Tuberculous adenopathies

Anatomic recall

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Most frequent localisations of TB adenopathies

Hilar adenopathies:

-Opacities with convexe external edge

- opacities overlapping normal vascular opacities

Bilateral adenopathies

Hilar adenopathy Normal hilus

The tuberculous adenopathies are:

• Sometimes unilateral (latero-tracheal )• Most often bilateral and asymetric • Sometimes compressive, especially in children• Some lesions are possible inside the bronchi:

compression or fistula • Adenopathies are frequent in cases of AIDS: they are

often bulky and associated with other pulmonary lesions or extra-pulmonary TB

• AFB are most often negative in sputum, except in cases of pulmonary lesions (pneumonia, cavern..) associated with adenopathies

The most important differential diagnosis are:

• Metastatic adenopathies of bronchial cancer

• Lymphoma and hodgkin disease• Sarcoïdosis (incidence in developping

countries ?)

Do not forget 2 radiological differential diagnosis:

- overlap sign of the hilus (anterior or posterior)

- vascular hypertrophy (convergence sign of the hilus)

Don’t forget:

For a good analysis of the mediastinum, it is necessary to have a good quality chest x-ray:

• Strictly front view• Complete inspiration • Patient standing up, postero-anterior

incidence

Bilateral tb adenopathies

Right latero-tracheal opacity: Tuberculous adenopathies

Normal CXR

Man, 20 years old , Asymptomatic,Good condition, HIV - systematic chest radio.AFB negative in sputum

Right latero-tracheal and precarena space adenopathies. AFB-, Diagnosis made by mediastinoscopy: epithelioid and gigantocellular

granuloma. Culture +

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Young woman, 22 years old. Weight loss and cough. Contact with a tuberculous case 6 monthes ago. Positive

skin test with phlyctena

Normal chest x-ray

African woman, 27 years old. Left cervical adenopathy

Left latero-aortic adenopathies in superior mediastinum

Puncture of the cervical adenopathy:Pus with AFB+

Tuberculous right hilar adenopathy

Widening of the mediastinum: adenopathies of superior and middle

mediastinum

Normal chest x-ray

/In subcarena and inter tracheo bronchial areas (red arrows) , lateral view

is usefull for diagnosis of adenopaties

Lateral view is very usefull for diagnosis of mediastnum adenopathies in sub carena and inter tracheo bronchial areas

Rx normale

Right hilar adenopathy. Is there mediastinum associated adenopathies? Notice mediastinum enlargment

Left side, previous case : hilar and mediastinum adenopathies.. On the right side normal lateral view. Lateral view is useful to confirm hilar and mediastinum adenopathies (red arrow) in the carena area. Notice partial atelectasis of the middle lobe (yellow arrow).

Normal lateral view

Bulky left hilar adenopathy. Associated mediastinum adenopathies are well visible on the lateral view

Normal lateral view

Young child, one year old: TB primary-infection

Notice the bilateral adenopathies with inferior lobe atelectasis (left inferior bronchus compressed by adenopathy )

Tuberculous bulky adenopathies. AIDS context. Infiltration into the surrounding lung tissu

Tuberculous adenopathies with endo-bronchial fistula(endoscopic view)

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Fistulas coming from TB adenopathiesFistula in the right para-cardiac bronchus

Tuberculosis / HIV +

Tuberculosis with mediastinal adenopathies and pneumonia in a patient with AIDS. AFB++ in sputum

The association of unilateral or bilateral pneumonia with mediastinal adenopathies

is very indicative of Tuberculosis, and often, HIV context.

Adenopathy in left aorto-pulmonary space( and widening of superior mediatinum due to TB adenopathies)

Normal chest radiography

Node calcifications: sequela of primary infection

Left hilar calcification: sequela of a TB primary infection

However, the mediastinal adenopathies are not always

tuberculous…

Male, poor health condition, smoker, dyspneaRight inferior lobe cancer and metastatic adenopathies

(laterotracheal space). Notice the associated emphysema.

Small cell carcinoma with bulky mediastinal adenopathies

Evolution after 6 cycles of chemotherapy

Bronchial cancer with superior vena cava syndrome(No superior vena cava syndrome in tubercular

adenopathies)

Bronchial cancer with right hilar metastatic adenopathy

Man, 60 years old, weight loss and asthenia, cough with hemoptoic sputum. AFB-

Bronchial cancer!Right superior bronchus

Spur infiltrated by the cancer

normal bronchus

Lymphoma (hodgkin disease)

Sarcoidosis

Trap: mediastinum enlargement in an older woman with cyphoscoliosis

Differential diagnosis: vascular bulky hilus: Convergence sign of the hilus

Differential diagnosis: posterior overlap sign

Differential diagnosis: Posterior overlap sign (2)

Differential diagnosis: anterior overlap

Differential diagnosis: Anterior overlap sign (courtesy of Dr. Bellamy)

anterior overlap