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Tuberculous adenopathies positive and differential diagnosis

Tuberculous adenopathies positive and differential diagnosis. Dr. Etienne Leroy- Terquem & Pr Pierre L’her S outien P neumologique I nternational. Session objectives. By the end of this session, you will be able to… identify chest x ray (CXR) abnormalities in the hilus areas

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Tuberculous adenopathies positive and differential diagnosis

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  1. Tuberculousadenopathiespositive and differentialdiagnosis Dr. Etienne Leroy-Terquem& Pr Pierre L’her SoutienPneumologiqueInternational

  2. Session objectives By the end of this session, you will be able to… • identify chest x ray (CXR) abnormalities in the hilus areas • understand the differences between hilaradenopathies and vascular enlargement or overlap by posterior or anterior opacity • identify radiological arguments for TB adenopathies or others pathologies

  3. Content Part 1: Pre-test Part 2: Normal chest x ray (CXR) and normal hilus Part 3: Hilusenlargement: arguments for adenopathies Part 4: Adenopathies: TB Part 5: Adenopathies: diagnoses otherthan TB Part 6: Conclusion Part 7: Post-test

  4. Part 1.A pre-test to test your current knowledge You will be shown 10 chest X rays (CXR)Of the threeanswersgiven, choose the one youfeelismostappropriate Part 1: Pre-test

  5. Slide 1: How wouldyouinterpretthis CXR? A: normal CXR B: badquality CXR not reliable for interpretation C: bilateralhilaradenopathies Part 1: Pre-test

  6. Slide 2: Whatdoesthis CXR represent? A: normal lateralview B : hilar and mediastinaladenopathies C: bronchial cancer Part 1: Pre-test

  7. Slide 3: Is thereanyabnormality on this CXR? A:bilateralhilaradenopathies B: normal chest x ray C: hilarvascularenlargment Part 1: Pre-test

  8. Slide 4: This is the CXR of a youngwoman, withfever, weightloss and asthenia. What do these CXR tell you? A : normal chest x ray B : bacterialpneumonia C : hilar and mediastinumadenopathies Part 1: Pre-test

  9. Slide 5: This is the CXR of a 60 yearold man whosuffersfromcough and severeexercisedyspnea. What do yousee on this CXR? A: bilateraladenopathies B: cardiacfailurewithvascularhilarenlargment C: normal CXR Part 1: Pre-test

  10. Slide 6: This is the CXR of a man withcought and weightloss. Whatcanyou tell fromthis CXR? A: : lefthilaradenopathy B: bronchial cancer C: non conclusive between A an B. Needlateralview Part 1: Pre-test

  11. Slide7: This is the CXR of a young man withdyspnea and significantweightloss, in an HIV-endemiccontext. Whatdoesthis CXR tell you? A:bacterialpneumonia B: tuberculouspneumoniawithtbmediastinaladenopathies C: Cardiacfailurewith pulmonary oedema Part 1: Pre-test

  12. Slide 8: This is the CXR of a 26-year oldwoman, withfever, cought and weightloss. She has negative AFB in hersputum. Whatdoesthis CXR represent? A: Normal CXR B: TB adenopathies C: Pneumonia Part 1: Pre-test

  13. Slide 9: This is the CXR of a 60-year old man, heavysmoker, withsuperiorvena cava syndrome and face oedema. What do yousee on this CXR? A: bronchial cancer B: tuberculousadenopathies C: right bacterial pneumonia Part 1: Pre-test

  14. Slide 10: This is the CXR of a 30-year old man, withchronicfever, cough and weightloss He has AFB negativesputum. What do this CXR tell you? A: pneumonia B: TB adenopathies C: normal CXR Part 1: Pre-test

  15. Part 2: What does a normalchest x ray (CXR) and a normal hiluslook like? Part 2: Normal CXR & normal hilus

  16. Hereyousee a normal front-viewchest x-ray (CXR) The technicalqualityis optimal. This is due to… • good inhalation • strictly front view • adequatecontrast and penetration • posteroanterior incidence of the x ray beam Part 2: Normal CXR & normal hilus

  17. Normal CXR: left & right pulmonary artery Asyoucansee on this animation, the twohilar areas are constituedwith pulmonary arteries and their ramifications. Pulmonary veins and bronchi are not visible on a normal CXR Left pulmonary artery Right pulmonary artery Part 2: Normal CXR & normal hilus

  18. Externallimits of the normal hilus Notice that normal externallimits of the hilus are rectilign or concave in external direction. This isshownwith the redarrows, whichrepresent the externallimits of main lobar pulmonary arteries. Part 2: Normal CXR & normal hilus

  19. A deceivingpicture! At first glance, youwouldthinkthat the mediastinumisenlarged. However, thisdiagnosisis not correct! The CXR was not takenunder optimal conditions: itis the CXR of an oldwomanwithcyphoscoliosiswhowastootired to stand up: the CXR wastaken in decubitus position. The consequencyis a false enlargement of the mediastinumwithoverlap of the twohilus areas Notice that the position of the patient has been notified on the right edge of the CXR Part 2: Normal CXR & normal hilus

  20. Anotherdeceivingpicture! This picture shows a false enlargement of the mediastinum area, due to an incomplete inspiration. You canseeonly 7 posteriorribs arches above the diaphragm: thereshouldbeat minimum 9 ribs visible! This CXR is not a front view: the spinal cord line is not strictly in the middle of the claviclesinternallimits, and thismakesitappear to be a (false) mediastinumenlargement Part 2: Normal CXR & normal hilus Part 2: Normal CXR & normal hilus

  21. Twoexamples of good quality CXR Hereyouseeexamples of two CXR with correct inhalation. On the CXR youcansee 9 posteriorrib arches above the diaphragm - or 6 anteriorrib arches abovediaphragm. The CXR are taken as strictly front view: the spinal cordis in the middle of the clavicleinternallimits Part 2: Normal CXR & normal hilus

  22. Normal lateralview CXR Here you can see a normal lateral view chest X ray made under good technical condition. It is important that you become familiar with the lateral view CXR. In the next part of this course, we will see that this position is helpful for diagnosis of adenopathies, especially in children. Part 2: Normal CXR & normal hilus

  23. Pulmonaryarteries projection on lateralview Aorticarch Leftpulmonary artery Right pulmonaryartery It isvery important thatyoubecomefamiliarwithradiologicalvascularanatomy on lateralview. It will help you to identifyadenopathies! Part 2: Normal CXR & normal hilus

  24. A normal hilarpictureisonly made with the main pulmonary artery and her ramifications. The externallimitsisrectilign or concave in external direction. For a good analysis of the mediastinum and hilar areas , it is necessary to have a good quality chest x-ray. This means: - Strictly front view- Complete inhalation- Patient standing up, postero-anterior incidence Summary part 2: normal CXR and normal hilus Becomefamiliarwith normal lateralview. It will help youwith the diagnosis of mediastinaladenopathies ! Part 2: Normal CXR & normal hilus

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