Computed tomography of bronchiectasis in association with tuberculosis

36

CLINICAL IMAGING

1989;36-43

COMPUTED TOMOGRAPHY OF BRONCHIECTASIS IN ASSOCIATION WITH TUBERCULOSIS MYUNG

S. SHIN,

MD

AND

KANG-JEY

Eight patients with pulmonary tuberculosis proven by positive sputum culture were found to have various degrees of bronchiectasis by computed tomography (CT) but not by plain chest radiography. The CT is characterized by cystic dilatation of the thickwalled bronchi manifested as strings or clusters of pearls or grapes for cystic bronchiectasis and a “tram-line” appearance for cylindrical bronchiectasis. We stress that bronchiectasis remains quite common in association with pulmonary tuberculosis, and CT can replace bronchography for its detection. KEY WORDS:

Pulmonary tuberculosis; Bronchiectasis

It has been well known that bronchiectasis occurs frequently in association with tuberculosis, particularly in its advanced stage (l-3). With the improvement of antituberculous therapy, the incidence of tuberculosis-associated bronchiectasis has appeared to decline (4, 5). In 154 children with culture-proven tuberculosis studied radiographically by Lamont et al. (4), bronchiectasis was detected in only three cases. In reviewing chest radiographs obtained from 107 patients with active pulmonary tuberculosis by Woodring et al. (5), no case of bronchiectasis was described. However, during the past

From the Departments of Radiology (M.S.S.) and Pathology (K.H.), School of Medicine, University of Alabama at Birmingham, and the Veterans Administration Hospital, Birmingham, Alabama. Address requests for reprints to: Myung S. Shin, MD, Department of Radiology, University of Alabama Hospital, 619 South 19th Street, Birmingham, AL 35233. Received January 22, 1988. 0 1989 by Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, 0149-936X/89/$3,50

New York, NY 10010

HO,

MD,

PhD

year we have seen eight patients with bronchiectasis in association with tuberculosis at both the University of Alabama Hospital and Veterans Administration Hospital, Birmingham. The lesions could not be definitely diagnosed by the conventional chest radiography without bronchography but were clearly demonstrated by computed tomography (CT). We stress that bronchiectasis is still quite common in patients with pulmonary tuberculosis, and CT is very useful in its detection. PATIENTS

AND METHODS

The medical histories, chest radiographs, and CT of eight patients with pulmonary tuberculosis confirmed by positive sputum cultures were reviewed (Table 1).These patients were examined at either the University of Alabama Hospital or the Birmingham Veterans Administration Hospital during 1986-1987 period. These cases were selected because of their abnormal chest radiographs associated with pulmonary tuberculosis and bronchiectasis confirmed by CT. The patients, four males and four females, were all adults ranging in age from 31 to 74 years. Except for two patients (cases 2 and 8), all had a long history of pulmonary tuberculosis with subsequent repeated episodes of hemoptysis or pulmonary infections. Sputum cultures were positive for Mycobacterium tuberculosis in six cases and M. avium intracellulare in two cases. Reactivation of pulmonary tuberculosis occurred in two cases as the consequence of immunosuppressive therapy for renal transplantation (case 7) or chronic active hepatitis (case 8). Abnormal chest radiography was discovered incidentally in case 2 when she was admitted for toxemia of pregnancy. This patient had a family history of tuberculosis. The CT scans were performed with a GE 9800, Philips TX60, or Picker 1200 scanner at continuous lo-mm thickness with a 5-second scan time. All pa-

MARCH

1989

CT OF BRONCHIECTASIS

TABLE 1. Summary of Clinical Bronchiectasis Associated with Patient

History

Case 1, 64-year-old

white male

Case 2, 32-year-old

black female

Case 3, 74year-old

white male

Case 4, 67-year-old

white male

Case 5, 5%year-old

white male

Case 6, 70-year-old white male

Case 7, 31-year-old white female

Case 8, 67-year-old white female

Abbreviations:

History, Chest Tuberculosis

History of pulmonary tuberculosis for more than 40 years with repeated episodes of pneumonia 37-week gestation with hypertension, proteinuria, dyspnea, and cough History of pulmonary tuberculosis, treated, with repeated lung infection History of pulmonary tuberculosis 7 years ago; repeated Pseudomonas infection; terminal disseminated candidiasis History of pulmonary tuberculosis 9 years ago, with repeated episodes of cough and hemophysis Long history of pulmonary tuberculosis, inadequately treated, with repeated pneumonia and hemoptysis History of pulmonary tuberculosis 6 years ago, renal transplantation for end-staged kidneys Z. years ago, recent hemoptysis Chronic active hepatitis treated with steroids, followed by cough and hemoptysis

Radiography,

CT, and Culture

Result

of Eight Patients

37

with

Chest radiography

CT

changes with volume loss, left

M. tuberculosis

lung multiple cavitary lesions, right lung Cavitary lesions, RUL; calcification, left hilum

Severe cystic bronchiectasis and atelectosis, left lung; cavitary lesions with air-fluid level, right lung Cystic bronchiectasis, posterior segment of RUL

Elliptical opacities, superior segment of RLL; fluffy opacities RLL; calcification, left hilum Large cavities, both apices; fluffy opacities; left lung, with volume loss

Cystic bronchiectasis with puddling of secretion, superior segment of RLL; calcified lymph node, left hilum Bronchiectasis with puddling of secretion, left lung; cavities, both apices

M. tuberculosis

Cystic lesion, LUL; nodular opacities, right lung

Cystic bronchiectasis, apical-posterior segment of LUL

M. avium intracellulare

Streaky opacities, both upper lobes with upward retraction of left hilum; a cavity with fungus ball, LUL

Cystic bronchiectasis LUL; cavity with fungus ball, apical-posterior segment of LUL

M. tuberculosis

A large cavity with fungus ball, RUL; streaky opacities, both lungs

Cylindrical bronchiectasis, LUL; varicose bronchiectasis, RML and RLL; a cavity with fungus ball, RUL

M. tuberculosis

Hazy opacities, both apices; streaky opacities, both upper lobes

Cystic bronchiectasis, apices

M. tuberculosis

Cystic

Culture

both

M. tuberculosis

M. avium intracellulare

RUL: right upper lobe; RLL: right lower lobe; LUL: left upper lobe.

tients received intravenous injections of iodinated contrast medium (30-40 g iodine). Bronchography was not done in these patients. RESULTS

Chest Radiography Streaky, fluffy, hazy, and nodular opacities in the lungs were the most common radiographic features found in this series of patients (Figures 3-8). Cavi-

tary lesions of various sizes were noted in five patients (Figures 1, 2, 4, 6, and 7). Most cavities were in the upper lobes. Fungus balls or aspergillomas were present in two cavities (Figures 6 and 7). Lymph node calcification was not a predominant sign and was present only in two cases (Figures 2 and 3). Cystic changes were observed in two cases (Figures 1 and 5). Although such cystic changes might be suggestive of bronchiectasis, bronchography or CT is required for its confirmation.

38

SHIN AND HO

CLINICAL

IMAGING

VOL. 13. NO. 1

FIGURE

1. Case 1.The Chest radiograph [left) shows cystic changes with volume loss (left lung) and multiple cavitary lesions (right lung). The CT [right) reveals severe

cystic bronchiectasis level [right lung).

CT Findings

most characteristic for bronchiectasis (Figures 1, 5, and 6). Bronchiectasis can be saccular [or cystic), cylindrical, or varicose (6). Most cases showed saccular or cystic bronchiectasis, characterized by strings or clusters of cysts (pearls or grapes). The cystically distended bronchi can be distinguished

All eight patients shared a common CT finding: bronchiectasis. One of the cardinal CT features of bronchiectasis is the dilatation of bronchi, which was observed in all eight patients (Figures l-8).The bronchial dilatation in the periphery of the lung is FIGURE 2. Case 2. The Chest radiograph [left) shows cavitary lesion in right upper lobe [arrows) and calcified lesions in left hilum. The CT (right) at the level of carina

(left lung) and a cavity with air-fluid

reveals cystic bronchiectasis wall (right upper lobe).

and a cavity with irregular

CT OF BRONCHIECTASIS

iMARCH 1989

FIGURE 3, Case 3. The Chest radiograph (left) shows elliptical and fluffy opacities, [right lower lobe) and calci-

FIGURE 4. Case 4. The Chest radiograph cavities, both apices, and fluffy opacities

[left) shows with volume

39

fication (left hilum). The CT (right) reveals cystic bronchiectasis with puddling of mucus (right lower lobe).

10s~ (left lung). The CT (right] reveals bronchiectasis puddling of mucus (left lung).

with

40

SHIN AND HO

CLINICAL

IMAGING

VOL. 13, NO. 1

FIGURE 5. Case 5. The Chest radiograph [left) shows cystic lesions (left upper lobe) and nodular opacities (right

lung). The CT (right) reveals cystic bronchiectasis

from emphysematous blebs by their thickened wall and accompanying vessels. The distended bronchi often show puddling of secretion and inflammatory exudate and, occasionally, air-fluid levels. The thickened bronchi with a “tram-line” appearance indicative of cylindrical bronchiectasis was noted in case 7 (Figure 7). The same case also exhibited changes compatible with varicose bronchiectasis. Other findings included cavitary lesions with or without air-fluid levels or fungus balls (Figures 1 and 7) and calcification of mediastinal and peribronchial lymph nodes.

eight patients showed cystic changes in the lung suggestive of bronchiectasis. It is, therefore, conceivable that a number of cases might be missed on plain chest film examination alone, and more cases of bronchiectasis might be detected by CT in the future. Six of our eight patients had a long history of pulmonary tuberculosis followed by repeated episodes of bronchitis and pneumonia manifested by cough, fever, and the expectoration of copious amounts of purulent sputum. Such a clinical course is in accordance with the hypothesis proposed by Rosenzweig and Stead (7) that tuberculosis often leads to simple dilatation of bronchi, and secondary bacterial infection is required for the development of a full-blown bronchiectasis. The simple bronchiectasis is the result of destruction of the bronchial wall by tuberculous granulomatous inflammation. The dilatation of bronchi, impairment of mucosal ciliary function, and retention of mucus predispose to secondary bacterial infection. The resulting obstruction, atelectasis, organizing pneumonia, and pulmonary fibrosis contribute to the further dilatation of bronchi with weakened wall (8). Reactivation of pulmonary tuberculosis during immunosuppressive therapy may lead to bronchiectasis, as observed in two of our patients. The radiographic manifestations of bronchiectasis on plain chest film, such as crowding and loss of definition of vascular markings, peribronchial fibrosis, loss of volume, and cystic spaces with or without air-fluid levels as described by Gudbjerg (9)

DISCUSSION Although bronchiectasis associated with pulmonary tuberculosis was quite common in the past [l-3), its true incidence at the present time is uncertain; it could not be determined by the present study because we did not review all cases of pulmonary tuberculosis during the same period of study and CT was applied to only a limited number of patients with tuberculosis. Since effective antituberculous chemotherapy became available, the incidence of tuberculosis-induced bronchiectasis has been declining steadily (4, 5). However, the true incidence at present could be much higher than is generally believed. In our laboratory, we have encountered eight such cases in a l-year period. Second, definite diagnosis of bronchiectasis by conventional chest radiography alone is extremely difficult, if not impossible. On plain chest films, only two out of our

posterior segment of left upper lobe).

(apical-

MARCH

1989

CT OF BRONCHIECTASIS

41

FIGURE 6. Case 6. The Chest radiograph (left, upper and

lower) shows streaky opacities (both upper lobes) with upward retraction of left hilum and a large cavity with a fungus ball (left upper lobe). The position of the myce-

toma changes from upright to lateral decubital position left lower (arrow). The CT shows fungus ball in the cavity (right, upper) and cystic bronchiectasis of left upper lobe (right, lower).

are not specific. Bronchography is required for a definitive diagnosis of bronchiectasis. Naidich et al. (10) applied CT to six patients with bronchiectasis and described its CT characteristics. Miller et al. (11) performed CT in 11 patients with a clinical history suggestive of bronchiectasis and concluded that CT may be useful in the diagnosis of cystic bronchiectasis but is unreliable in detecting cylindrical and varicose changes, a finding supported by Silverman et al. (12) and Phillips et al. (13). Recently Grenier et al. (14) applied thin-section CT to 36 patients and concluded that thin-section CT was an accurate procedure in the recognition of all kinds of bronchiectasis. In our study CT was performed with regular IO-mm-thick sections instead

of 1.5mm sections, yet bronchiectasis was clearly demonstrated in all eight subjects with no difficulty. This could be attributable to the fact that the findings in these patients were all quite advanced. It is conceivable that if thin-section CT were applied, more cases of bronchiectasis, particularly those in the early stage, could be detected. The CT characteristics of bronchiectasis include cluster of cysts, bronchial dilatation with thickened wall, puddling of mucus or air-fluid level in distended bronchi, and tram-line configuration (Figures l-8). From our own experience, cystic bronchiectasis is much more common than cylindrical and varicose forms, for the former is readily diagnosed with the standard lo-mm-thick section CT (10, 11). Patients

42

SHIN

AND

CLINICAL

HO

IMAGING

VOL.

13, NO.

FIGURE 7. Case 7. The Chest radiograph [left) shows streaky opacities in both lungs and a large cavity with a fungus ball (right upper lobe). The CT (right) reveals cy-

lindrical bronchiectasis (left upper lobe) and varicose bronchiectasis [right middle and lower lobes).

with

monary

the

latter

forms

of bronchiectasis

show areas of cystic changes. three morphologic variants of is often difficult and may not the value of such subclasses still not been established. In summary, bronchiectasis

also

often

Distinction of these bronchiectasis by CT be necessary because of bronchiectasis has associated

with pul-

tuberculosis

remains

quite

common,

1

espe-

cially in patients with a long history of tuberculosis followed by repeated episodes of pulmonary infection. A definitive diagnosis of advanced bronchiectasis can be made by CT but not chest radiography alone. It is therefore recommended that CT be applied to patients with pulmonary tuberculosis man-

FIGURE 8. Case 8. The Chest radiograph (left) shows hazy and streaky opacities reveals cystic bronchiectasis in both apices.

(both upper lobes).

The CT (right)

MARCH

1989

ifested by chronic cough with copious amounts of sputum for detection of bronchiectasis. The noninvasive CT can replace the traditional bronchography for diagnosis of bronchiectasis.

CT OF BRONCHIECTASIS

6. Reid L. Reduction in bronchial tasis. Thorax 1950; 5:233-247.

subdivision

43

in bronchiec-

7. Rosenzweig DY, Stead WW. The role of tuberculosis and other forms of bronchopulmonary necrosis in the pathogenesis of bronchiectasis. Am Rev Resp Dis 1966; 93:769-785. 8. Westcott JL, Cole SR. Traction bronchiectasis in end-stage pulmonary fibrosis. Radiology 1986; 161:665-669.

REFERENCES disease in 1. Olson DE, Jones FS, Angevine DM. Bronchial lungs resected for pulmonary tuberculosis. Am Rev Tuberc 1953; 68:657-677. and his2. Corpe RF, Hwa ECA. A correlated bronchographic topathologic study of bronchial disease in 216 tuberculous patients. Am Rev Tuberc 1956; 73:681-689. RH: Correlations of tomo3. Juhl JH, Alt WJ, Wasserburger graphic and bronchographic findings in apical bronchiectasis. Am Rev Tuberc 1956; 74:388-399.

9. Gudbjerg CE. Roentgenologic diagnosis of bronchiectasis. An analysis of 112 cases. Acta Radio1 (Stockholm) 1955; 43:209226. 10. Naidich DP, McCauley DI, Khouri NF, Stitik SS. Computed tomography of bronchiectasis. sist Tomogr 1982; 6:437-444.

FP, Siegelman J Comput As-

11. Muller NL, Bergin CJ, Ostrow DN, Nichols DM. Role of computed tomography in the recognition of bronchiectasis. AJR 1984; 143:971-976. 12. Silverman PM, Godwin JD. CTibronchographic correlations in bronchiectasis. J Comput Assist Tomogr 1987; 11:52-56.

4. Lamont AC, Cremin BJ, Pelteret RM. Radiological patterns of pulmonary tuberculosis in the paediatric age group. Pediatr Radio1 1986; 16:2-7.

13. Phillips MS, Williams MP, Flower CDR. How useful is computed tomography in the diagnosis and assessment of bronchiectasis. Radiology 1986; 37:321-325.

HM, Fried AM, Dillon ML, Wil5. Woodring JH, Vandiviere liams TD, Melvin IG. Update: The radiographic features of pulmonary tuberculosis. AJR 1986; 146:497-506.

14. Grenier P, Maurice F, Musset D, Menu Y, Nahum H. Bronchiectasis: assessment by thin-section CT. Radiology 1986; 161:95-99.