Extra- pulmonary tuberculosis · los casos de afección del aparato digestivo. También son sitios frecuentes de afección el aparato genitouri-nario y el sistema linfático, en particular

25Vol. 5 / Nº 14 - Septiembre 2016

Extra-pulmonary tuberculosisLuciana Sánchez, Federico Felder, Marcos Dellamea, María Paz García Kosinsky, Andrés Sáez, Mariano Volpacchio.

Pictorial essay

Resumen

La tuberculosis (TBC) continúa siendo un importante

problema de salud pública a nivel mundial y una causa

significativa de enfermedad y muerte en muchos

países. El incremento de la prevalencia en las últimas

décadas se debe al aumento en el número de pa-

cientes inmunocomprometidos, frecuentemente con

afección extra-pulmonar. Dado que puede compro-

meter cualquier parte del cuerpo humano, es una de

las entidades a tener en cuenta entre los diagnósticos

diferenciales, sea cual fuera el área afectada. Así, la

diversidad de los hallazgos radiológicos de la TBC

dificulta reconocer esta entidad y realizar su diagnós-

tico. El compromiso extra-pulmonar se presenta en el

sistema músculo esquelético y el área más afectada es

la columna vertebral. En el sistema nervioso central

adquiere varias formas que incluyen meningitis, tuber-

Abstract

Tuberculosis (TB) remains a major public health pro-

blem worldwide and a significant cause of illness and

death in many countries. The increasing prevalence in

recent decades is due to the increase in the number of

immunocompromised patients, often with extrapul-

monary conditions. Since it can involve any part of the

body, it is one of the entities to be considered in the

differential diagnosis, whatever the affected area is. The

diversity of radiological findings of TB makes it difficult

to recognize this entity and provide a diagnosis. Extra-

pulmonary involvement occurs in the musculoskeletal

system and the most affected area is the spine. In the

central nervous system, it acquires several forms inclu-

ding meningitis, tuberculoma, abscesses, cerebritis and

miliary spread of mycobacterium tuberculosis. Ileocecal

involvement is present in 80-90% of cases of gastroin-

Contact information:

Luciana Sánchez.

Hospital de Clínicas José de San Martín - Ciudad de Bs. As.

E-mail: [email protected]

Recibido: 10 de agosto de 2015 / Aceptado: 12 de noviembre de 2015

Received: August 10, 2015 / Accepted: November 12, 2015

26 Revista Argentina de Diagnóstico por Imágenes

Sánchez L. et al.Extrapulmonary tuberculosis

culoma, abscesos, cerebritis y diseminación miliar. El

compromiso ileocecal está presente en el 80-90% de

los casos de afección del aparato digestivo. También

son sitios frecuentes de afección el aparato genitouri-

nario y el sistema linfático, en particular en los niños

con adenopatías cervicales o supraclaviculares. Otros

infrecuentes son mamas, laringe, glándulas suprarre-

nales y partes blandas. Nuestro objetivo es describir

las manifestaciones extra-pulmonares de la TBC y es-

tablecer los diagnósticos diferenciales con patologías

que presentan patrones similares en imágenes.

Palabras clave: Tuberculosis extrapulmonar, enferme-

dad de Pott, tuberculosis ileocecal, meningitis tuber-

culosa, tuberculosis peritoneal.

testinal conditions. Other common sites of involvement

are the genitourinary system and the lymphatic system,

particularly in children with cervical or supraclavicular

lymphadenopathy. Some less frequent sites are breasts,

the larynx, adrenal glands and soft tissues. Our purpose

is to describe extrapulmonary manifestations of TB and

establish differential diagnosis with other pathologies

with similar patterns in images.

Key words: Extrapulmonary tuberculosis, Pott disease,

ileocecal tuberculosis, meningitis, peritoneal tuberculosis.

IntroductionTuberculosis (TB) is generally associated with the in-

volvement of the respiratory system; however, it can

affect any organ. Its increasing prevalence is related

to the increase in the number of immunocompro-

mised patients and the resistance to pharmacologic

treatment. These determining factors make TB an

important entity that has to be taken into account

in the diagnosis, especially in developing countries.

This article presents the most frequent radiological

findings of extrapulmonary TB.

Musculoskeletal systemTB of the musculoskeletal system represents up to

35% of cases of extrapulmonary tuberculosis. Howe-

ver, only 1-3% of all cases of TB show this type of in-

volvement and less than 50% have evidence of con-

comitant active thoracic TB (1, 2). The most frequent

forms of presentation are spondylitis, arthritis, and

osteomyelitis. Bone conditions and joint destruction

cause a severe morbidity. Vertebral involvement cau-

ses severe neurological consequences (2).

Spondylitis (Pott disease)In the musculoskeletal system, the most affected site

by TB is the spine, and the most affected levels are

the lower dorsal region and the upper lumbar region.

Generally, it involves more than one vertebral body,

although isolated involvement of one vertebra can be

observed. It is believed that the process is a result of

homogeneous dissemination through venous plexus.

The infection starts in the anterior part of the verte-

bral body adjacent to the inferior plates, followed by

demineralization of the vertebral plate with a loss

of image definition and extension towards the ad-

jacent intervertebral disc. The alteration of the in-

ternal structure of the disk allows the dissemination

towards the contiguous vertebral segment, resulting

in the classical pattern of more than one vertebral

body with intervertebral disc involvement (Figures

1a and 1b). The infection can also extend towards

paravertebral tissue, creating muscle abscesses (Figu-

res 1c and 1d), including the psoas muscle (Figure

2). A delay in treatment can cause vertebral collapse

or anterior wedging of the vertebral body with for-

mation of a hump. As a consequence of treatment,

there can be ankylosis of the affected segment. The

2Vol. 5 / Nº 14 - Septiembre 2016 22

Extrapulmonary tuberculosisSánchez L. et al.

differential diagnosis includes metastatic disease,

pyogenic infection, brucellosis, mycosis, and sarcoi-

dosis. The main difference with metastasis lies in the

lack of frequency with which TB involves posterior

vertebral elements. In initial stages, it is difficult to

differentiate the involvement of pyogenic infection

due to TB and, therefore, it is essential to consider

the clinical evolution of the patient to differentiate

the conditions (3).

Arthritis The tuberculous arthritis is a monoarthritis that pro-

gresses slowly and compromises the joints that su-

pport weight, such as the hip and knees. The disse-

mination is produced from a focal point of diaphyseal

osteomyelitis that goes through the metaphysis and

opens towards the joint. With less frequency, it dis-

seminates hematogenously towards the synovial

membrane. Radiological findings are unspecific and

similar to other types of inflammatory or infectious

arthritis with osteopenia, synovitis, soft tissue in-

flammation, marginal erosion mainly at the synovial

insertion, partial destruction of the cartilage, and

decreased articular space in later stages. In young

patients, synovial compromise causes hyperemia and

epiphyseal overgrowth. The progression of the infec-

tion can cause bone sequestration. The final result is

fibrous ankylosis of the joint. The clinical presenta-

tion is insidious and causes pain, joint edemas and

a decrease in the range of movement. Diagnosis is

established due to clinical evolution, mild sclerosis

compared to other entities, limited periosteal reac-

tion and lack of alterations in the articular space in

later stages. The differential diagnosis includes pyo-

genic and fungal infection.

Osteomyelitis Extraspinal tuberculous osteomyelitis often appears with

local pain and can affect any bone, mainly the femur,

the shinbone or the bones of hands and feet. Generally,

it appears with osteolytic lesion and minimal sclerosis

at the level of metaphysis (Figure 3). Also, it can cause

bone destruction, bone sequestration and extension to

soft tissues. The involvement of adjacent structures can

lead to complications such as carpal tunnel syndrome,

tenosynovitis and facial paralysis (5). Tuberculous os-

teomyelitis without associated arthritis is not frequent.

Central Nervous SystemAround 5% of patients with TB have CNS compro-

mise, although this prevalence increases in immu-

nocompromised patients. Generally, dissemination

occurs hematogenously and can manifest itself

as a meningoencephalitis, communicating hydro-

cephalus, tuberculoma, tuberculous abscess or ce-

rebritis (1).

Meningoencephalitis Meningeal TB is the most common manifestation of

the central nervous system. Its early diagnosis is es-

sential due to the associated morbidity and mortality.

Dissemination can be hematogenously or through

direct extension of CSF. A typical finding is menin-

geal enhancement with intravenous contrast, more

marked in basal cisterns, cerebral convexity and Syl-

vian fissures (Figure 4). The most frequent complica-

tion is communicating hydrocephalus and ischemic

stroke due to vascular compression and occlusion of

small puncturing vessels (6) (Figure 5). Radiological

findings are unspecific and the differential diagnosis

is done with other infectious agents, sarcoidosis and

neoplastic involvement.

TuberculomaThe most frequent lesion of the cerebral parenchy-

ma is tuberculoma or tuberculous granuloma. It can

be isolated or multiple and its most frequent loca-

tion is frontal or parietal. They appear as nodules

or rounded masses of variable density in CT with

homogenous enhancement or ring enhancement af-

ter contrast administration (Figure 6). In some cases,

there is a target sign due to the presence of a central

calcification. The appearance in MRI depends on the

level of central caseous necrosis showing a hyper-

intense center in case of liquid content. Perilesional

edema is variable and generally less than the metas-

tatic lesions. Tuberculomas can be associated with

meningoencephalitis (7).

Tuberculous abscessTuberculous abscess are masses with a multilocula-

ted liquid center, heterogeneous enhancement af-

ter contrast administration, severe edema and mass

effect. The differential diagnosis includes other abs-

cesses of infectious origin.



Abdominal tuberculosis Gastrointestinal TBGastrointestinal compromise is rare and the ileocecal

region is the most affected (80-90%). Typically, it is

presented with concentric parietal thickening of the

cecum wall, terminal ileum and ileocecal valve (Figu-

re 7). It can cause a luminal stenosis with intestinal

occlusion, dilation of loops and appear with regional

mesenteric adenopathy. When the disease is advan-

ced, there can be deformity, stenosis, shortening or

retraction of the intestine. Differential diagnosis is

made with adenocarcinoma, intestinal inflammatory

diseases, amebiasis and Behçet’s disease (8).

Hepatosplenic TBThis form of presentation generally occurs in patients

with disseminated disease and can adopt a micro-

or macro-nodular pattern. The micro-nodular or mi-

liary form is seen in patients with miliary lung TB. It

appears with dispersed small nodules measuring less

than 2 mm. They can be seen with MRI but they may

not be seen with CT. Differential diagnosis is made

with metastasis, mycosis or sarcoidosis (Figure 8).

Macronodular form is rare and it is also called tuber-

culoma. It can be isolated or multiple, it measures

from 1 to 3 cm, it is hypodense in CT, hypointense in

T1 and hyperintense in T2. Enhancement is variable,

but most frequently marginal. Differential diagnosis

is made with metastasis, primary neoplasia or pyoge-

nic abscesses (9).

Peritoneal TBFrequently, peritoneal involvement is associated with

other types of gastrointestinal tuberculosis. Dissemi-

nation can be hematogenously or direct. The most

frequent form of presentation is with great amount

of free liquid or loculated viscous fluid, omental and

mesenteric multinodular thickening simulating a pe-

ritoneal carcinomatosis. There is also a fibrotic retrac-

table form with mesenteric thickening and intestinal

adhesions (10) (Figure 9).

Figure 1. Spondylitis due to TB. Images of the cervical rachis. MRI in T1 (A) and STIR (B). CT with contrast

(C and D). Hyperintense signal of bone marrow in C6, C7 and interverte-

bral disc in A and B (arrows). Large paravertebral collection (C) and lytic

involvement of vertebral bodies (D) (arrows).

A B

D

C

2Vol. 5 / Nº 14 - Septiembre 2016


Figure 2. CT of lumbar spine.Osteolytic lesion due to TB (A) and small abscess of the left psoas muscle (B) (arrows).

A

B

Figure 3. Tuberculous osteomyelitis in CT.Metaphyseal lytic lesion in the medial end of the left collarbone (A) with a collection of fluid (B) (arrows).

A B

Figure 4. Meningoencephalitis.Sagittal T1 with contrast (A) and FLAIR (B). There is meningeal enhancement and thickening in cerebral convexity

(A) and right parietal edema (B) (arrows).

A

B



Figure 5. Skull CT without contrast. Communicating hydrocephalus in patient with tuberculous

meningitis.

Figure 6. Skull CT with contrast in two patients with tuberculoma (A and B). Intraparenchymatous nodules with annular enhancement and scarce perilesional edema (arrows).

A

B

Figure 7. Abdominal CT with contrast in pa-tient with ileocecal TB. Concentric ileocecal parietal thickening and node with

necrotic center in the root of the mesenterium (arrows).



Figure 8. Abdominal CT with contrast. Small hypodense images in the hepatic parenchyma in

patient with disseminated tuberculosis (arrows).

Figure 9. Abdominal CT without contrast. Patient with disseminated tuberculosis showing ascites

with multinodular peritoneal thickening.

Genitourinary systemRenal TBFrequently, renal compromise is unilateral in 75% of

patients in its initial presentation. It appears as a cor-

tical caseous lesion with destruction of the tissue. Ge-

nerally, it is self-limited. In other occasions, it evolves

progressively adopting the following patterns:

1- Nodular form: It is similar to tuberculoma in other

locations; however, it is rare (Figure 10).

2- Cavitary exudate/caseous form: It is the most fre-

quent and it is characterized by caseous necrosis and

a tendency to open towards the calyx or renal pelvis.

3- Mastic kidney: It represents the natural healing of

renal TB. It is also called retractable fibro-caseous

renal tuberculosis and corresponds to the destruc-

tion of the renal parenchyma after accumulation of

caseous material due to ureter obstruction of inflam-

matory origin.

Radiological findings include erosion of calyxes

that is evident in excretory phase, hydronephrosis

of irregular margins, filling defects due to caseous

material, and cavitation of the renal parenchyma. In

later stages, more than 50% of the cases present lobar

calcifications, scars and retractions (11).

Ureteral TBDilation and irregular appearance of urothelium are

the first signs of ureteral TBC. Ureteral dilation is cau-

sed mainly by an inflammation of the uretero-vesical

union due to urethritis or tuberculous cystitis. In later

stages there can be areas of stenosis, shortenings,

filling defects or calcifications (11) (Figure 11).

Vesical TBTuberculous cystitis in initial stages does not present

specific characteristics, although in later stages it can



be small, irregular and calcified. Differential diagno-

sis is made with schistosomiasis, actinic changes or

calcified carcinoma (11) (Figure 12).

Female genital TBFemale genital TB compromises the fallopian tubes

in 94% of the cases and can disseminate towards pe-

ritoneum, endometrium, ovaries, cervix, and vagina.

Patients have pelvic pain, present infertility and va-

ginal bleeding. Tubo-ovarian abscesses with intra- or

extra-peritoneal extension are suggestive of tubercu-

losis (12).

Male genital TBThe most affected organ by TB is the prostate. Ultra-

sound shows hypoechogenic areas with an irregular

pattern that predominates in the peripheral region.

Lesions are hypodense in CT, and they cannot be

differentiated with pyogenic prostatic abscesses or

neoplasia. To be able to do it, MRI is the most useful

means due to its high contrast definition (12).

Lymphatic systemAdenopathy is a frequent form of presentation in

extrapulmonary TB, especially at the cervical and

supracervical level in pediatric patients. CT shows

adenopathic conglomerates with hypodense cen-

ter due to caseous necrosis and marginal enhan-

cement with intravenous contrast injection (13)

(Figure 13).

Other rare forms of presentationAdrenal TB Generally, TB compromise is bilateral and asymme-

trical with diffuse enlargement of the glands, creating

big heterogeneous masses that are difficult to diffe-

rentiate from metastasis. After treatment, the glands

are stunted and there is diffuse calcification of them

(Figure 14).

Mammary TBIs a rare condition. Even though findings are uns-

pecific, it can be seen as a hypoechogenic mass of

abscesses in ultrasound with moving internal echoes

and posterior acoustic enhancement. In MRI, these

abscesses are hypointense in T1, hyperintense in T2

and have peripheral enhancement (2).

Laryngeal TB Radiological findings of laryngeal TB are thickening

of soft tissues with infiltration of pre-epiglottic and

para-laryngeal fatty space, which is impossible to

differentiate from other inflammatory or neoplastic

processes, such as lymphoma (14) (Figure 15).

Ocular TB It is an infrequent condition and can compromise

any component of the orbit. Habitual forms are chro-

nic anterior uveitis, choroiditis and sclerokeratitis.

However, choroidal tuberculoma is the best docu-

mented form of presentation (15) (Figure 16).

Cutaneous TBCutaneous presentation is not frequent and it is ge-

nerally associated with disseminated disease. Infec-

tion can occur due to direct inoculation, which is

rare, or hematogenously. Radiologically, they are

seen as subcutaneous lesions with soft tissue density

of unspecific aspect (16) (Figure 17).

Pancreatic TBIt is an atypical condition by TB and can simulate

a carcinoma, lymphoma, cystic neoplasia, pancrea-

titis or pseudocyst. It affects immunocompromised

patients and has multiple hypodense areas with mar-

ginal enhancement in the pancreatic parenchyma,

with a tendency to present central liquefaction (17)

(Figure 18).

Vol. 5 / Nº 14 - Septiembre 2016


Figure 10. Abdominal CT with contrast. Small hypodense subcortical nodules in both kidneys

with alteration of the nephrogram in patient with disse-

minated hematogenous tuberculosis (arrow).

Figure 11. Abdominal CT with contrast.Coronal (A), sagittal (B) and axial (C) view. Left ure-

teral dilation with stenosis areas in the uretero-vesi-

cal union of tuberculous origin (arrows).

A

B

C

Figure 12. Abdominal CT with contrast. Consequence of tuberculous cystitis with retracted

bladder (arrow).



Figure 13. CT of three patients with adenitis due to TB. Cervical and supracervical location (A and B);

necrosis mediastinal location (C); and retro-

peritoneal location (D) (arrows).

A

B

C

D

Figure 14. Abdominal CT. A) Increase in the size of the left adrenal gland of tuberculous origin and B) adrenal calcifica-

tions due to TBC (arrows).

A

B



Figure 15. Neck CT with contrast (A and B). Concentric laryngeal thickening with involvement of the pre-epiglottic space due to TB in a

pediatric patient (arrows).

A B

Figure 16. Orbits CT with contrast.Posterior focal thickening of the left ocu-

lar membranes with protrusion towards

the interior of the eyeball and enhan-

cement with contrast in a patient with

disseminated TB (arrows).

A B

C



Figure 17. Patient with HIV and disseminated tuberculosis. Multiple cutaneous/subcutaneous lesions that are visible in CT (A and B) (arrows).

A B

Figure 18. Abdominal CT without contrast (A), with contrast (B), oblique reconstruction (C) and late phase (D). HIV patient with disseminated TB and pancreatic involvement with two hypodense images,

necrotic center and marginal enhancement (arrows).

A B

C

D

Vol. 5 / Nº 14 - Septiembre 2016


Conclusion Radiological characteristics of extrapulmonary TB

can simulate multiple diseases. It is essential to sus-

pect the condition with high certainty, especially in

risk patients. Generally, microbiological culture and

anatomic pathology of the lesion are indicated to

reach a definite diagnosis.

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Documents

Extra- pulmonary tuberculosis · los casos de afección del aparato digestivo. También son sitios frecuentes de afección el aparato genitouri-nario y el sistema linfático, en particular