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Radiology module

NTM-LD and bronchiectasis. Radiology module. NP-EU6-00064. Development of the slide repository and financial support. The slide repository was developed by a multidisciplinary European scientific committee: Gianluca Milanese, Radiologist University of Parma, Italy

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Radiology module

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  1. NTM-LD and bronchiectasis Radiology module NP-EU6-00064

  2. Development of the slide repository and financial support • The slide repository was developed by a multidisciplinaryEuropean scientific committee: • Gianluca Milanese, Radiologist University of Parma, Italy • Stefano Aliberti, Respiratory Physician University of Milan, Italy • Claire Andrejak, Pulmonologist CHU Amiens-Picardie, Amiens, France • James Chalmers, Respiratory Physician Ninewells Hospital, Dundee, UK • Jakko van Ingen, Clinical Microbiologist Radboud University Medical Centre, Nijmegen, The Netherlands • Eva Polverino, Pulmonologist, expert in respiratory infections Vall d’Hebron University Hospital, Barcelona, Spain • Dirk Wagner, Infectious disease expert University of Freiburg Medical Centre, Germany • The development of this slide repository by the multidisciplinary European scientific committee was facilitated by Physicians World Europe GmbH and funded by Insmed

  3. Radiology module – Table of contents Diagnosis of NTM-LD • Diagnostic criteria: Clinical, radiographic, and microbiological criteria must be met to make a diagnosis of NTM-LD • Chest radiography versus HRCT (procedure, limitations) • Chest radiography versus HRCT (benefits/advantages) • Chest radiography versus HRCT (example images) • How frequently should chest radiography be performed? Chest radiography • Nodular/bronchiectatic form of NTM-LD • Fibrocavitary form of NTM-LD • Hypersensitivity-like pneumonitis High resolution computed tomography (HRCT) • Radiographic criteria • HRCT – current practice in European countries • Nodular/bronchiectatic form of NTM-LD • Fibrocavitary form of NTM-LD • Hypersensitivity-like pneumonitis • Presentation of NTM-LD by HRCT in immunocompromised patients • NTM-LD pulmonary comorbidities – Bronchiectasis • HRCT: NTM-LD in bronchiectasis • Three main radiological categories ofbronchiectasis • NTM-LD pulmonary comorbidities – Cystic fibrosis • NTM-LD pulmonary comorbidities – COPD • NTM-LD pulmonary comorbidities – Aspergillosis/ABPA • Tree-in-bud pattern: Differential diagnoses • Cavities: Differential diagnoses • Comparison of CT features in tuberculosis and NTM-LD • Pulmonary TB and NTM-LD: Comparison of radiographic findings Radiological diagnosis and follow-up of NTM-LD: Multidisciplinary management of the assessment journey Summary Glossary COPD, chronic obstructive pulmonary disease; CT, computed tomography; HRCT, high resolution computed tomography; NTM-LD, non-tuberculous mycobacterial lung disease; TB, tuberculosis.

  4. Diagnosis of NTM-LD

  5. Diagnostic criteria: Clinical, radiographic, and microbiological criteria must be met to make a diagnosis of NTM-LD Positive culture required Sputum, bronchial wash* or lung biopsy Pulmonary symptoms Exclusion of other diagnoses Clinical criteria Microbiological criteria ? Radiographic criteria HRCT: Chest radiograph: multifocal bronchiectasis, multiple nodules, cavitary disease Nodular and cavitary opacities *Bronchial wash only used when sputum samples are unavailable. HRCT, high resolution computed tomography; NTM-LD, non-tuberculous mycobacterial lung disease. Griffith DE, et al. Am J Respir Crit Care Med 2007; 175:367-416.

  6. Chest radiography versus HRCT Plain chest radiography HRCT • Initial workup/first diagnostic tool, preliminary procedure as HRCT is required for full diagnosis1 • No considerable risks to patients (non-invasive, very high benefit-risk ratio)1 • Thin volumetric acquisition; expiratory acquisition in selected patients1 • Reduced risk to patients due to low dose scanning protocol1 • CT follow up scan should be done in the same hospital using the same acquisition procedures1 • Focus on whole pulmonary parenchyma1 Procedure • Usually not specific • Difficult to differentiate from TB, granulomatous fungal infections, sarcoidosis, organizing pneumonia or other diseaseswith upper lobe opacities (e.g. cancer)1,2 • Findings of focal bronchiectasis associated with early NTM infections are easily missed • Only 70% of patients with established bronchiectasis by CT scan have a detectable abnormality on chest radiographs2 • Abnormalities on plain chest radiography, including the persistence of cavities, have been reported in up to 75% of patients at the end of treatment, even among those who had shown a satisfactory clinical response and culture conversion3 • Number limited based on clinical decisions depending on disease severity and response to treatment1 • Often nonspecific • Certain patterns on HRCT scans are associated with high specificity, atypical presentations of pulmonary TB and granulomatous fungal infections, which can mimic those of NTM-LD2 • Typical patterns, e.g. multifocal bronchiectasis with patchy consolidation and centrilobular nodules, have been defined and have a high positive predictive value2 • CT provides a better depiction of important abnormalities2 ! Limitations CT, computed tomography; HRCT, high resolution computed tomography; NTM, non-tuberculous mycobacteria; NTM-LD, non-tuberculous mycobacterial lung disease; TB, tuberculosis.1. Personal communication by scientific committee (G Milanese, S. Aliberti, E Polverino, D. Wagner, J van Ingen, J Chalmers), scientific committee meeting Paris, France 15/09/2018; 2. Agrawal A. Medscape 2003, updated 2016; (https://emedicine.medscape.com/article/358828-print); 3. Haworth CS, et al. Thorax 2017; 72:ii1-ii64.

  7. Chest radiography versus HRCT HRCT Plain chest radiography • Useful in identifying specific diagnostic features of NTM infections: • Multiple small parenchymal nodules in a centrilobular pattern • Associated multifocal bronchiectasis involving more than 1 lobe • Progressive fibrosis and atelectasis of the affected areas • Endobronchial spread (5–10 mm centrilobular peribronchiolar opacities with clustering) • More extensive nodular-bronchiectatic disease with scattered centrilobular nodules, a tree-in-bud pattern, and focal bronchiectasis • Abnormalities in immunocompromised patients that can be missed on chest radiographs • Subtle disease, cavitation and effusions that can be missed by chest radiographs • In appropriate clinical contexts, typical findings have a high predictive value • MAC infections may be distinguished from TB by the presence of widespread bronchiectasis, particularly if it involves the right middle lobe and lingula • Cavitation is usually associated with positive sputum results Benefits/Advantages HRCT, high resolution computed tomography; MAC, Mycobacterium Avium Complex; NTM, non-tuberculous mycobacteria; NTM-LD, non-tuberculous mycobacterial lung disease; TB, tuberculosis.Agrawal A. Medscape 2003, updated 2016; (https://emedicine.medscape.com/article/358828-print).

  8. Chest radiography versus HRCT HRCT Plain chest radiography Imaging First radiographic findings of NTM-LD can be identified by chest radiography. HRCT is needed to image more detailed patterns for a specific diagnosis HRCT, high resolution computed tomography; NTM-LD, non-tuberculous mycobacterial lung disease. Personal communication by scientific committee (G Milanese, S. Aliberti, E Polverino, D. Wagner, J van Ingen, J Chalmers), scientific committee meeting Paris, France 15/09/2018. Images provided by S. Aliberti.

  9. How frequently should chest radiography be performed? • Timing and technique for follow up imaging depends on patients’ situation, clinical conditions and available clinic equipment1 • Chest radiography or CT scan should be performed if NTM-LD is suspected2 • CT scan should be performed shortly before starting NTM treatment and at the end of NTM treatment to document the radiological response to treatment2 • During the course of NTM-LD therapy, more frequent radiological monitoring may be indicated in selected individuals to inform treatment decisions2 • There are no prospective studies indicating which radiological features are most informative during and following treatment for NTM-LD2 • Timing of the two procedures must be carefully considered to limit the number of CT scans1 CT, computed tomography; NTM, non-tuberculous mycobacteria; NTM-LD, non-tuberculous mycobacterial lung disease.1. Personal communication by scientific committee (G Milanese, S. Aliberti, E Polverino, D. Wagner, J van Ingen, J Chalmers), scientific committee meeting Paris, France 15/09/2018; 2. Haworth CS, et al. Thorax 2017; 72:ii1-ii64.

  10. Chest radiography

  11. Chest radiographyNodular/bronchiectatic form of NTM-LD • Bronchiectasis and clusters of small nodules1 • Branching linear structures involving middle lobe and lingula1 • NTM-LD should be suspected in patients (especially elderly females) with tubular or ill-defined opacities in middle lobe or lingula2 NTM-LD, non-tuberculous mycobacterial lung disease. 1. Kwon YS, Koh W-J. Korean Med Sci 2016; 31: 649-659; 2. Mycobacterium Avium Complex - Radiology Key 2018 (https://radiologykey.com/mycobacterium-avium-complex). Images provided by G. Milanese.

  12. Chest radiographyFibrocavitary form of NTM-LD • Consolidation of thin-walled cavities predominant in the upper lobes with areas of increased opacity1–3 • Marked involvement of pleura over involved areas of lungs; pleural effusions2,4 • Pleural thickening and volume loss by fibrosis with traction bronchiectasis are frequent3 • Lesions are indolent and progress slowly3 • No lymph node calcification3 • NTM-LD should be suspected in any patient with unexplained upper lung zone opacities5 NTM-LD, non-tuberculous mycobacterial lung disease. 1. Kwon YS, Koh W-J. Korean Med Sci 2016; 31: 649-659; 2. Griffith DE, et al. Am J Respir Crit Care Med 2007; 175:367-416; 3. Ryu YJ, et al. Tuberc Respir Dis (Seoul) 2016; 79:74-84; 4. Personal communication by scientific committee (G Milanese, S. Aliberti, E Polverino, D. Wagner, J van Ingen, J Chalmers), scientific committee meeting Paris, France 15/09/2018; 5. Mycobacterium Avium Complex - Radiology Key 2018 (https://radiologykey.com/mycobacterium-avium-complex). Images provided by G. Milanese.

  13. Chest radiographyHypersensitivity-like pneumonitis • Chest radiographs are often normal1 • Numerous poorly defined, small (<5 mm) opacities throughout both lungs, sometimes with sparing of the apices and bases1 • Nonspecific diffuse interstitial or nodular ground-glass opacities2 • Zonal distribution varies from patient to patient and may vary over time in the same patient1 • A pattern of fine reticulation and volume loss may occur, particularly in the upper lungs1 • Peribronchial thickening may be visible1 1. Hirschmann JV, et al. Radiographics 2009; 29:1921-38; 2. Mycobacterium Avium Complex - Radiology Key 2018 (https://radiologykey.com/mycobacterium-avium-complex).

  14. High resolution computed tomography (HRCT)

  15. Radiographic criteria • Radiographic criteria1 • Nodular or cavitary opacities on chest radiograph • Or multifocal bronchiectasis with multiple small nodules on HRCT scan • Fibrocavitary disease1 • Chest HRCT indicated for evaluation • Nodular/bronchiectatic disease1 • Chest HRCT indicated for evaluation HRCT should also be used during treatment follow-up2,3 HRCT, high resolution computed tomography. 1. Griffith DE, et al. Am J Respir Crit Care Med 2007; 175:367-416; 2. Personal communication by scientific committee (G Milanese, S. Aliberti, E Polverino, D. Wagner, J van Ingen, J Chalmers), scientific committee meeting Paris, France 15/09/2018; 3. Elicker BM, et al. Eur Respir Rev 2017; 26.

  16. HRCT – current practice in European countries • Current protocols: Volumetric acquisition and thin section reconstructions (<1.5mm)1 • Volumetric acquisition should be performed if multidetector scanners are available1 Multiplanar reformatted images: Coronal and sagittal views may facilitate the evaluation of disease distribution and extent1 Minimum intensity projections: Allow for evaluation of low contrast structures such as airways1 Expiratory acquisition: To detect air trapping1 • How can the radiation burden be reduced?1 • Lower tube current to 20–30 mA • Automatic exposure control • Iterative reconstruction algorithms HRCT allows evaluation of the whole pulmonary parenchyma, even in regions that might be difficult to assess by plain chest radiography1,2 HRCT, high resolution computed tomography. 1. Personal communication by scientific committee (G Milanese, S. Aliberti, E Polverino, D. Wagner, J van Ingen, J Chalmers), scientific committee meeting Paris, France 15/09/2018; 2. Verschakelen J. ILD Care Today 2016; 9:20-30.

  17. HRCT: Nodular/bronchiectatic form of NTM-LD HRCT, high resolution computed tomography; NTM-LD, non-tuberculous mycobacterial lung disease.1. Griffith DE, et al. Am J Respir Crit Care Med 2007; 175:367-416; 2. Kwon YS, Koh W-J. Tuberc Respir Dis 2014; 77: 1-5; 3. Mycobacterium Avium Complex - Radiology Key 2018 (https://radiologykey.com/mycobacterium-avium-complex); 4. Weiss CH, Glassroth J. Expert Rev Respir Med 2012; 6:597-612; quiz 3. Image provided by G. Milanese. • Bilateral multifocal bronchiectasis and bronchiolitis1,2 manifested by: • Mosaic pattern of perfusion or hyperinflation with airway narrowing3 • Characteristic pulmonary infiltrates in “tree-in-bud” pattern:1,4 Branching centrilobular nodules that occur within lobes affected with bronchiectasis but also scattered throughout uninvolved lung3 • Cylindrical bronchiectasis often affects the right middle lobe and the lingula, middle and lower lung fields1 • Bilateral small nodules in the lungs1,4 • In later stages cavities may also develop4

  18. HRCT: Fibrocavitary form of NTM-LD HRCT, high resolution computed tomography; NTM-LD, non-tuberculous mycobacterial lung disease. 1. Griffith DE, et al. Am J Respir Crit Care Med 2007; 175:367-416; 2. Bonaiti G, et al. Biomed Res Int 2015; 2015:197950; 3. Agrawal A. Medscape 2003, updated 2016; (https://emedicine.medscape.com/article/358828-print). Images provided by G. Milanese. • Radiological features are similar to tuberculosis1 • Areas of increasing opacity and cavitation2 • Usually the upper lobes of the lung are affected2 • Frequent apical pleural thickening and fibrosis with volume loss and bronchiectasis visible2 • Pleural effusions are infrequent but not rare3 • Differences to tuberculosis:1 • Thin-walled cavities with less surrounding parenchymal opacity • Less bronchogenic, but more related spread of the disease • Increased involvement of the pleura in the affected areas of the lungs

  19. HRCT: Hypersensitivity-like pneumonitis Chest CT scans are always abnormal Most show diffuse nodular infiltration Ground-glass opacities and mosaic patterns are commonly observed CT, computed tomography; HRCT, high resolution computed tomography. Griffith DE, et al. Am J Respir Crit Care Med 2007; 175:367-416. Image provided by W. Hoefsloot.

  20. Presentation of NTM-LD by HRCT in immunocompromised patients One recognised pattern is scattered alveolar opacities and bilateral nodules, but this is not specific for the disease Segmental or lobar consolidation may be seen Miliary spread is occasionally observed Lymphadenopathyand pleural effusions may be the only abnormalities, with no evidence of parenchymal disease • Immunocompromised patients with clinical infection may have no radiographic abnormalities due to abnormal inflammatory responses • A high index of suspicion should be maintained in patients with HIV as a wide spectrum of radiological findings can be seen HIV, human immunodeficiencyvirus; HRCT, High-resolution computed tomography; NTM-LD, non-tuberculous mycobacterial lung disease. Agrawal A. Medscape 2003, updated 2016; (https://emedicine.medscape.com/article/358828-print).

  21. NTM-LD pulmonary comorbidities – Bronchiectasis Chest CT • Bronchus visible within 1 cm of pleural surface • Lack of tapering • Increased bronchial:arterial ratio • Bronchial wall thickening • Mucoid impaction • Air trapping and mosaic perfusion Chest radiograph • Abnormal findings but usually inadequate for diagnosis or quantification • May include: • Tram track opacities • Air-fluid levels • Poor definition of pulmonary vasculature • Increased bronchovascular markings CT, computed tomography; NTM-LD, non-tuberculous mycobacterial lung disease. Bronchiectasis. 2018. (Accessed September, 2018, at https://radiopaedia.org/articles/bronchiectasis).

  22. HRCT:NTM-LD in bronchiectasis • Approximately 8% of patients with adult‑onset bronchiectasis diagnosed by HRCT are found to have an active NTM infection1 • Typical HRCT findings of bronchiectasis coinciding with NTM: • Multiple small nodules along with the occasional appearance of one or more cavities combined with diffuse bronchiectasis2 * • Clinicians should be aware that bronchiectasis and NTM-LD are connected • Because of considerable overlap in common HRCT findings, it is difficult to differentiate species of NTM-LD based on radiologic patterns3 *NTM active disease. HRCT, High-resolution computed tomography; NTM, non-tuberculous mycobacteria; NTM-LD, non-tuberculous mycobacterial lung disease. 1. Fowler SJ, et al. Eur Respir J 2006; 28:1204-10; 2. Mirsaeidi M, et al. Int J Infect Dis 2013; 17:e1000-4; 3. Ryu YJ, et al. Tuberc Respir Dis (Seoul) 2016; 79:74-84.Images provided by G. Milanese.

  23. Three main radiological categories of bronchiectasis • In 1950, Reid categorized bronchiectasis as having 3 main radiological phenotypes:1,2 • Tubular (aka follicular or cylindrical) • Characterized by smooth dilation of the bronchi • Varicose (bulbous) • The bronchi are dilated with multiple indentations • Cystic (saccular/balloon appearance) • Dilated bronchi end in blind ending sacs • May be confused with cavitary lung disease 1. Reid LM. Thorax 1950; 5:233-47; 2. King PT. Int J Chron Obstruct Pulmon Dis 2009; 4:411-9. Images provided by G. Milanese.

  24. NTM-LD pulmonary comorbidities – Cystic fibrosis Chest CT • Bronchial wall and peribronchial interstitial thickening • Acute infectious bronchiolitis • Tree-in-bud appearance • Centrilobular nodular and branching opacities • Bronchiectasis • Mosaic attenuation pattern • Mucus plugging within bronchi Chest radiograph • Presence of thick walled bronchiectasis – from cylindrical to varicoid and cystic forms • Perihilar distribution • Found in upper lobes and in apical segments of lower lobes • Hyperinflation • Lobar collapse • Pulmonary arterial enlargement due to pulmonary hypertension CT, computed tomography; NTM-LD, non-tuberculous mycobacterial lung disease. Cystic fibrosis (pulmonary manifestations). 2018. (Accessed September, 2018, at https://radiopaedia.org/articles/cystic-fibrosis-pulmonary-manifestations-1). Images provided by G. Milanese.

  25. NTM-LD pulmonary comorbidities – COPD Chest CT • Centrilobular, panlobular or panseptal emphysema • Bronchial wall thickening • Air trapping • Narrowing of trachea in coronal plane • Pulmonary artery enlargement in pulmonary hypertension Chest radiograph • Poor sensitivity to detect COPD • Possible findings include • Flattened diaphragm due to hyperexpansion • Decreased peripheral bronchovascular markings • Loss of lung parenchyma • Bullae • Hilar vessel prominence in patients with pulmonary hypertension COPD, chronic obstructive pulmonary disease; CT, computed tomography; NTM-LD, non-tuberculous mycobacterial lung disease. COPD - summary. 2018. (Accessed September, 2018, at https://radiopaedia.org/articles/copd-summary); Images provided by G. Milanese.

  26. NTM-LD pulmonary comorbidities – Aspergillosis/ABPA Chest CT • Temporary pulmonary opacities • Centrilobular nodule (dilated and opacified bronchioles) • Bronchiectasis(particularly upper lobe saccular bronchiectasis) • Mucoid impaction • Bronchial wall thickening • Calcification in impacted mucus • Upper lobe pulmonary fibrosis (chronic disease) • Cavitation in 10% patients Chest radiograph • Transient patchy areas of consolidation (eosinophilic pneumonia) • Bronchiectasis, branching dilated bronchi • “Finger in glove” sign • Pulmonary collapse due to endobronchial mucoid impaction • Temporary shadows on the lung (representing pulmonary infiltrates) ABPA, Allergic Bronchopulmonary Aspergillosis; CT, computed tomography; NTM-LD, non-tuberculous mycobacterial lung disease. Allergic bronchopulmonary aspergillosis. 2018. (Accessed at https://radiopaedia.org/articles/allergic-bronchopulmonary-aspergillosis.). Image provided by G. Milanese.

  27. Tree-in-bud pattern: Differential diagnoses Infections Other causes • Postprimary tuberculosis (A)Associated with malnutrition and immune suppression • NTMLacks upper-lobe predominance • Viral infectionsCytomegalovirus (B)and respiratory syncytial virus • FungiNeutropenic and immunosuppressed patients • Congenital disordersCystic fibrosis, Kartagener syndrome (C) • Idiopathic disordersObliterative bronchiolitis, diffuse panbronchiolitis • Aspiration of foreign substances • Immunological disorders • Connective tissue disorders • Peripheral pulmonary vascular disease NTM, non-tuberculous mycobacteria. Gosset N, et al. AJR American journal of roentgenology 2009; 193:W472-7. Images provided by G. Milanese.

  28. Cavities: Differential diagnoses Infections Other causes • NTMIncluding slow- and fast-growing mycobacteria • TuberculosisParticularly common in diabetics • Necrotising pneumoniaDue to Streptococcus pneumoniae, Haemophilus influenza, Klebsiella pneumoniae, Staphylococcus aureus (A) • Parasitic infectionsEchinococcus (tapeworm); Paragonimiasis (trematode) • Fungi Aspergillus species can form cavities containing mycetoma (B) • Malignancies (C) • Autoimmune diseasesGranulomatosis with polyangiitis (GPA) (D) • Pulmonary embolism (E) • Organising pneumoniaCalled cryptogenic organising pneumonia when no underlying etiology (F) NTM, non-tuberculous mycobacteria. Gadkowski LB, Stout JE. Clinical microbiology reviews 2008; 21:305-33. Images provided by G. Milanese.

  29. Comparison of CT features in tuberculosis and NTM-LD Tuberculosis1,2 NTM-LD1,2 • Cavity wall <3 cm • Small parenchymal nodules • Lymph node calcification • Cavity wall >3 cm • Pulmonary consolidation • Patchy, reticular infiltrates • Atelectasis • Mediastinal and hilar lymph nodes • Lymph node calcification • Pleural effusion There is considerable overlap in the radiographic manifestations of pulmonary TB and NTM-LD, and radiographic find­ings alone cannot be used to differentiate between the two diseases3 CT, computed tomography; NTM-LD, non-tuberculous mycobacterial lung disease; TB, tuberculosis. 1. Yuan M-K, et al. BMC Pulm Med 2014; 14:65; 2. Kim C, et al. PLoS One 2017; 12:e0174240; 3. Kwon YS, Koh W-J. Tuberc Respir Dis 2014; 77: 1-5. Images provided by G. Milanese.

  30. Pulmonary TB and NTM-LD: Comparison of radiographic findings HRCT, high resolution computed tomography; NTM-LD, non-tuberculous mycobacterial lung disease; TB, tuberculosis.1. Kwon YS, Koh W-J. Tuberc Respir Dis 2014; 77: 1-5; 2. Kwon YS, Koh W-J. Korean Med Sci 2016; 31: 649-659; 3. Griffith DE, et al. Am J Respir Crit Care Med 2007; 175:367-416.

  31. Radiological diagnosis and follow-up of NTM-LD: Multidisciplinary management of the assessment journey NTM-LD cannot be diagnosed using radiologic imaging alone Diagnosis requires the clinical/pathologic demonstration of disease, followed by definitive microbiological isolation of the organism1–3 A multidisciplinary approach supports diagnosis and management1,4 • Radiologists: • Interpret follow-up CT scans; symptoms may have improved but radiographic findings may not • Pulmonologists: • Provide other diagnostic information about the patient which may be suggestive of NTM-LD (e.g. sputum culture results) CT, computed tomography; NTM-LD, non-tuberculous mycobacterial lung disease. 1. Personal communication by scientific committee (G Milanese, S. Aliberti, E Polverino, D. Wagner, J van Ingen, J Chalmers), scientific committee meeting Paris, France 15/09/2018; 2. Griffith DE, et al. Am J Respir Crit Care Med 2007; 175:367-416; 3. Agrawal A. Medscape 2003, updated 2016; (https://emedicine.medscape.com/article/358828-print); 4. Ryu YJ, et al. Tuberc Respir Dis (Seoul) 2016; 79:74-84.

  32. Summary • Radiology is an important component of the diagnosis and follow-up of NTM‑LD1 • Diagnosis also requires microbiological and clinical criteria to be fulfilled1 • Patients with NTM-LD may suffer from a number of comorbidities, which should be considered when making a radiological diagnosis1 • Classic signs of NTM-LD (cavitation and tree-in-bud opacities) may overlap those of other diseases2,3 • It is not possible to differentiate between tuberculosis and NTM-LD using radiological criteria alone4,5 • The radiologist is a key part of the multidisciplinary team required to manage patients with NTM-LD6 NTM-LD, non-tuberculous mycobacterial lung disease. 1. Griffith DE, et al. Am J Respir Crit Care Med 2007; 175:367-416; 2. Gosset N, et al. AJR American journal of roentgenology 2009; 193:W472-7; 3. Gadkowski LB, Stout JE. Clinical microbiology reviews 2008; 21:305-33; 4. Yuan M-K, et al. BMC Pulm Med 2014; 14:65; 5. Kim C, et al. PLoS One 2017; 12:e0174240; 6. Ryu YJ, et al. Tuberc Respir Dis (Seoul) 2016; 79:74-84.

  33. Glossary BullaeDilated air space in the lung parenchyma measuring >1 cm “Finger in glove” signMucoid impactions in large airways that are visualized as tubular opacities Kartagener syndromeDisorder characterized by chronic respiratory tract infections and abnormally positioned internal organs Miliary spreadWidespread dissemination via haematogenous spread Perihilar Area around the hilum of each lung, where the bronchus, blood vessels and nerves enter the organ Tram track opacitiesParallel line opacities

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