal enhancement (arrows).
A B
C
D
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Extrapulmonary tuberculosisSánchez L. et al.
Conclusion Radiological characteristics of extrapulmonary TB
can simulate multiple diseases. It is essential to sus-
pect the condition with high certainty, especially in
risk patients. Generally, microbiological culture and
anatomic pathology of the lesion are indicated to
reach a definite diagnosis.
Bibliography1- Burrill J, Williams CJ, Bain G, Conder G, Hine AL, Misra RR. Tuberculosis: A radiologic review. Radiographics 2007;
27: 1255-1273
2- Engin G, Acunas B, Acunas G, Mehtap T. Imaging of extrapulmonary tuberculosis. Radiographics 2000; 20: 471-488.
3- Moon MS. Tuberculosis of the spine. Controversies and a new challenge. Spine 1997; 22 (15): 1791-1797
4- Yao DC, Sartoris DJ. Musculoskeletal tuberculosis. Radiol Clin North Am 1995; 33 (4):679-689.
5- Resnick D. Tuberculous infection. In: Resnick D, ed. Diagnosis of bone and joint disorders. 3rd ed. London, United
Kingdom: Saunders, 2002; 2525-2545.
6- Whiteman ML. Neuroimaging of central nervous system tuberculosis in HIV-infected patients. Neuroimaging Clin N
Am 1997; 7 (2):199-214.
7- Morgado C, Ruivo N. Imaging meningo-encephalic tuberculosis. Eur J Radiol 2005; 55 (2): 188-192.
8- Gore RM, Ghahremani GG. Radiologic investigation of acute inflammatory and infectious bowel disease. Gastroen-
terol Clin North Am 1995; 24 (2): 353-384.
9- Suri S, Gupta S, Suri R. Computed tomography in abdominal tuberculosis. Br J Radiol 1999; 72 (853): 92-98.
10- Marshall JB. Tuberculosis of the gastrointestinal tract and peritoneum. Am J Gastroenterol 1993; 88 (7): 989-999.
11- Wang LJ, Wong YC, Chen CJ, Lim KE. CT features of genitourinary tuberculosis. J Comput Assist Tomogr 1997; 21
(2): 254-258.
12- Golden MP, Vikram HR. Extrapulmonary tuberculosis: an overview. American Family Physician 2005; 72 (9): 1761-
1768.
13- Mert A, Tabak F, Ozaras R, Tahan V, Ozturk R, Aktuglu Y. Tuberculous lymphadenopathy in adults: a review of 35
cases. Acta Chir Belg 2002; 102 (2): 118-121.
14- Moon WK, et al. CT and MR imaging of head and neck tuberculosis. Radiographics 1997; 17 (2): 391-402.
15- Tognon MS, et al. Tuberculosis of the eye in Italy: a forgotten extrapulmonary localization. Infection 2014; 42 (2):
335-42.
16- Dias MF, Bernardes Filho F, Quaresma MV, Nascimento LV, Nery JA, Azulay DR. Update on cutaneous tuberculosis.
An Bras Dermatol 2014; 89 (6): 925-38.
17- Meesiri S. Pancreatic tuberculosis with acquired immunodeficiency syndrome: a case report and systematic review.
World J Gastroenterol 2012; 18 (7): 720-726.