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Imaging of Extrapulmonary Tuberculosis1
Gülgün Engin, MD,
Bülent Acuna , MD ,
Gülden Acuna, MD and
Mehtap Tunaci, MD
1 From the Department of Radiology, Istanbul Faculty of Medicine, University of Istanbul, Millet Street, Çapa 34390, Istanbul, Turkey. Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received February 4, 1999; revision requested April 8 and received May 18; accepted May 18. Address reprint requests to G.E. (e-mail: istrady@escortnet.com).
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Abstract |
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Diagnosis of extrapulmonary tuberculosis is often difficult. Although positive chest radiographic findings or a positive tuberculin skin test supports the diagnosis, negative results do not exclude extrapulmonary tuberculosis. However, recognition and understanding of the radiologic findings of extrapulmonary tuberculosis can help in diagnosis. The spine is the most common site of skeletal involvement. The femur, tibia, and small bones of the hands and feet are most commonly involved by tuberculous osteomyelitis. Tuberculosis of the joints is characteristically monoarticular; the knee and hip are most frequently affected. Central nervous system tuberculosis takes various forms, including meningitis, tuberculoma, abscess, cerebritis, and miliary tuberculosis. Ileocecal involvement is seen in 80%–90% of patients with abdominal tuberculosis. The most common manifestation of abdominal tuberculosis is lymphadenopathy. Genitourinary tuberculosis is the most common manifestation of extrapulmonary tuberculosis. Lymphatic tuberculosis is more common among children, with cervical or supraclavicular nodes most frequently involved. Tuberculosis of the breast is extremely rare and occurs most often in young, multiparous, lactating women. The radiologic features of extrapulmonary tuberculosis mimic those of many diseases. A high level of suspicion is required, especially in high-risk populations. A positive culture or histologic analysis of biopsy specimens is still required in many patients for definitive diagnosis.
Index Terms:
Tuberculosis, central nervous system, 10.23, 30.23 • Tuberculosis, gastrointestinal, 70.23 • Tuberculosis, genitourinary, 80.23 • Tuberculosis, musculoskeletal, 40.23
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Introduction |
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In the past decade, there has been a significant rise in the prevalence of tuberculosis as well as an increase in the extrapulmonary manifestations worldwide (1,2). Factors that have contributed to this increase are the rising number of people with suppression of the immune system, the development of drug-resistant strains of Mycobacterium tuberculosis, aging population demographics, and an increase in the number of health care workers exposed to the disease (3).
Diagnosis of extrapulmonary tuberculosis is often difficult. Although a positive chest radiograph or positive tuberculin skin test supports the diagnosis, negative results do not exclude the possibility of extrapulmonary tuberculosis (4–6). However, recognition and understanding of the common and uncommon radiologic findings of extrapulmonary tuberculosis can help in diagnosis.
In this article, the radiologic manifestations of extrapulmonary tuberculosis are reviewed. Findings in musculoskeletal tuberculosis, central nervous system tuberculosis, abdominal tuberculosis, lymph node tuberculosis, and breast tuberculosis are discussed.
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Musculoskeletal Tuberculosis |
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Skeletal involvement occurs in approximately 1%–3% of patients with tuberculosis. Evidence of concurrent active intrathoracic tuberculosis is present in less than 50% of these patients (6).
Tuberculous Spondylitis
The spine is the most common site of osseous involvement by tuberculosis. Spinal tuberculosis accounts for approximately 50% of cases of skeletal tuberculosis (7). The most common location is L1. More than one vertebral body is typically affected; however, single-level involvement sparing the adjacent disk spaces does occur (Fig 1). The disease process most often begins in the anterior part of the vertebral body adjacent to the end plate. The disk space may then become involved via a number of routes. Extension may occur along the anterior or posterior longitudinal ligament or directly through the end plate. Less often, posterior elements of the spine may become involved. Collapse of a vertebral body, particularly the anterior segment, may result in tuberculous kyphosis (Fig 2). Paraspinal infection may involve the psoas muscle, resulting in psoas abscess (Fig 3a), which can extend into the groin and thigh. Calcification within the abscess is virtually pathognomonic of tuberculosis (4,8).
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Figure 1a. Tuberculous spondylitis in a 17-year-old girl with low back pain. (a, b) Anteroposterior (a) and lateral (b) plain radiographs of the lower lumbar spine show loss of vertebral body height (arrowhead in a), sclerosis of the end plates, and anterior scalloping (arrowheads in b). (c) Sagittal T1-weighted magnetic resonance (MR) image (repetition time msec/echo time msec = 360/15) shows focal decreased signal intensity (arrow). (d, e) Sagittal T2-weighted (4,300/112) (d) and contrast material-enhanced coronal T1-weighted (360/15) (e) MR images show increased signal intensity (arrow). Tuberculous disease was confirmed with bone biopsy.
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Figure 1b. Tuberculous spondylitis in a 17-year-old girl with low back pain. (a, b) Anteroposterior (a) and lateral (b) plain radiographs of the lower lumbar spine show loss of vertebral body height (arrowhead in a), sclerosis of the end plates, and anterior scalloping (arrowheads in b). (c) Sagittal T1-weighted magnetic resonance (MR) image (repetition time msec/echo time msec = 360/15) shows focal decreased signal intensity (arrow). (d, e) Sagittal T2-weighted (4,300/112) (d) and contrast material-enhanced coronal T1-weighted (360/15) (e) MR images show increased signal intensity (arrow). Tuberculous disease was confirmed with bone biopsy.
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Figure 1c. Tuberculous spondylitis in a 17-year-old girl with low back pain. (a, b) Anteroposterior (a) and lateral (b) plain radiographs of the lower lumbar spine show loss of vertebral body height (arrowhead in a), sclerosis of the end plates, and anterior scalloping (arrowheads in b). (c) Sagittal T1-weighted magnetic resonance (MR) image (repetition time msec/echo time msec = 360/15) shows focal decreased signal intensity (arrow). (d, e) Sagittal T2-weighted (4,300/112) (d) and contrast material-enhanced coronal T1-weighted (360/15) (e) MR images show increased signal intensity (arrow). Tuberculous disease was confirmed with bone biopsy.
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Figure 1d. Tuberculous spondylitis in a 17-year-old girl with low back pain. (a, b) Anteroposterior (a) and lateral (b) plain radiographs of the lower lumbar spine show loss of vertebral body height (arrowhead in a), sclerosis of the end plates, and anterior scalloping (arrowheads in b). (c) Sagittal T1-weighted magnetic resonance (MR) image (repetition time msec/echo time msec = 360/15) shows focal decreased signal intensity (arrow). (d, e) Sagittal T2-weighted (4,300/112) (d) and contrast material-enhanced coronal T1-weighted (360/15) (e) MR images show increased signal intensity (arrow). Tuberculous disease was confirmed with bone biopsy.
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Figure 1e. Tuberculous spondylitis in a 17-year-old girl with low back pain. (a, b) Anteroposterior (a) and lateral (b) plain radiographs of the lower lumbar spine show loss of vertebral body height (arrowhead in a), sclerosis of the end plates, and anterior scalloping (arrowheads in b). (c) Sagittal T1-weighted magnetic resonance (MR) image (repetition time msec/echo time msec = 360/15) shows focal decreased signal intensity (arrow). (d, e) Sagittal T2-weighted (4,300/112) (d) and contrast material-enhanced coronal T1-weighted (360/15) (e) MR images show increased signal intensity (arrow). Tuberculous disease was confirmed with bone biopsy.
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Figure 2a. Tuberculous spondylitis with psoas abscess in a 21-year-old woman. (a) Midsagittal T1-weighted MR images (519/16) show loss of vertebral body height and decreased signal intensity at T4 (arrows). (b) Coronal T2-weighted MR image (5,000/36) of the upper dorsal spine shows bilateral paraspinal abscesses (arrows) with involvement of T4. (c, d) Axial T2-weighted (2,247/985) (c) and parasagittal T2-weighted (2,247/985) (d) MR images show a large, lobulated paraspinal mass with high signal intensity that extends to the posterior paravertebral region (arrows). The diagnosis was confirmed with biopsy of the abscess.
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Figure 2b. Tuberculous spondylitis with psoas abscess in a 21-year-old woman. (a) Midsagittal T1-weighted MR images (519/16) show loss of vertebral body height and decreased signal intensity at T4 (arrows). (b) Coronal T2-weighted MR image (5,000/36) of the upper dorsal spine shows bilateral paraspinal abscesses (arrows) with involvement of T4. (c, d) Axial T2-weighted (2,247/985) (c) and parasagittal T2-weighted (2,247/985) (d) MR images show a large, lobulated paraspinal mass with high signal intensity that extends to the posterior paravertebral region (arrows). The diagnosis was confirmed with biopsy of the abscess.
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Figure 2c. Tuberculous spondylitis with psoas abscess in a 21-year-old woman. (a) Midsagittal T1-weighted MR images (519/16) show loss of vertebral body height and decreased signal intensity at T4 (arrows). (b) Coronal T2-weighted MR image (5,000/36) of the upper dorsal spine shows bilateral paraspinal abscesses (arrows) with involvement of T4. (c, d) Axial T2-weighted (2,247/985) (c) and parasagittal T2-weighted (2,247/985) (d) MR images show a large, lobulated paraspinal mass with high signal intensity that extends to the posterior paravertebral region (arrows). The diagnosis was confirmed with biopsy of the abscess.
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Figure 2d. Tuberculous spondylitis with psoas abscess in a 21-year-old woman. (a) Midsagittal T1-weighted MR images (519/16) show loss of vertebral body height and decreased signal intensity at T4 (arrows). (b) Coronal T2-weighted MR image (5,000/36) of the upper dorsal spine shows bilateral paraspinal abscesses (arrows) with involvement of T4. (c, d) Axial T2-weighted (2,247/985) (c) and parasagittal T2-weighted (2,247/985) (d) MR images show a large, lobulated paraspinal mass with high signal intensity that extends to the posterior paravertebral region (arrows). The diagnosis was confirmed with biopsy of the abscess.
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Figure 3a. Tuberculous spondylitis and tuberculous osteomyelitis in a 21-year-old woman with sacral pain. (a) Computed tomographic (CT) scan (bone window) of L1 shows bone destruction and bilateral psoas abscesses with multiloculated pus collections surrounded by a rim-enhancing inflammatory capsule (arrows, arrowheads). (b) CT scan (bone window) of S2 shows a well-defined lytic lesion surrounded by a sclerotic margin (arrow). Tuberculous disease was confirmed with bone biopsy.
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Figure 3b. Tuberculous spondylitis and tuberculous osteomyelitis in a 21-year-old woman with sacral pain. (a) Computed tomographic (CT) scan (bone window) of L1 shows bone destruction and bilateral psoas abscesses with multiloculated pus collections surrounded by a rim-enhancing inflammatory capsule (arrows, arrowheads). (b) CT scan (bone window) of S2 shows a well-defined lytic lesion surrounded by a sclerotic margin (arrow). Tuberculous disease was confirmed with bone biopsy.
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CT and MR imaging are of great value in demonstrating a small focus of bone infection and the extent of the disease (4).
Many disease processes including metastatic disease and low-grade pyogenic infections such as brucellosis, fungal infections, and sarcoidosis have imaging findings similar to those of spinal tuberculosis. However, the diagnosis of tuberculosis is favored if a large, calcified paravertebral mass and absence of sclerosis or new bone formation are noted. Conversely, intervertebral disk destruction is more characteristic of a pyogenic infection. Characteristic features of brucellar spondylitis include gas within the disk, a minimal associated paraspinal mass, absence of kyphosis, and a predilection for the lower lumbar spine (4).
Tuberculous Osteomyelitis
The femur, the tibia, and the small bones of the hands and feet are most commonly involved. Typically, the metaphyses are affected. Radiographic findings include osteopenia, osteolytic foci with poorly defined edges, and varying amounts of sclerosis (4). Also, CT and MR imaging demonstrate the extent of the active infection and its complications (Fig 4).
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Figure 4a. Tuberculous osteomyelitis in a 52-year-old woman with pain. (a, b) Anteroposterior plain radiograph of the pelvis (a) and magnified radiograph of the left proximal femur (b) show bone destruction with calcifications. (c) CT scan (soft-tissue window) shows destruction of medullary and cortical bone. There are also calcifications within the bone lesion and the perilesion soft tissue (arrow). (d) Fat-suppressed coronal T1-weighted MR image (640/15) of the proximal femur shows heterogeneous increased signal intensity with cortical destruction. Hyperintense soft-tissue infection is evident. (e) Contrast-enhanced fat-suppressed axial T1-weighted MR image (740/17) shows enhancement of affected soft tissues (arrowheads) and bone marrow (arrow). Tuberculous disease was confirmed with bone biopsy.
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Figure 4b. Tuberculous osteomyelitis in a 52-year-old woman with pain. (a, b) Anteroposterior plain radiograph of the pelvis (a) and magnified radiograph of the left proximal femur (b) show bone destruction with calcifications. (c) CT scan (soft-tissue window) shows destruction of medullary and cortical bone. There are also calcifications within the bone lesion and the perilesion soft tissue (arrow). (d) Fat-suppressed coronal T1-weighted MR image (640/15) of the proximal femur shows heterogeneous increased signal intensity with cortical destruction. Hyperintense soft-tissue infection is evident. (e) Contrast-enhanced fat-suppressed axial T1-weighted MR image (740/17) shows enhancement of affected soft tissues (arrowheads) and bone marrow (arrow). Tuberculous disease was confirmed with bone biopsy.
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Figure 4c. Tuberculous osteomyelitis in a 52-year-old woman with pain. (a, b) Anteroposterior plain radiograph of the pelvis (a) and magnified radiograph of the left proximal femur (b) show bone destruction with calcifications. (c) CT scan (soft-tissue window) shows destruction of medullary and cortical bone. There are also calcifications within the bone lesion and the perilesion soft tissue (arrow). (d) Fat-suppressed coronal T1-weighted MR image (640/15) of the proximal femur shows heterogeneous increased signal intensity with cortical destruction. Hyperintense soft-tissue infection is evident. (e) Contrast-enhanced fat-suppressed axial T1-weighted MR image (740/17) shows enhancement of affected soft tissues (arrowheads) and bone marrow (arrow). Tuberculous disease was confirmed with bone biopsy.
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Figure 4d. Tuberculous osteomyelitis in a 52-year-old woman with pain. (a, b) Anteroposterior plain radiograph of the pelvis (a) and magnified radiograph of the left proximal femur (b) show bone destruction with calcifications. (c) CT scan (soft-tissue window) shows destruction of medullary and cortical bone. There are also calcifications within the bone lesion and the perilesion soft tissue (arrow). (d) Fat-suppressed coronal T1-weighted MR image (640/15) of the proximal femur shows heterogeneous increased signal intensity with cortical destruction. Hyperintense soft-tissue infection is evident. (e) Contrast-enhanced fat-suppressed axial T1-weighted MR image (740/17) shows enhancement of affected soft tissues (arrowheads) and bone marrow (arrow). Tuberculous disease was confirmed with bone biopsy.
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Figure 4e. Tuberculous osteomyelitis in a 52-year-old woman with pain. (a, b) Anteroposterior plain radiograph of the pelvis (a) and magnified radiograph of the left proximal femur (b) show bone destruction with calcifications. (c) CT scan (soft-tissue window) shows destruction of medullary and cortical bone. There are also calcifications within the bone lesion and the perilesion soft tissue (arrow). (d) Fat-suppressed coronal T1-weighted MR image (640/15) of the proximal femur shows heterogeneous increased signal intensity with cortical destruction. Hyperintense soft-tissue infection is evident. (e) Contrast-enhanced fat-suppressed axial T1-weighted MR image (740/17) shows enhancement of affected soft tissues (arrowheads) and bone marrow (arrow). Tuberculous disease was confirmed with bone biopsy.
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One specific type of tuberculous osteomyelitis is cystic tuberculosis. At radiography, the lesions are radiolucent, well defined, and round or oval and demonstrate variable amounts of sclerosis (Fig 3b). The radiographic characteristics of cystic tuberculosis resemble those of eosinophilic granuloma, sarcoidosis, cystic angiomatosis, plasma cell myeloma, chordoma, fungal infections, and metastases (4,8).
Tuberculous involvement of the short, tubular bones of the hands and feet is termed tuberculous dactylitis. This form of tuberculosis is especially frequent in children. Fusiform soft-tissue swelling and periostitis are the most common radiographic findings (Fig 5). As underlying bone is destroyed, a cystlike cavity forms and the remaining bone appears to be ballooned out. This appearance is termed spina ventosa ("wind-filled sail") (4) (Fig 6).
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Figure 5. Tuberculous dactylitis in a 16-year-old boy. Lateral (left) and anteroposterior (right) radiographs show fusiform soft-tissue swelling of the proximal and middle phalanges of the middle finger and periostitis (arrowheads).
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Figure 6a. Spina ventosa in a 22-year-old woman. Anteroposterior (a) and magnified (b) radiographs show extensive soft-tissue swelling with ballooning of the third metacarpal of the left hand. Findings of tuberculous arthritis are also seen in the adjacent joint (arrowheads).
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Figure 6b. Spina ventosa in a 22-year-old woman. Anteroposterior (a) and magnified (b) radiographs show extensive soft-tissue swelling with ballooning of the third metacarpal of the left hand. Findings of tuberculous arthritis are also seen in the adjacent joint (arrowheads).
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Tuberculous osteomyelitis can be mimicked by pyogenic or fungal infections. A helpful feature in distinguishing tuberculous from pyogenic infection is that transphyseal spread occurs in the former; however, fungal infections can also extend across the physis. Syphilitic dactylitis in the pediatric population produces bilateral and symmetric involvement, with less soft-tissue swelling and sequestration than in tuberculous dactylitis. Other diseases such as sarcoidosis, hemoglobin-opathies, hyperparathyroidism, and leukemia may produce changes similar to those of tuberculous dactylitis (4).
Tuberculous Arthritis
Tuberculosis of the joints is characteristically a monoarticular disease. The knee and hip are the most frequently affected. The triad of juxtaarticular osteoporosis, peripherally located osseous erosions, and gradual narrowing of the interosseous space is termed the Phemister triad and is characteristic of tuberculous arthritis (Fig 7). However, these features can also be observed in fungal disease and rheumatoid arthritis (4,8). Relative preservation of the joint space is highly suggestive of tuberculous arthritis; early loss of articular space is more typical of rheumatoid arthritis. The eventual result in tuberculous arthritis is usually fibrous ankylosis of the joint. Bony ankylosis is occasionally seen, but this sequela is more frequent in pyogenic arthritis. Moreover, periostitis and osseous proliferation are generally more frequent and extensive in pyogenic arthritis than in tuberculous arthritis (8).
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Figure 7a. Tuberculous arthritis in a 28-year-old man with pain. Anteroposterior (a) and magnified (b) radiographs show marginal osseous erosions of the femoral head (arrows) with relative preservation of the left hip joint space. There is also evidence of periarticular osteopenia. Tuberculous disease was confirmed with bone biopsy.
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Figure 7b. Tuberculous arthritis in a 28-year-old man with pain. Anteroposterior (a) and magnified (b) radiographs show marginal osseous erosions of the femoral head (arrows) with relative preservation of the left hip joint space. There is also evidence of periarticular osteopenia. Tuberculous disease was confirmed with bone biopsy.
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Central Nervous System Tuberculosis |
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The initial subependymal or subpial focus of tuberculosis (Rich focus) arises from earlier hematogenous dissemination and may be located in the meninges, brain, or spinal cord. Central nervous system tuberculosis may take a variety of forms, including meningitis, tuberculoma, abscess, cerebritis, and miliary tuberculosis. Tuberculous meningitis is believed to be caused by rupture of a Rich focus into the cerebrospinal fluid. However, tuberculoma may be secondary to hematogenous spread of systemic disease or evolve from extension of cerebrospinal fluid infection into the adjacent parenchyma (9,10).
Cranial Tuberculous Meningitis
Abnormal meningeal enhancement that is typically most pronounced in the basal cisterns may be well seen at both CT and MR imaging (Fig 8a). This enhancement of the basal cisterns corresponds to the gelatinous exudate. Communicating hydrocephalus is the most common complication of cranial tuberculous meningitis. However, obstructive hydrocephalus may result from obstruction of the cerebrospinal fluid pathway by a focal parenchymal lesion. Also, ischemic infarcts are commonly seen as a complication of cranial tuberculous meningitis. The majority of the infarcts are seen in the basal ganglia and internal capsule and result from vascular compression and occlusion of small perforating vessels (9–11) (Fig 8b).
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Figure 8a. Meningeal tuberculosis in a 28-year-old woman. (a) Contrast-enhanced sagittal T1-weighted MR image (433/16) shows abnormal meningeal enhancement in the basal cisterns (arrows). (b) Nonenhanced CT scan shows hydrocephalus and ependymal calcification (arrow), which represent sequelae of tuberculosis. A chronic infarct of the internal capsule secondary to prior tuberculous arteritis is also shown (arrowhead). (c) Contrast-enhanced sagittal T1-weighted MR image (433/16) shows large loculi of cerebrospinal fluid, which lead to spinal cord compression (long arrows) and enhancement of the meninges (short arrow). (d) Sagittal T2-weighted MR image (3,000/96) shows hyperintense syringomyelia involving the cervicothoracic spinal cord. The diagnosis was confirmed by isolating M tuberculosis in a culture of cerebrospinal fluid.
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Figure 8b. Meningeal tuberculosis in a 28-year-old woman. (a) Contrast-enhanced sagittal T1-weighted MR image (433/16) shows abnormal meningeal enhancement in the basal cisterns (arrows). (b) Nonenhanced CT scan shows hydrocephalus and ependymal calcification (arrow), which represent sequelae of tuberculosis. A chronic infarct of the internal capsule secondary to prior tuberculous arteritis is also shown (arrowhead). (c) Contrast-enhanced sagittal T1-weighted MR image (433/16) shows large loculi of cerebrospinal fluid, which lead to spinal cord compression (long arrows) and enhancement of the meninges (short arrow). (d) Sagittal T2-weighted MR image (3,000/96) shows hyperintense syringomyelia involving the cervicothoracic spinal cord. The diagnosis was confirmed by isolating M tuberculosis in a culture of cerebrospinal fluid.
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Figure 8c. Meningeal tuberculosis in a 28-year-old woman. (a) Contrast-enhanced sagittal T1-weighted MR image (433/16) shows abnormal meningeal enhancement in the basal cisterns (arrows). (b) Nonenhanced CT scan shows hydrocephalus and ependymal calcification (arrow), which represent sequelae of tuberculosis. A chronic infarct of the internal capsule secondary to prior tuberculous arteritis is also shown (arrowhead). (c) Contrast-enhanced sagittal T1-weighted MR image (433/16) shows large loculi of cerebrospinal fluid, which lead to spinal cord compression (long arrows) and enhancement of the meninges (short arrow). (d) Sagittal T2-weighted MR image (3,000/96) shows hyperintense syringomyelia involving the cervicothoracic spinal cord. The diagnosis was confirmed by isolating M tuberculosis in a culture of cerebrospinal fluid.
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Figure 8d. Meningeal tuberculosis in a 28-year-old woman. (a) Contrast-enhanced sagittal T1-weighted MR image (433/16) shows abnormal meningeal enhancement in the basal cisterns (arrows). (b) Nonenhanced CT scan shows hydrocephalus and ependymal calcification (arrow), which represent sequelae of tuberculosis. A chronic infarct of the internal capsule secondary to prior tuberculous arteritis is also shown (arrowhead). (c) Contrast-enhanced sagittal T1-weighted MR image (433/16) shows large loculi of cerebrospinal fluid, which lead to spinal cord compression (long arrows) and enhancement of the meninges (short arrow). (d) Sagittal T2-weighted MR image (3,000/96) shows hyperintense syringomyelia involving the cervicothoracic spinal cord. The diagnosis was confirmed by isolating M tuberculosis in a culture of cerebrospinal fluid.
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Spinal Tuberculous Meningitis
The MR imaging features of spinal tuberculous meningitis include cerebrospinal fluid loculi and obliteration of the spinal subarachnoid space with loss of outline of the spinal cord in the cervicothoracic spine and matting of the nerve roots in the lumbar region. Contrast-enhanced MR images reveal nodular, thick, linear intradural enhancement (Fig 8c) (11,12). Syringomyelia can occur as a complication of arachnoiditis and is seen as cord cavitation that typically demonstrates cerebrospinal fluid signal intensity on both T1- and T2-weighted images and does not enhance (11) (Fig 8d).
Parenchymal Tuberculosis
Parenchymal disease can occur with or without meningitis and usually manifests as tuberculomas.
Tuberculomas may be solitary but are more commonly multiple. The frontal and parietal lobes are the most commonly affected regions. At CT, tuberculomas appear as rounded or lobulated masses with low or high attenuation. They demonstrate homogeneous or ring enhancement and have irregular walls of varying thickness (Fig 9a). The MR imaging features of a tuberculoma depend on whether it is noncaseating or caseating. Noncaseating tuberculomas are often hyperintense on T2-weighted images with homogeneous (nodular) enhancement. Caseating tuberculomas are isointense to markedly hypointense on T2-weighted images and exhibit rim enhancement (9–11) (Fig 9b).
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Figure 9a. Parenchymal tuberculosis in a 28-year-old woman. Contrast-enhanced CT scan (a) and contrast-enhanced axial T1-weighted MR image (433/16) (b) through the quadrigeminal bodies show multiple parenchymal and meningeal caseating tuberculomas (arrows). The diagnosis was confirmed by isolating M tuberculosis in a culture of cerebrospinal fluid.
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Figure 9b. Parenchymal tuberculosis in a 28-year-old woman. Contrast-enhanced CT scan (a) and contrast-enhanced axial T1-weighted MR image (433/16) (b) through the quadrigeminal bodies show multiple parenchymal and meningeal caseating tuberculomas (arrows). The diagnosis was confirmed by isolating M tuberculosis in a culture of cerebrospinal fluid.
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Rare forms of parenchymal tuberculosis are abscess and cerebritis (9).
Miliary central nervous system tuberculosis is usually associated with cranial tuberculous meningitis. Miliary tubercles appear as numerous round, homogeneously enhancing lesions less than 2 mm in diameter (11,13).
The differential diagnosis of cranial and spinal tuberculosis includes other infectious or noninfectious diseases (eg, sarcoidosis, toxoplasmosis, lymphoma, pyogenic and fungal infections), multicentric primary neoplasms (eg, hemangioblastoma, gliomas), and metastases (11).
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Abdominal Tuberculosis |
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Gastrointestinal Tuberculosis
Ileocecal involvement is seen in 80%–90% of patients with abdominal tuberculosis (14). Thickening of the valve lips or wide gaping of the valve with narrowing of the terminal ileum (the Fleischner sign) has been described as a characteristic of tuberculosis. At double-contrast barium examination, shallow ulcers that are typically linear or stellate with characteristic elevated margins are seen. The ulcers in tuberculosis tend to be larger than those in Crohn disease and tend to be oval rather than round. Moreover, tuberculosis produces greater thickening of the bowel wall. Fistulas and sinus tracts are rare. In advanced disease, characteristic deformities include symmetric annular "napkin ring" stenoses and obstruction, shortening, retraction, and pouch formation (Fig 10a). The cecum classically becomes amputated. Amputation of the cecum may be seen in amebiasis, but this disease rarely involves the small intestine to the same degree as does tuberculosis. Amputation and focal stricture of the intestine can also mimic carcinoma, but cecal carcinoma rarely extends beyond the ileocecal valve. At CT, one-half of patients with gastrointestinal tuberculosis show circumferential thickening of the cecum and terminal ileum, enlargement of the ileocecal valve, and mesenteric lymphadenopathy (Fig 10b–10d). However, other findings such as asymmetry of the ileocecal valve, thickening of the medial cecal wall, exophytic extension and engulfment of the terminal ileum, and massive adenopathy are more suggestive of tuberculosis (5,14–16).
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Figure 10a. Ileocecal tuberculosis in a 51-year-old man. (a) Anteroposterior image from an enteroclysis study shows thickened folds in the cecum and an irregular cecal contour. (b) CT scan shows minimal thickening of the cecum with pericecal inflammatory changes. Mesenteric lymph nodes are also evident (arrows). (c) CT scan shows circumferential thickening of the cecum and terminal ileum. (d) CT scan shows inflammation that extends through the peritoneum into the psoas muscle. The diagnosis was confirmed with endoscopic biopsy.
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Figure 10b. Ileocecal tuberculosis in a 51-year-old man. (a) Anteroposterior image from an enteroclysis study shows thickened folds in the cecum and an irregular cecal contour. (b) CT scan shows minimal thickening of the cecum with pericecal inflammatory changes. Mesenteric lymph nodes are also evident (arrows). (c) CT scan shows circumferential thickening of the cecum and terminal ileum. (d) CT scan shows inflammation that extends through the peritoneum into the psoas muscle. The diagnosis was confirmed with endoscopic biopsy.
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Figure 10c. Ileocecal tuberculosis in a 51-year-old man. (a) Anteroposterior image from an enteroclysis study shows thickened folds in the cecum and an irregular cecal contour. (b) CT scan shows minimal thickening of the cecum with pericecal inflammatory changes. Mesenteric lymph nodes are also evident (arrows). (c) CT scan shows circumferential thickening of the cecum and terminal ileum. (d) CT scan shows inflammation that extends through the peritoneum into the psoas muscle. The diagnosis was confirmed with endoscopic biopsy.
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Figure 10d. Ileocecal tuberculosis in a 51-year-old man. (a) Anteroposterior image from an enteroclysis study shows thickened folds in the cecum and an irregular cecal contour. (b) CT scan shows minimal thickening of the cecum with pericecal inflammatory changes. Mesenteric lymph nodes are also evident (arrows). (c) CT scan shows circumferential thickening of the cecum and terminal ileum. (d) CT scan shows inflammation that extends through the peritoneum into the psoas muscle. The diagnosis was confirmed with endoscopic biopsy.
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Tuberculous Peritonitis
Peritoneal involvement is frequently seen in association with other forms of gastrointestinal tuberculosis. Three types of tuberculosis peritonitis have been described. The wet type, which is characterized by a large amount of free or loculated viscous fluid, is seen in most patients (Fig 11). The fibrotic-fixed type and the dry or plastic type are less common. A similar peritoneal appearance may occur with carcinomatosis, mesothelioma, or nontuberculous peritonitis (5,16).
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Figure 11. Peritoneal tuberculosis (wet type) in a 27-year-old woman with ileocecal tuberculosis. CT scan shows a high-attenuation, loculated fluid collection and mesenteric lymph nodes (arrow) with fine nodular irregularity of the mesenteric surface. Marked thickening of the cecum and terminal ileum is also shown. The diagnosis was confirmed with culture of peritoneal fluid.
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Hepatosplenic Tuberculosis
Hepatosplenic tuberculosis generally manifests in a micronodular (miliary) or macronodular (tuberculoma) form. The micronodular form usually occurs in association with miliary pulmonary tuberculosis. On CT scans, innumerable tiny, low-attenuation foci may be seen. The macronodular form is rare. On CT scans, hypoattenuating lesions 1–3 cm in diameter or a single mass is seen in a diffusely enlarged liver or spleen (5,16). MR imaging shows hypointense and minimally enhancing honeycomblike lesions on T1-weighted images. On T2-weighted images, the lesions are hyperintense with a less intense rim relative to the surrounding liver (17) (Fig 12). The differential diagnosis of the miliary form includes metastases, fungal infection, sarcoidosis, and lymphoma. The macronodular form can be mistaken for metastases, primary malignant tumor, or pyogenic abscess.
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Figure 12a. Hepatic tuberculosis (macronodular type) in a 19-year-old woman with peritoneal tuberculosis. (a) Coronal T1-weighted MR image (15/4) shows hypointense masses in the liver (arrows). (b) Contrast-enhanced coronal T1-weighted MR image (15/4) shows peripheral enhancement of the masses with a honeycomblike appearance (arrows). (c) Axial T2-weighted MR image (1,800/80) shows a hyperintense liver mass (arrow) and perihepatic fluid. The diagnosis was confirmed with ultrasonographically (US) guided biopsy.
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Figure 12b. Hepatic tuberculosis (macronodular type) in a 19-year-old woman with peritoneal tuberculosis. (a) Coronal T1-weighted MR image (15/4) shows hypointense masses in the liver (arrows). (b) Contrast-enhanced coronal T1-weighted MR image (15/4) shows peripheral enhancement of the masses with a honeycomblike appearance (arrows). (c) Axial T2-weighted MR image (1,800/80) shows a hyperintense liver mass (arrow) and perihepatic fluid. The diagnosis was confirmed with ultrasonographically (US) guided biopsy.
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Figure 12c. Hepatic tuberculosis (macronodular type) in a 19-year-old woman with peritoneal tuberculosis. (a) Coronal T1-weighted MR image (15/4) shows hypointense masses in the liver (arrows). (b) Contrast-enhanced coronal T1-weighted MR image (15/4) shows peripheral enhancement of the masses with a honeycomblike appearance (arrows). (c) Axial T2-weighted MR image (1,800/80) shows a hyperintense liver mass (arrow) and perihepatic fluid. The diagnosis was confirmed with ultrasonographically (US) guided biopsy.
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Adrenal Tuberculosis
Bilateral and asymmetric involvement is common. Soft-tissue masses with a nonspecific appearance are seen in the acute and subacute stages (Fig 13). The appearance overlaps that of malignant processes. The gland may undergo atrophy and calcification in the end stage of disease (18) (Fig 14).
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Figure 13a. Adrenal tuberculosis in a 59-year-old man. In-phase (a) and out-of-phase (b) axial breath-hold gradient-echo MR images (126/6) show a right adrenal mass (arrow), which does not lose signal intensity on the out-of-phase image (b). The mass has nonspecific features but proved to be tuberculosis at biopsy.
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Figure 13b. Adrenal tuberculosis in a 59-year-old man. In-phase (a) and out-of-phase (b) axial breath-hold gradient-echo MR images (126/6) show a right adrenal mass (arrow), which does not lose signal intensity on the out-of-phase image (b). The mass has nonspecific features but proved to be tuberculosis at biopsy.
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Figure 14. Adrenal tuberculosis in a 57-year-old woman with adrenal insufficiency. Contrast-enhanced CT scan shows bilateral adrenal masses with low-attenuation centers and peripheral calcifications (arrows).
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Tuberculous Lymphadenitis
Lymphadenopathy is the most common manifestation of abdominal tuberculosis. The nodes are usually multiple and large, averaging 2–3 cm in diameter. The mesenteric and peripancreatic groups are the most commonly affected (19).
Genitourinary Tuberculosis
Genitourinary tuberculosis is the most common manifestation of extrapulmonary tuberculosis. M tuberculosis reaches the genitourinary organs, particularly the kidneys, by the hematogenous route from the lungs. The kidneys and possibly the prostate and seminal vesicles are often the primary sites of genitourinary tuberculosis. All other genital organs, including the epididymis and bladder, become involved by ascent or descent of M tuberculosis. The testicle may become involved by direct extension from an epididymal infection, but hematogenous spread to the testicle is rarely seen (20).
Renal Tuberculosis.—The earliest urographic abnormality is a "moth-eaten" calix due to erosion (Fig 15a). This finding is followed by papillary necrosis. Poor renal function, dilatation of the pelvicaliceal system due to a stricture of the ureteropelvic junction, or destructive dilatation or localized hydrocalycosis related to an infundibular stricture may be seen. Cavitation within the renal parenchyma may be detected as irregular pools of contrast material. Cicatricial contracture of fibrotic parenchyma may lead to caliceal or renal pelvic traction. Calculi may be present within the renal collecting system. Characteristic calcifications in a lobar distribution are often seen in end-stage tuberculosis. End-stage fibrosis and subsequent obstructive uropathy produce autonephrectomy. At this time, renal assessment is best achieved with US, CT, or MR imaging (5,21,22) (Fig 15b, 15c). Similar lesions may be found in acute focal bacterial nephritis, in xanthogranulomatous pyelonephritis, and with small benign or malignant tumors.
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Figure 15a. Tuberculous pyonephrosis in a 48-year-old man. (a) Anteroposterior conventional urogram shows dilatation of the caliceal system without pelvic dilatation. The margins of the middle calices are irregular (moth-eaten calix), and there are multiple internal filling defects caused by caseous debris (arrow). (b) CT scan shows a high-attenuation debris collection within dilated upper pole calices as well as a calculus (arrow). (c) Fat-suppressed coronal T2-weighted MR urogram (6,800/119) shows marked dilatation of the left upper pole calices due to infundibular stenosis. There is minimal dilatation of the left lower pole calices due to a distal ureteral stricture. (d) Longitudinal US scan shows a short stricture and wall thickening of the left distal ureter (arrow) with proximal dilatation. The diagnosis was confirmed with biopsy of the left ureter.
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Figure 15b. Tuberculous pyonephrosis in a 48-year-old man. (a) Anteroposterior conventional urogram shows dilatation of the caliceal system without pelvic dilatation. The margins of the middle calices are irregular (moth-eaten calix), and there are multiple internal filling defects caused by caseous debris (arrow). (b) CT scan shows a high-attenuation debris collection within dilated upper pole calices as well as a calculus (arrow). (c) Fat-suppressed coronal T2-weighted MR urogram (6,800/119) shows marked dilatation of the left upper pole calices due to infundibular stenosis. There is minimal dilatation of the left lower pole calices due to a distal ureteral stricture. (d) Longitudinal US scan shows a short stricture and wall thickening of the left distal ureter (arrow) with proximal dilatation. The diagnosis was confirmed with biopsy of the left ureter.
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Figure 15c. Tuberculous pyonephrosis in a 48-year-old man. (a) Anteroposterior conventional urogram shows dilatation of the caliceal system without pelvic dilatation. The margins of the middle calices are irregular (moth-eaten calix), and there are multiple internal filling defects caused by caseous debris (arrow). (b) CT scan shows a high-attenuation debris collection within dilated upper pole calices as well as a calculus (arrow). (c) Fat-suppressed coronal T2-weighted MR urogram (6,800/119) shows marked dilatation of the left upper pole calices due to infundibular stenosis. There is minimal dilatation of the left lower pole calices due to a distal ureteral stricture. (d) Longitudinal US scan shows a short stricture and wall thickening of the left distal ureter (arrow) with proximal dilatation. The diagnosis was confirmed with biopsy of the left ureter.
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Figure 15d. Tuberculous pyonephrosis in a 48-year-old man. (a) Anteroposterior conventional urogram shows dilatation of the caliceal system without pelvic dilatation. The margins of the middle calices are irregular (moth-eaten calix), and there are multiple internal filling defects caused by caseous debris (arrow). (b) CT scan shows a high-attenuation debris collection within dilated upper pole calices as well as a calculus (arrow). (c) Fat-suppressed coronal T2-weighted MR urogram (6,800/119) shows marked dilatation of the left upper pole calices due to infundibular stenosis. There is minimal dilatation of the left lower pole calices due to a distal ureteral stricture. (d) Longitudinal US scan shows a short stricture and wall thickening of the left distal ureter (arrow) with proximal dilatation. The diagnosis was confirmed with biopsy of the left ureter.
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Ureteral Tuberculosis.—Dilatation and a ragged irregular appearance of the urothelium are the first signs of ureteral tuberculosis. Dilatation is primarily due to obstruction at the ureterovesical junction secondary to tuberculous cystitis and ureteritis. In advanced disease, ureteral strictures (Fig 15d), ureteral shortening, ureteral filling defects, or ureteral wall calcifications may be seen (5,22).
Bladder Tuberculosis.—The most common finding in tuberculous cystitis is reduced bladder capacity (Fig 16). In advanced disease, the bladder is small, irregular, and calcified (5,22). Calcified tuberculous cystitis must be differentiated from schistosomiasis, cystitis due to cyclophosphamide, radiation-induced changes, and calcified bladder carcinoma.
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Figure 16. Bladder tuberculosis in a 38-year-old woman with renal tuberculosis. Anteroposterior cystogram shows reduced bladder capacity as well as a diverticulum (arrow). The diagnosis was confirmed with histopathologic analysis.
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Female Genital Tuberculosis.—Fallopian tubes are affected in 94% of women with genital tuberculosis. Salpingitis caused by hematogenous dissemination is almost always bilateral (5). A tubo-ovarian abscess that extends through the peritoneum into the extraperitoneal compartment suggests tuberculosis (Fig 17).
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Figure 17a. Tuberculous tubo-ovarian abscess in a 21-year-old woman with lower abdominal pain and fever. (a) Contrast-enhanced CT scan shows a multiloculated mass with peripheral enhancement around centers of low, soft-tissue attenuation. The lesion extends to the iliac muscle (arrow). (b) Coronal T2-weighted MR image (7,200/90) shows the abscess (arrows). The diagnosis was confirmed with culture of a US-guided aspiration sample.
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Figure 17b. Tuberculous tubo-ovarian abscess in a 21-year-old woman with lower abdominal pain and fever. (a) Contrast-enhanced CT scan shows a multiloculated mass with peripheral enhancement around centers of low, soft-tissue attenuation. The lesion extends to the iliac muscle (arrow). (b) Coronal T2-weighted MR image (7,200/90) shows the abscess (arrows). The diagnosis was confirmed with culture of a US-guided aspiration sample.
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Male Genital Tuberculosis.—At transrectal US, the most common finding of tuberculous prostatitis is hypoechoic areas with an irregular pattern in the peripheral zone of the prostate. Contrast-enhanced CT shows hypoattenuating prostatic lesions, which likely represent foci of caseous necrosis and inflammation (Fig 18a). Nontuberculous pyogenic prostatic abscesses have a similar CT appearance (5). At MR imaging, a prostatic abscess demonstrates peripheral enhancement (Fig 18b, 18c). This finding helps differentiate an abscess from prostatic malignancy. In addition, MR imaging shows diffuse, radiating, streaky areas of low signal intensity in the prostate ("watermelon skin" sign) on T2-weighted images (23) (Fig 18d). Tuberculous epididymitis or epididymo-orchitis has nonspecific imaging findings (20,24) (Fig 18e).
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Figure 18a. Tuberculous prostatitis and orchitis in a 69-year-old man with diabetes mellitus. (a) Contrast-enhanced CT scan shows an amorphous calcification (arrowhead) and diffuse low-attenuation areas in the peripheral zone of the prostate (arrows). (b) Axial T2-weighted endorectal MR image (4,700/112) shows a focal, heterogeneous area of high signal intensity, which corresponds to an abscess (arrow). (c) Contrast-enhanced axial T1-weighted endorectal MR image (600/15) shows peripheral enhancement of the abscess (arrow). (d) Axial T2-weighted endorectal MR image (4,700/112) shows diffuse, radiating, streaky areas of low signal intensity in the peripheral zone of the prostate (watermelon skin sign) (arrowheads). (e) Coronal T2-weighted MR image (3,200/119) shows focal hypointense areas in the testicles. The diagnosis was confirmed with transrectal US-guided biopsy.
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Figure 18b. Tuberculous prostatitis and orchitis in a 69-year-old man with diabetes mellitus. (a) Contrast-enhanced CT scan shows an amorphous calcification (arrowhead) and diffuse low-attenuation areas in the peripheral zone of the prostate (arrows). (b) Axial T2-weighted endorectal MR image (4,700/112) shows a focal, heterogeneous area of high signal intensity, which corresponds to an abscess (arrow). (c) Contrast-enhanced axial T1-weighted endorectal MR image (600/15) shows peripheral enhancement of the abscess (arrow). (d) Axial T2-weighted endorectal MR image (4,700/112) shows diffuse, radiating, streaky areas of low signal intensity in the peripheral zone of the prostate (watermelon skin sign) (arrowheads). (e) Coronal T2-weighted MR image (3,200/119) shows focal hypointense areas in the testicles. The diagnosis was confirmed with transrectal US-guided biopsy.
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Figure 18c. Tuberculous prostatitis and orchitis in a 69-year-old man with diabetes mellitus. (a) Contrast-enhanced CT scan shows an amorphous calcification (arrowhead) and diffuse low-attenuation areas in the peripheral zone of the prostate (arrows). (b) Axial T2-weighted endorectal MR image (4,700/112) shows a focal, heterogeneous area of high signal intensity, which corresponds to an abscess (arrow). (c) Contrast-enhanced axial T1-weighted endorectal MR image (600/15) shows peripheral enhancement of the abscess (arrow). (d) Axial T2-weighted endorectal MR image (4,700/112) shows diffuse, radiating, streaky areas of low signal intensity in the peripheral zone of the prostate (watermelon skin sign) (arrowheads). (e) Coronal T2-weighted MR image (3,200/119) shows focal hypointense areas in the testicles. The diagnosis was confirmed with transrectal US-guided biopsy.
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Figure 18d. Tuberculous prostatitis and orchitis in a 69-year-old man with diabetes mellitus. (a) Contrast-enhanced CT scan shows an amorphous calcification (arrowhead) and diffuse low-attenuation areas in the peripheral zone of the prostate (arrows). (b) Axial T2-weighted endorectal MR image (4,700/112) shows a focal, heterogeneous area of high signal intensity, which corresponds to an abscess (arrow). (c) Contrast-enhanced axial T1-weighted endorectal MR image (600/15) shows peripheral enhancement of the abscess (arrow). (d) Axial T2-weighted endorectal MR image (4,700/112) shows diffuse, radiating, streaky areas of low signal intensity in the peripheral zone of the prostate (watermelon skin sign) (arrowheads). (e) Coronal T2-weighted MR image (3,200/119) shows focal hypointense areas in the testicles. The diagnosis was confirmed with transrectal US-guided biopsy.
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Figure 18e. Tuberculous prostatitis and orchitis in a 69-year-old man with diabetes mellitus. (a) Contrast-enhanced CT scan shows an amorphous calcification (arrowhead) and diffuse low-attenuation areas in the peripheral zone of the prostate (arrows). (b) Axial T2-weighted endorectal MR image (4,700/112) shows a focal, heterogeneous area of high signal intensity, which corresponds to an abscess (arrow). (c) Contrast-enhanced axial T1-weighted endorectal MR image (600/15) shows peripheral enhancement of the abscess (arrow). (d) Axial T2-weighted endorectal MR image (4,700/112) shows diffuse, radiating, streaky areas of low signal intensity in the peripheral zone of the prostate (watermelon skin sign) (arrowheads). (e) Coronal T2-weighted MR image (3,200/119) shows focal hypointense areas in the testicles. The diagnosis was confirmed with transrectal US-guided biopsy.
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Lymph Node Tuberculosis |
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Lymphatic tuberculosis is more common among children. Cervical or supraclavicular nodes are most commonly involved (25). At CT, nodes demonstrate peripheral enhancement with low-attenuation centers (Fig 19). This appearance is highly suggestive but not pathognomonic of tuberculosis. A similar pattern may be seen in metastatic malignancy, lymphoma, and inflammatory conditions.
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Figure 19a. Tuberculous lymphadenitis in a 30-year-old man with miliary tuberculosis. (a) Contrast-enhanced CT scan shows a lymph node with peripheral enhancement and a low-attenuation center (arrow). (b) Transverse US scan shows multiple tiny calcifications within the hypoechoic lymph node.
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Figure 19b. Tuberculous lymphadenitis in a 30-year-old man with miliary tuberculosis. (a) Contrast-enhanced CT scan shows a lymph node with peripheral enhancement and a low-attenuation center (arrow). (b) Transverse US scan shows multiple tiny calcifications within the hypoechoic lymph node.
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Breast Tuberculosis |
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Tuberculosis of the breast is extremely rare. Young, multiparous, lactating women are commonly affected. The most frequently encountered clinical finding is a mass with or without ulceration (26). Mammographic findings are nonspecific. At US, the findings of abscesses and sinus tracts and of circumscribed hypoechoic masses with moving internal echoes and posterior enhancement may aid in differential diagnosis. At MR imaging, parenchymal asymmetry with enhancement, microabscesses, and peripherally enhanced masses can be seen (Fig 20).
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Figure 20a. Tuberculous mastitis in a 26-year-old woman with clinical findings of acute mastitis. (a) Axial T2-weighted MR mammogram (4,250/90) shows a hyperintense mass (arrow). (b) Axial T1-weighted MR mammogram (620/15) shows a hypointense mass (arrow), as well as diffuse skin thickening and parenchymal distortion. (c) Contrast-enhanced axial T1-weighted MR mammogram (786/15) shows significant enhancement of the mass (arrow), skin, and parenchyma. The diagnosis was confirmed with excisional biopsy.
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Figure 20b. Tuberculous mastitis in a 26-year-old woman with clinical findings of acute mastitis. (a) Axial T2-weighted MR mammogram (4,250/90) shows a hyperintense mass (arrow). (b) Axial T1-weighted MR mammogram (620/15) shows a hypointense mass (arrow), as well as diffuse skin thickening and parenchymal distortion. (c) Contrast-enhanced axial T1-weighted MR mammogram (786/15) shows significant enhancement of the mass (arrow), skin, and parenchyma. The diagnosis was confirmed with excisional biopsy.
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Figure 20c. Tuberculous mastitis in a 26-year-old woman with clinical findings of acute mastitis. (a) Axial T2-weighted MR mammogram (4,250/90) shows a hyperintense mass (arrow). (b) Axial T1-weighted MR mammogram (620/15) shows a hypointense mass (arrow), as well as diffuse skin thickening and parenchymal distortion. (c) Contrast-enhanced axial T1-weighted MR mammogram (786/15) shows significant enhancement of the mass (arrow), skin, and parenchyma. The diagnosis was confirmed with excisional biopsy.
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Conclusions |
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The clinical and radiologic features of extrapulmonary tuberculosis may mimic those of many diseases. A high index of suspicion is required, especially in high-risk populations. Although a positive culture or histologic analysis of biopsy specimens is still required in many patients to yield the definitive diagnosis, recognition and understanding of the spectrum of imaging features of extrapulmonary tuberculosis can aid in diagnosis.
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TOP
Abstract
Introduction
BRTS
