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Radiological diagnosis of TB and
the role of bronchoscopy
Christoph Lange
Clinical Infectious Diseases, Research Center Borstel
University of Lübeck; Germany
Graham Bothamley
Homerton University Hospital
NHS Foundation Trust, London; UK
T
B
Causes of pneumonia
hospital acquired
community acquired
Streptococcus pneumoniae
Chlamydophila pneumoniae
Viruses
Haemophilus influenzae
Aspiration
Legionella pneumophila
Staphylococcus aureus
Mycoplasma pneumoniae
Gram neg. rods
Unclear
31 (15-49) %
12 (0-32) %
11 (0 –35) %
9 (4 –22) %
8 (6 –10) %
6 (0 –23) %
5 (0- 22) %
5 (0 –13) %
4 (0 –18) %
45 (25-66) %
Hoeffken et al. 2005. Pneumologie 59: e1-e63
d1-7
Staphylococcus aureus
26 %
Pseudomonas aeruginosa
12 %
Escherichia coli
11 %
Klebsiella pneumoniae
11 %
Enterobacter spec.
7%
Haemophilus influenzae
7%
Streptococcus pneumoniae
9%
Acinetobacter spp.
3%
Stenotrophomonas spec.
1%
Vonberg et al 2005. Anaesthesist 54: 975-78
d>7
21 %
20 %
10 %
13 %
9%
3%
4%
5%
4%
Rare causes of pneumonia
(selection)
Bacteria
Acinetobacter spec.
Actinomyces spec.
Bacillus spec.
Burkholderia cepacia
Campylobacter fetus
Chlamydia psittaci
Coxiella burnetti
Francisella tularensis
Leptospira spec.
Mycobacterium spec.
Nocardia spec.
Pasteurella multocida
Pseudomonas pseudomallei
Rhodococcus equi
Yersinia pestis
Fungi
Viruses
Aspergillus spec.
Blastomyces dermatis
Candida spec.
Coccidioides immitis
Cryptococcus neoformans
Cryptosporidium parvum
Histoplasma capsulatum
Mucor spec.
Penicillium marneffei
Pneumocystis jirovecii
Adeno-Virus
Cytomegalo-Virus
Coxsackie-Virus
Echo-Virus
Epstein-Barr-Virus
Influenza A Virus
Influenza B Virus
Hanta-Virus
Herpes-Simplex-Virus
Human-Herpes-Virus 6
Measles-Virus
Parainfluenza-Virus
Respiratory-Synticial-Virus
Rhino-Virus
SARS-Corona-Virus
Varizella-Zoster-Virus
Parasites
Ascaris lumbricoides
Echinococcus spec.
Strongyloides stercoralis
Toxoplasma gondii
Tuberkulose
Influenza
Aspergillose
Radiological differential diagnosis
imaging differential diagnosis
diffuse infiltrates
focal infiltrates
?
?
hilar enlargement
?
pleural effusion
?
nodular opacities
?
cavitations
?
imaging differential diagnosis
diffuse infiltrates
• PCP, TB, CMV, other viral
infections, mycoplasma,
chlamydia
DD
hypers. pneumonitis
sarkoidosis
alveolar proteinosis
imaging differential diagnosis
focal infiltrates
• bacterial pneumonia, TB,
aspergillosis
DD
carcinoma
COP/BOOP
eos. pneumonia
imaging differential diagnosis
sarkoidosis
PAH
DD
hilar enlargement
•
cardiac decomp.
TB, NTM, HIV-infection
imaging differential diagnosis
nodular opacities
• TB, NTM, PCP, aspergillus
DD
toxic alveolitis
Wegener disease
metastasis
imaging differential diagnosis
pulmonary embolus
cardiac decomp.
DD
pleural effusion
• TB, aspergillosis,
pneumococcal pneumonia
malignancy
acid fast bacilli in sputum
M. abscessus
M. avium- complex
M. tuberculosis
M. malmoense
M. celatum
M. kansasii
Tuberkulose
Influenza
Aspergillose
Is bronchoscopy indicated in the
differential diagnosis of tuberculosis?
CID 2007; 44:S27-72
73% positive BAL cultures
45 % of cultures were polymicrobial
In 76% of cases with positive BAL culture results a change in
therapy followed
No difference in mortality outcome was observed related to the
change of the interventions
Chest 2000; 118:1739-46
Broncoscopic diagnostic does not lead to improved
survival in patients with severe pneumonia
White et al. BMT 1997; 20: 681-687
Methods for bronchoscopic diagnostic of
infectious diseases
+
-
comment
BS
low risk
contamination
Bronchoscopy not necessary
BAL
low risk
contamination
no histology
Gold standard
PBS
less contamination
no histology
bleeding
cytological diagnosis
SH Bx
histology
contamination
bleeding
Rarely indicated
TBBx
histology
pneumothorax
Mandatory for fungal infections
When is a biopsy mandatory for the diagnosis
of pulmonary infectious diseases
Aspergillus spec.
Candida spec.
(CMV)
BAL
alterted cytology in infectious diseases
disease
lymphocytes
PMN
eosinophiles
bacterial pneumonia



tuberculosis



viral pneumonia






fungal pneumonia
PMN
lymphocytes
eosinophils
Gram + cocci
Gram + rods
Gram - cocci
Cryptococcus spec.
Aspergillus spec.
P. jirovecii
Bronchoscopic diagnosis of infectious diseases
M. tuberculosis-specific ELISPOT
Isolation of mononuclear cells
BAL-fluid
blood
Antigen-specific cells
secrete IFN-g
Jafari C et al. Am J Resp Crit Care Med 2006
BLUT
BAL-F
Jafari C et al. Eur Resp J 2008
Jafari C et al. Am J Resp Crit Care Med
Jafari C et al. Am J Resp Crit Care Med 2009
Hoerster R et al. Clin Respir J 2009
Bronchoscopic diagnosis of infectious diseases
Aspergillus fumigatus
•
Sensitivity 76-85 %
Specificity 94-100 %
Meersseman W et al. Am J Respir Crit Care Med 2008
Bronchoscopic diagnosis of infectious diseases
Bild Poster Borstel
Pneumocystis jirovecii
Bronchoscopic diagnosis of infectious diseases
Bronchoscopic diagnosis of infectious diseases
Conclusions
There is a long list of differential diagnoses for the etiology of pulmonary iniltrates,
consolidations and cavitating diseases that include infectious and non-infectious
diseases
Targeted use of bronchoscopy including transbronchial biopsies, protected brush
sampling and bronchoalveolar lavage are safe procedures. They are often
necessary for the rapid differentiation of pulmonary infections from non-infectious
etiologies and for treatment decisions
Bronchoscopy is unavailable in many parts of the world where it would be needed
to improve patient care