Tuberculous adenopathies positive and differential diagnosis

Prsentation PowerPoint

Tuberculous adenopathiespositive and differential diagnosis

Dr. Etienne Leroy-Terquem & Pr Pierre Lher Soutien Pneumologique International1Is it Pr Pierre or Dr Pierre? Session objectivesBy the end of this session, you will be able toidentify chest x ray (CXR) abnormalities in the hilus areas

understand the differences between hilar adenopathies and vascular enlargement or overlap by posterior or anterior opacity

identify radiological arguments for TB adenopathies or others pathologies

Would we loose much if we would say something like: By the end of the session, you will be able to properly read a chest x-ray and detect abnormalities understand the difference between xxx and xxxx (?) diagnose TB adenopathies and other lung pathologies using radiology

2ContentPart 1: Pre-testPart 2: Normal chest x ray (CXR) and normal hilus Part 3: Hilus enlargement: arguments for adenopathiesPart 4: Adenopathies: TBPart 5: Adenopathies: diagnoses other than TBPart 6: ConclusionPart 7: Post-test

Does everyone know what a hilus is? 3Part 1. A pre-test to test your current knowledge

You will be shown 10 chest X rays (CXR) Of the three answers given, choose the one you feel is most appropriatePart 1: Pre-testChoose only one answer on 3 is unclear: Maybe something like: Of the three answers given, choose the one that you feel is most appropriate4

A: normal CXR

B: bad quality CXR not reliable for interpretation

C: bilateral hilar adenopathiesPart 1: Pre-testSlide 1: How would you interpret this CXR? Add title: what does this slide represent? And what does the [1] in the right upper corner refer to? 5

A: normal lateral view

B : hilar and mediastinal adenopathies

C: bronchial cancerPart 1: Pre-testSlide 2: What does this CXR represent? Add title6

A: bilateral hilar adenopathies

B: normal chest x ray

C: hilar vascular enlargmentPart 1: Pre-testSlide 3: Is there any abnormality on this CXR? Add title and spell out7

A : normal chest x rayB : bacterial pneumoniaC : hilar and mediastinum adenopathies Part 1: Pre-testSlide 4: This is the CXR of a young woman, with fever, weight loss and asthenia. What do these CXR tell you?

A: bilateral adenopathies

B: cardiac failure with vascular hilar enlargment

C: normal CXRPart 1: Pre-testSlide 5: This is the CXR of a 60 year old man who suffers from cough and severe exercise dyspnea. What do you see on this CXR? Write out: this is the x-ray of a man of 60 years old, who suffers from cough and severe exercise dyspnea9

A: : left hilar adenopathy

B: bronchial cancer

C: non conclusive between A an B. Need lateral viewPart 1: Pre-testSlide 6: This is the CXR of a man with cought and weight loss. What can you tell from this CXR? As before10

A: bacterial pneumonia

B: tuberculous pneumonia with tb mediastinal adenopathies

C: Cardiac failure with pulmonary oedemaPart 1: Pre-testSlide 7: This is the CXR of a young man with dyspnea and significant weight loss, in an HIV-endemic context. What does this CXR tell you? As before11

A: Normal CXR

B: TB adenopathies

C: PneumoniaPart 1: Pre-testSlide 8: This is the CXR of a 26-year old woman, with fever, cought and weight loss. She has negative AFB in her sputum. What does this CXR represent?

A: bronchial cancer

B: tuberculous adenopathies

C: right bacterialpneumoniaPart 1: Pre-testSlide 9: This is the CXR of a 60-year old man, heavy smoker, with superior vena cava syndrome and face oedema. What do you see on this CXR?

Part 1: Pre-testSlide 10: This is the CXR of a 30-year old man, with chronic fever, cough and weight loss He has AFB negative sputum. What do this CXR tell you? A: pneumonia

B: TB adenopathies

C: normal CXRPart 2: What does a normal chest x ray (CXR) and a normal hilus look like? Part 2: Normal CXR & normal hilusSpell out what this section is about in more detail15

The technical quality is optimal. This is due togood inhalationstrictly front viewadequate contrast and penetration postero anterior incidence of the x ray beamPart 2: Normal CXR & normal hilusHere you see a normal front-view chest x-ray (CXR) good inspiration meaning that the patient took a proper breathe while the photo was taken? changed to inhalationadequate contrast and penetration of what? postero anterior incidence of the x ray beam - dont understand this?

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Right pulmonary arteryLeft pulmonary arteryAs you can see on this animation, the two hilar areas are constitued with pulmonary arteries and their ramifications.Pulmonary veins and bronchi are not visible on a normal CXRPart 2: Normal CXR & normal hilusNormal CXR: left & right pulmonary artery17Title of slide? I dont understand: constitued with pulmonary arteries and their ramifications.

Notice that normal external limits of the hilus are rectilign or concave in external direction. This is shown with the red arrows, which represent the external limits of main lobar pulmonary arteries. Part 2: Normal CXR & normal hilusExternal limits of the normal hilusIs title correct? I dont understand this sentence: rectilign, external directions, lobar arteries? 18

At first glance, you would think that the mediastinum is enlarged. However, this diagnosis is not correct! The CXR was not taken under optimal conditions: it is the CXR of an old woman with cyphoscoliosis who was too tired to stand up: the CXR was taken in decubitus position. The consequency is a false enlargement of the mediastinum with overlap of the two hilus areas

Notice that the position of the patient has been notified on the right edge of the CXRPart 2: Normal CXR & normal hilusA deceiving picture!19What is decubitus position? I dont see something noted on the right edge of the CXR?

This picture shows a false enlargement of the mediastinum area, due to an incomplete inspiration. You can see only 7 posterior ribs arches above the diaphragm: there should be at minimum 9 ribs visible!

This CXR is not a front view: the spinal cord line is not strictly in the middle of the clavicles internal limits, and this makes it appear to be a (false) mediastinum enlargementPart 2: Normal CXR & normal hilusAnother deceiving picture!Part 2: Normal CXR & normal hilusShould the red accolade be somewhere else? 20

Here you see examples of two CXR with correct inhalation. On the CXR you can see 9 posterior rib arches above the diaphragm - or 6 anterior rib arches above diaphragm. The CXR are taken as strictly front view: the spinal cord is in the middle of the clavicle internal limitsPart 2: Normal CXR & normal hilusTwo examples of good quality 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 hilusNormal lateral view CXR Right pulmonary artery Left pulmonary artery

Pulmonary arteries projection on lateral viewAortic archIt is very important that you become familiar with radiological vascular anatomy on lateral view. It will help you to identify adenopathies!Part 2: Normal CXR & normal hilus23A normal hilar picture is only made with the main pulmonary artery and her ramifications. The external limits is rectilign 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

Become familiar with normal lateral view. It will help you with the diagnosis of mediastinal adenopathies ! Summary part 2: normal CXR and normal hilusPart 2: Normal CXR & normal hilus24This sentence is not clear: Normal hilar picture is only made with main pulmonary artery and her ramifications. The external limits is rectilign or concave in external direction.

Poster-anterior incidence I dont understand the word incidence?