肺外结核影像学表现

Extra-Pulmonary Tuberculosis Christina Dancz Harvard Medical School Year III Gillian Lieberman, MD Christina Dancz Gillian Lieberman, MD July 2002 2 Our First Patient • 32 year old man from Brazil • Remote history of gunshot wound • One month history of: – Bilateral lower extremity pain – Progressive ataxia – Sensory Loss – Night sweats – Weakness – Urge Incontinence Christina Dancz Gillian Lieberman, MD 3 Physical Exam • Spastic Legs • Hyper-reflexia • Sensory Loss • Cord Lesion (upper motor neuron, sensory neuron) at T4 Christina Dancz Gillian Lieberman, MD 4 Possible Imaging Modalities • X-ray – Poor sensitivity for spinal injuries • CT – Indicated for bony abnormalities and fractures – Myelogram – for stenosis or tumors • MRI – Spinal cord – Blood Clots – Disks – Soft Tissue Masses – Degree of Involvement Christina Dancz Gillian Lieberman, MD 5 KUB Christina Dancz Gillian Lieberman, MD An abdominal film was ordered, to determine the presence and location of the bullet from a previous wound Beth Israel Deaconess - PACS 6 MRI – T1 Weighted Christina Dancz Gillian Lieberman, MD T1 Weighted Image Without Contrast T1 Weighted Image With Contrast Beth Israel Deaconess - PACS 7 MRI – T2 Weighted Christina Dancz Gillian Lieberman, MD At around T1 (arrow) we see enhancement of the spinal cord, indicating fluid within the cord itself. Beth Israel Deaconess - PACS 8 Differential Diagnosis • Patchy Enhancement/Thickening on MR – Extrinsic Compression • Disk • Tumor – Infectious • TB/Brucellosis/Fungal – Inflammatory • MS • Myelitis – Neoplasm • Ependymoma, astrocytoma – Syringomyelia, Hydromyelia • Next Step: – Cord Biopsy and Culture Christina Dancz Gillian Lieberman, MD 9 Diagnosis: Pott’s Disease • Tuberculosis involving the Vertebral Bodies • Interesting Information about Pott’s Disease – Evidence of Pott’s Disease has been found in the vertebrae of Egyptian mummies dating from 3000 BC – 1-5% of TB cases have skeletal involvment – 50% of patients with Pott’s disease have no pulmonary manifestations • TB is clinically relevant in the U.S. – 2-8% of people with HIV will contract TB (CDC) • TB is clinically relevant worldwide Christina Dancz Gillian Lieberman, MD 10 Global Prevalence of TB JAMA. 1999;282:677-686 Christina Dancz Gillian Lieberman, MD 11 Extrapulmonary TB – page 1 • Abdominal – Peritonitis – Hepato-Splenic • Genito-Urinary – Renal – Urethral – Bladder – Genital • Lymph Nodes • Breast Christina Dancz Gillian Lieberman, MD 12 Extrapulmonary TB – page 2 • CNS – Meningitis – Parenchymal (Tuberculomas) • Musculoskeletal Involvement – Spondylitis (Pott’s Disease) – Osteomyelitis – Dactylitis – Arthritis Christina Dancz Gillian Lieberman, MD 13 Etiology of Musculoskeletal TB • Hematogenous spread through vertebral arteries • Soft tissue involvement will result in – Abscess (quite large in TB, versus other infections) – Phlegmon Christina Dancz Gillian Lieberman, MD 14 Access to the Spinal Column • Bacteria lodge under the end plate and spread – Directly to disk – Across the joint space – Under the anterior and posterior longitudinal ligaments Christina Dancz Gillian Lieberman, MD Gray’s Anatomy http://www.yahooligans.com/reference/gray /72.html#4 15 Musculoskeletal TB • Characteristic features found in our Patient – Inflammation of the Spinal Cord • Other Characteristic Features – Preferential Involvement of L1 – Erosion of Endplates – Involvement of multiple vertebral segments • Preferentially anterior destruction • Resulting in Kyphosis – Elongated paravertebral abscess • May calcify (Pathognomonic) – Narrowing of Joint Space • Usually in TB shows relative sparing of joint space, until late in disease Christina Dancz Gillian Lieberman, MD 16 Our Second Patient • 25 year old man from Kenya • Four month history of: – Pain, tingling, burning of left thigh • One month history of: – Lower back pain • 9 day history of: – Severe left thigh pain • 5 day history of: – Diarrhea, night sweats Christina Dancz Gillian Lieberman, MD 17 Our Second Patient • Other Relevant History: – BCG vaccine – 2 years ago lived with a cousin who was diagnosed with TB Christina Dancz Gillian Lieberman, MD 18 Abdominal X-ray • Characteristic Findings: Narrowing of disk space Involvement of end plate Destruction of vertebral body Beth Israel Deaconess - PACS Christina Dancz Gillian Lieberman, MD 19 Characteristic CT Findings • Destruction of the vertebral body • Enhancing region within cord • Large paravertebral abscess Beth Israel Deaconess - PACS Christina Dancz Gillian Lieberman, MD 20 CT of the Psoas Abscess Extending into the Pelvis Extending into the Thigh Beth Israel Deaconess - PACS Christina Dancz Gillian Lieberman, MD 21 CT Coronal View • Large paravertebral abscess extending from upper kidney to groin Beth Israel Deaconess - PACS Christina Dancz Gillian Lieberman, MD 22 Treatment Drain the Abscess IV and Oral Antibiotics L2-L3 Vertebrectomy Beth Israel Deaconess - PACS Christina Dancz Gillian Lieberman, MD 23 Acknowledgements Michelle Swire, MD Phillip Boiselle, MD Daniel Saurborn, MD Priscilla Slanetz, MD, MPH • Larry Barbaras and Cara Lyn D’amour our Webmasters • Gillian Lieberman, MD • Pamela Lepkowski Christina Dancz Gillian Lieberman, MD 24 References • Kandel E, Schwartz, J. 1985. Principles of Neural Science. New York, NY: Elsevier Science Publishing Co., Inc. • Engin G, Acunas B, Acunas G, Tunaci A. Imaging of Extrapulmonary Tuberculosis. RadioGraphics 2000; 20:471-488. • Juhl J, Crummy A, Kuhlman J. 1998. Paul and Juhl’s Essentials of Radiologic Imaging. Baltimore, MD: Lippincott Williams & Wilkins. • http://www.yahooligans.com/reference/gray/72.html#4 • http://www.spinenet.com/backRounds/tuberc.html • Dye C, Scheele S, Dolin P, Pathania V, Raviglione M. Global Burden of Tuberculosis. JAMA 1999; 282: 677-686. • www.cdc.gov/nchstp/tb/pubs/corecurr/Chapter_5_Medical_Evaluation.html • www.cdc.gov/mmwr/preview/mmwrhtml/0005537.html • Post, M. 1984. Computed Tomography of the Spine. Baltimore, MD: Williams and Wilkins. Christina Dancz Gillian Lieberman, MD Extra-Pulmonary Tuberculosis Our First Patient Physical Exam Possible Imaging Modalities KUB MRI – T1 Weighted MRI – T2 Weighted Differential Diagnosis Diagnosis: Pott’s Disease Global Prevalence of TB Extrapulmonary TB – page 1 Extrapulmonary TB – page 2 Etiology of Musculoskeletal TB Access to the Spinal Column Musculoskeletal TB Our Second Patient Our Second Patient Abdominal X-ray Characteristic CT Findings CT of the Psoas Abscess CT Coronal View Treatment Acknowledgements Slide Number 24