Tuberculosis—The Great Mimicker

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Tuberculosis is an immense health problem in the developing world, and it remains a health care challenge in the developed world. It can affect virtually any organ system in the body. Diagnosis of tuberculosis is often difficult. Many patients with tuberculosis present with nonspecific symptoms, negative purified protein derivative skin test result, and negative findings on culture specimens. Cross-sectional imaging with ultrasound, multidetector computed tomography, and magnetic resonance imaging plays an important role in the diagnosis of tuberculosis. Tuberculosis demonstrates a variety of radiologic features depending on the organ involved and can mimic a number of other disease entities. Cross-sectional imaging alone is insufficient in reaching a conclusive diagnosis. Tuberculosis is a great mimicker as its radiologic manifestations can simulate numerous other diseases across the body systems. However, recognition and understanding of the common and uncommon radiologic manifestations of tuberculosis should alert considering tuberculosis in the high-risk population and correct clinical setting to enable appropriate treatment.

Introduction

Tuberculosis (TB) continues to be a health problem in the developing world and remains a health care challenge in the developed world owing to immigration from endemic areas, increased prevalence of immunosuppression, and emergence of multidrug- and extensively drug-resistant strains of Mycobacterium tuberculosis.1, 2, 3, 4, 5 Although manifestations of TB are usually limited to the chest, the disease can affect any organ system, and in patients infected with human immunodeficiency virus (HIV), it usually involves multiple organs. Many patients with TB present with nonspecific symptoms and negative purified protein derivative skin test result. In addition, culture of specimens may show negative finding for TB, or the presence of TB in a culture may be obscured or confounded by coexistent pathogens. TB demonstrates a variety of clinical and radiologic features depending on the organ involved and can mimic a number of other disease entities.6, 7 Therefore, in many cases, histologic analysis of biopsy specimens is still required to make a definitive diagnosis. In this article, we discuss and illustrate the imaging features of various types of TB affecting the lungs, central nervous system (CNS), bones, joints, gastrointestinal system, and genitourinary system.

Section snippets

Pulmonary TB

Pulmonary TB has been divided into primary and postprimary TB, with primary TB being considered a disease of childhood and postprimary TB a disease of adulthood.

TB Involving CNS

CNS TB is a result of hematogenous spread of Mycobacterium bacilli to the brain parenchyma. Tubercular bacilli initiate a granulomatous inflammatory reaction involving different tissue types of the CNS such as the meninges, brain, spinal cord, and covering bones. The CNS manifestation is in a variety of forms, such as TB meningitis, focal cerebritis, tuberculoma, tubercular abscess, tubercular vasculopathy and its complications such as basal ganglia infarcts and hydrocephalus, pott spine with

Skeletal TB

TB of the musculoskeletal system is rare and accounts for only up to 3% of all TB infections. The musculoskeletal system may be involved in 1 of 2 ways: by either hematogenous spread from primary infection of the lungs or reactivation in a bone or joint.32, 33

Abdominal TB

TB can affect any organ or tissue in the abdomen and can be mistaken for other inflammatory or neoplastic conditions. The most common sites of TB in the abdomen include lymph nodes, genitourinary tract, peritoneal cavity, and gastrointestinal tract. The liver, spleen, biliary tract, pancreas, and adrenals are rarely affected but are more likely in HIV-seropositive patients and in miliary TB.38, 39, 40

Breast

Tuberculous mastitis as the primary manifestation of the disease is rare. The most frequent mode of infection is retrograde spread from axillary nodes, followed by direct extension from contiguous structures such as the chest wall. Hematogenous dissemination is another cause of infection and has been observed in patients with acquired immune deficiency syndrome with miliary breast involvement. Direct inoculation of the nipple via the lactiferous ducts may account for some pregnancy-related

Conclusions

TB demonstrates a variety of radiologic features depending on the organ involved and can mimic a number of other disease entities. Cross-sectional imaging alone is insufficient in reaching a conclusive diagnosis. However, recognition and understanding of the common and uncommon radiologic manifestations of TB should alert considering TB in the high-risk population and correct clinical setting to enable appropriate treatment.

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