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Canadian Association of Radiologists Journal 64 (2013) 319e324

www.carjonline.org

Computed Tomography / Tomodensitometrie

Extrapulmonary Tuberculosis: Imaging Features Beyond the Chest
Kelly A. MacLean, MDa, Annalisa K. Becker, MDa, Silvia D. Chang, MDb,
Alison C. Harris, BSc(Hons), MBChB, MRCP, FRCR, FRCPCb,*
a
Radiology Residency Program, University of British Columbia, Vancouver, British Columbia, Canada
b
Abdominal Division, Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada

Abstract
The purpose of this pictorial review is to illustrate the various imaging findings of extrapulmonary tuberculosis. Manifestations of cardiac,
central nervous system, head and neck, musculoskeletal, abdominal, genitourinary, and breast tuberculosis will be discussed. Extrapulmonary
tuberculosis presents a difficult diagnostic challenge for the radiologist and requires a high index of suspicion, particularly in high-risk
populations.

Resume
Cette revue iconographique vise a illustrer les divers resultats d’imagerie associes a la tuberculose extrapulmonaire. L’analyse portera sur
les manifestations de la tuberculose au niveau du cœur, du systeme nerveux central, de la t^ete et du cou, du systeme musculosquelettique, de
l’abdomen, du systeme uro-genital et du sein. Pour le radiologiste, la tuberculose extrapulmonaire constitue un veritable defi sur le plan
diagnostique et exige un fort indice de suspicion, particulierement chez les groupes a risque eleve.
Ó 2013 Canadian Association of Radiologists. All rights reserved.

Key Words: Tuberculosis; Extrapulmonary tuberculosis; Radiography; Computed tomography; Magnetic resonance imaging

Although the prevalence of tuberculosis (TB) has TB is most commonly limited to the chest, but manifesta-
continued to decline in North America, it is rising in some tions can occur in any organ system, particularly in immuno-
parts of the United States and among certain populations. compromised hosts. Recognition of the radiologic findings of
Since the mid 1980s, there has been a resurgence of TB in extrapulmonary TB, which can often mimic other disease
nonendemic populations, due to AIDS, increased migration, entities, is an important step in accurate diagnosis [3,4]. In this
and the increasing number of drug-resistant strains of pictorial review, we aim to illustrate the common imaging
Mycobacterium tuberculosis. The incidence in Africa, Asia, findings in cardiac, central nervous system, head and neck,
and Europe is reported to be rising by approximately 1.1% musculoskeletal, abdominal, genitourinary, and breast TB.
per year, particularly among immunocompromised patients
[1,2]. Multidrug resistant (MDR) TB has the same imaging
features as non–MDR-TB and is no more infective. Never- Cardiac
theless, MDR-TB is more serious due to the requirement of
prolonged treatment with more toxic second-line drugs that Cardiac involvement is uncommon, with only 0.5% of
are associated with higher morbidity and mortality. Immu- extrapulmonary TB involving the heart. The most common
nocompromised patients are more likely to be infected with finding is of tuberculous pericarditis, manifested by peri-
MDR-TB, and these strains have a greater tendency to cardial thickening >3 mm, which is often associated with
involve extrapulmonary sites [1e3]. mediastinal lymphadenopathy (LAN). Nonspecific findings
associated with tuberculous pericarditis may include disten-
tion of the inferior vena cava >3 cm, deformity of the
* Address for correspondence: Alison C. Harris, MRCP, Abdominal
Division, Department of Radiology, University of British Columbia, 899 interventricular septum, and pleural effusions. Myocardial
West 12th Avenue, Vancouver, British Columbia V5Z 1M9, Canada. involvement is less common, usually asymptomatic, and
E-mail address: Alison.Harris@vch.ca (A. C. Harris). most often identified at postmortem [1].

0846-5371/$ - see front matter Ó 2013 Canadian Association of Radiologists. All rights reserved.
http://dx.doi.org/10.1016/j.carj.2012.07.002

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white arrow) and midline shift to the right are due to the ventricular weighted image demonstrates a perforator artery infarction that involved mass lesion. which can Approximately 15% of extrapulmonary TB cases involve be a helpful clue to diagnosis [6]. associated with moderate to severe oedema. Coronal T1- weighted gadolinium-enhanced magnetic resonance image demonstrates characteristic abnormal leptomeningeal enhancement (short. Copyright ©2016.320 K. tuberculomas are low. thick. usually manifesting as bilateral painless culous meningitis include communicating hydrocephalus. white arrow). the posterior limb of the right internal capsule (arrow). Pathologic nervous system (CNS) involvement. multiple. and Leptomeninges demonstrate intense. due to Approximately 5% of patients with TB have central mass effect of a tuberculoma (Figure 1). which is best demonstrated with demonstrating rim enhancement (Figure 1). . and/or miliary TB [1]. A 41-year-old woman with human immunodeficiency virus and arrows). Figure 1. bacteria or fungi. Parenchymal Lesions Tuberculous Meningitis The most common CNS parenchymal lesion is the tuberculoma. the head and neck. often homogeneous is most often found within the frontal and parietal lobes. Entrapment of the left temporal horn (long. commonly may also be affected. and the differential diagnosis ance of tuberculomas. typically most prominent at the basal cisterns. and leptomeningeal metastases or Head and Neck lymphoma [1]. such as tuberculomas. Nodes are initially homo- geneous and later demonstrate central necrosis. All rights reserved. Magnetic resonance diffusion- thick. Fluorodeoxyglucose positron that enhance diffusely (Figure 1) [5]. Elsevier Inc. At enhancement. or miliary. The prevalence involvement of small perforating vessels can cause infarc- increases to 15% in patients with TB and concomitant AIDS. A. They are often gadolinium-enhanced magnetic resonance imaging (MRI). Coexisting extrapulmonary TB at other sites may occur in up to 50% of patients with CNS TB. MacLean et al. usually within the basal ganglia or internal capsule CNS involvement may present as tuberculous meningitis or (Figure 2).or high- Sulci over the cerebral convexities and the sylvian fissures attenuation rounded or lobulated masses. and noncommunicating hydrocephalus. tions. which demonstrates bright meninges on T1-weighted images however. High signal within the left frontal lobe represents an enhancing hepatitis C. tuberculous abscesses. as a variety of parenchymal infections. computed tomography (CT). cervical LAN known as scrofula. later tuberculoma (thin white arrow). inflammatory disease such as rheumatoid arthritis or sarcoidosis. who presented with acute left arm weakness and numbness. Calcification. / Canadian Association of Radiologists Journal 64 (2013) 319e324 Central Nervous System due to blockage of the basal cisterns by inflammatory exudates. with intense tracer uptake at the includes other infectious agents such as nontuberculous periphery and low central uptake [7]. Downloaded from ClinicalKey.com at Universitas Kristen Duta Wacana November 18. A 41-year-old man with tuberculous meningitis. No other uses without permission. 2016. is uncommon [1]. Complications of tuber. with intensely enhancing walls of both lateral ventricles (black Figure 2. For personal use only. characterized by low attenuation and rim enhancement at CT (Figure 3). Leptomeningeal emission tomography demonstrates a ‘‘doughnut’’ appear- enhancement is nonspecific. which may be solitary. found to have tuberculous meningitis.

patients with extrap- large associated para-articular soft-tissue calcifications and ulmonary TB commonly have musculoskeletal involvement. bodies (black arrows).9]. Although only 1%-3% of all TB cases are reported to Associated findings that suggest tuberculous arthritis include involve the musculoskeletal system. There is relative sparing of the intervertebral disk space. abscesses. Copyright ©2016. Contrast-enhanced computed tomography demonstrates rim-enhancing lymphadenopathy (arrow). osteomyelitis typically affects the femur. Downloaded from ClinicalKey. Tuberculous arthritis typically manifests as a mono- arthritis that involves large weight-bearing joints. 2016. respectively. and anterior extension of abscesses that displace the anterior longitudinal ligament [3. marginal erosions. Elsevier Inc. and gradual joint space radiograph demonstrates marked osteopenia and axial joint space loss of the narrowing. The metaphyses demonstrate osteopenia. A 48-year-old man with tuberculous arthritis. Central hypoattenuation is consistent with central necrosis. with periph. Tuberculous usually in the lower thoracic and upper lumbar regions. In addition. delay of 16-19 months between the onset of symptoms and poorly defined lytic lesions. These features help to distinguish tuberculous spondylitis from Musculoskeletal System pyogenic infection. or scrofula. For personal use only. develops in late TB. relative sparing of the intervertebral disk space.com at Universitas Kristen Duta Wacana November 18. No other uses without permission. and minimal surrounding diagnosis. Anteroposterior osteoporosis. Nodal calcification often tuberculous involvement of the cervical and upper thoracic vertebral bodies. together known as Phemister triad (Figure 5) [8]. whereas rheu- mately 50%-70% of musculoskeletal TB involves the spine. A 44-year-old patient with cervical tuberculous spondylitis. tuberculous spondylitis can lead to vertebral collapse and anterior wedging. within the left neck. Bone and joint from rheumatoid arthritis. such as the hip and knee. on T1. matoid synovitis tends to be uneven and thick.and T2-weighted images. Typical imaging features include severe juxta-articular Figure 5. Tuber- culous spondylitis differs from pyogenic infection in its involvement of multiple vertebral levels. including severe para-articular abscesses favor TB. with additional epidural abscess posterior to the vertebral squamous cell carcinoma metastases [1]. If left untreated. and bones of Radiographic diagnosis is difficult. Approxi- related to TB tends to be smooth and thin. MRI may help differentiate tuberculous arthritis where it accounts for 25% of cases [8]. which may help to distinguish it from Abscess formation is seen posterior to the anterior longitudinal ligament (white arrows). tibia. which results in an average the hands and feet. where large bone erosions and destruction can cause significant morbidity. Sagittal contrast-enhanced T1-weighted image demonstrates extensive eral rim enhancement as with CT. All rights reserved. A 23-year-old woman who presented with a left-sided neck mass that had progressed for 4 weeks. right hip (arrow) due to extensive chronic synovitis. Extrapulmonary tuberculosis / Canadian Association of Radiologists Journal 64 (2013) 319e324 321 Figure 3. The appearance is nonspecific and is often similar to other infectious or inflammatory arthritides. synovitis neurologic sequelae in the case of spinal disease. MRI demonstrates central hypointensity and hyperintensity Figure 4. which causes a kyphosis known as a gibbus deformity (Figure 4). .

less commonly. For personal use only. periportal.8]. peripancreatic. Hepatosplenic TB is found at autopsy in most patients with disseminated TB. later found to have tuberculous peritonitis and salpingitis. with the mesenteric. enhancement (arrow). and upper para-aortic lymph nodes most commonly involved [10]. Fluorodeoxyglucose positron emission tomography omental caking (thin white arrow). which is and feet is termed tuberculous dactylitis and is more difficult to detect at CT and usually only manifests as common in children [1. highly vascular lesion that involves tomography image in the portal venous phase demonstrates a retracted segments VII and VIII. Central hypoattenuation is characteristic of caseous appearance of the cecum. and Spleen The most common form of abdominal TB is LAN. MacLean et al. / Canadian Association of Radiologists Journal 64 (2013) 319e324 Figure 6. microabscesses of another etiology. A 30-year-old man with human immunodeficiency virus and micronodular hepatosplenic tuberculosis. Copyright ©2016. Contrast-enhanced computed tomography image in the portal venous phase demonstrates massive ascites (23 HU). The most common form Painless involvement of the short tubular bones of the hands of hepatosplenic TB is micronodular (<10 mm). 2016. Ultrasound may demonstrate diffuse hyperechogenicity or. Ultrasound demonstrates innu- merable hypoechoic lesions (arrows) of the spleen. moderate hepatosplenomegaly [10]. nodes are enlarged and most commonly demonstrate the rim-enhancement and hypoattenuating centers characteristic of caseous necrosis. osteomyelitis and demonstrates increased fluorodeox- yglucose uptake in areas with active inflammation [7]. All rights reserved. and the differential diagnosis includes metastatic disease and Figure 8. Liver. Coronal contrast-enhanced computed demonstrates a peripherally enhancing. Figure 7. A. pericaval.com at Universitas Kristen Duta Wacana November 18. These findings are nonspecific. and nodular soft-tissue thickening (thick is highly sensitive yet nonspecific for chronic tuberculous white arrow). Elsevier Inc. On CT. Downloaded from ClinicalKey. Abdomen Lymph Nodes. yet it is rarely seen on imaging [10]. A 44-year-old man with macronodular hepatic tuberculosis.322 K. diffuse peritoneal enhancement (black arrow). with mural thickening and mucosal hyper- necrosis (arrow). A 60-year-old man presenting with right lower quadrant pain was Contrast-enhanced computed tomography image in the portal venous phase found to have ileocecal tuberculosis. No other uses without permission. A 30-year-old woman who presented with fever of unknown origin. . omental. sclerosis. Figure 9.

with the differential diagnosis including malig- nancy. . Patients may present with this appearance includes metastatic disease and pyogenic an addisonian-type clinical picture. B) caused by stricturing and thickening of the distal ureter (arrow. thickened bowel loops and nodular soft tissue. Copyright ©2016. Hepatic tuberculomas are known to eventually calcify. which demonstrates large amounts of free or loculated ascites. and amebiasis [11]. Char. rim enhancement and central low attenuation consistent with caseous necrosis (arrow). with concentric mural thickening and localized LAN. Pancreas Peritoneal Surfaces TB that involves the pancreas is extremely rare. after the liver.11].com at Universitas Kristen Duta Wacana November 18. enhancement and central low attenuation. Downloaded from ClinicalKey. Macronodular hepatosplenic involvement is The gland becomes enlarged and demonstrates rim uncommon and appears as hypoattenuating. A 60-year-old woman with adrenal tuberculosis. Elsevier Inc. Elsewhere in the small bowel. Figure 10. Again. C) Contrast-enhanced computed tomography image in the portal venous phase of the same patient demonstrates right- sided hydronephrosis (arrow. this is a nonspecific finding. When it does. to definitively differentiate TB of Figure 11. All rights reserved. Advanced involvement of the ileocecal junction is demonstrated clas- sically with barium studies as a conical. skip areas of mural thickening and luminal narrowing with or without proximal dilatation may be identified.3. many other organ systems. The adrenal gland is reported to be the fifth most common site of extrapulmonary TB. Peripancreatic lymph nodes will often be enlarged. As with acteristic findings include omental and mesenteric caking. and bones. Extrapulmonary tuberculosis / Canadian Association of Radiologists Journal 64 (2013) 319e324 323 along with matted. Contrast-enhanced CT demonstrates a mass of low attenua- which usually is caused by hematogenous spread. shrunken cecum elevated out of the right iliac fossa by mesocolonic retraction [3]. histopathologically represent a caseating granuloma. nontuberculous peritonitis. C). 2016. (B. Another form of abdominal TB is tuberculous peritonitis. Contrast. Gastrointestinal Tract TB rarely affects the gastrointestinal tract. (A) Retrograde pyelogram image demonstrates irregularity of the ureter and absence of contrast in the strictured distal portion (arrow). No other uses without permission. rim. (Figure 6). are which may be slightly hyperattenuating (20-45 HU) relative most commonly found in the head or neck of the pancreas. again consistent enhancing lesions (Figure 7). Adrenal Gland enhanced computed tomography image in the portal venous phase demon- strates right adrenal enlargement. kidneys. Adrenal involvement is seen in up to 6% of multiple hypoechoic and occasional hyperechoic nodules patients with active TB and is nearly always bilateral [1]. to water due to its high protein and cellular content. with the differential diagnosis including disseminated malignancy. the ileocecal junction is most commonly involved. ill-defined. These lesions. Imaging findings are largely nonspecific. Crohn’s disease. This appearance may also be appreciated at CT (Figure 9). and mesothelioma [1. For personal use only. abscesses. ultrasound reveals a focal hypoechoic mass. The peritoneum often enhances and appears diffusely thickened (Figure 8). CT tion with peripheral enhancement. spleen. Most commonly. A 75-year-old woman with ureteric tuberculosis. The differential diagnosis for with caseous necrosis (Figure 10).

Ultrasound may demonstrate circumscribed hypoechoic masses with moving internal echoes and posterior acoustic enhancement. Imaging of extrapulmonary tuber- and hydronephrosis. Kumar S. Eur J focal or diffuse areas of decreased echogenicity. Bain G. a small. Vanhoenacker FM. irregular. For personal use only. et al. Contrast- enhanced computed tomography demonstrates ascites with thickened. Pulmonary tuberculosis: the essentials. Ureteric walls become thickened and strictured. eaten appearance due to erosions that progress to papillary [2] Gouliamos A. Pictorial essay: PET/CT in tuberculosis. De Backer AI. Elsevier Inc. and genitourinary systems as outlined. [7] Anand S. Parizel PM. head and neck. 2016. Mammog- raphy does not reliably demonstrate any specific findings. Paschos P. et al. ulceration. Tuberculosis: a radiologic review. McLoud T. consistent with patho. which is well seen at CT. Radiology 1999. prostate may become calcified [1]. Central nervous system tuberculosis. calcified bladder. icoureteric junction [1]. Neuroimaging filling defects caused by caseous debris (Figure 11). along with abscesses and sinus tracts. Semin Musculoskel Radiol 2011. which in turn is more likely to enhancing peritoneum (white arrows).20:449e70. Prostatic TB also mani. . RadioGraphics 2007. Shepard J. A.14: fests as hypoattenuating lesions at CT. gastrointestinal. Indian J Radiol Imaging 2008. The most common clinical picture is a mass with or without ulceration in young.23:1074e7. Endometrial and tenosynovitis. Eur granulomatous material. and an increase in MDR strains. Intestinal tuberculosis: tuberculous pyogenic abscesses).324 K. Kehagias D.18:141. MRI findings include parenchymal asymmetry with enhancement. Sivasomboon C.15:459e69. Dash A. Eur Radiol 2004. No other uses without permission. central logic diagnosis of tuberculous salpingitis. Intravenous urography demonstrates calyces with a moth. the pancreas from neoplastic and other infectious diseases. Op de Beeck B. et al. [3] Harisinghani M. et al. RadioGraphics 2000. the seminal vesicles or 307e21. et al. / Canadian Association of Radiologists Journal 64 (2013) 319e324 Breast TB that involves the breast is extremely rare. Ultrasound demonstrates a diagnostic challenged case report and review of the literature. to be infected with MDR-TB. [5] Gupta R. Williams C. et al.com at Universitas Kristen Duta Wacana November 18. Tuberculous arthritis multiple strictures and obstruction (Figure 12). RadioGraphics 2000. Eventually. which is complicated by hydroureter [4] Engin G. 575e9. pelvic brim. system in the body. with [8] Pattamapaspong N. adhesions can form. Bladder Clin N Am 2011. MR imaging of tuber- culous vertebral osteomyelitis: pictorial review. Gastroenterol Hepatol 2011. A common clinical presentation of extrapulmonary TB is References one of genitourinary involvement.27:1255e73.21:759e814. Extrapulmonary TB can involve any ovarian structures is also present (black arrows). In women. et al. Immunocompromised patients are more likely Figure 12. In men. foci of caseous necrosis and inflammation (similar to none [11] Giouleme O. [10] Vanhoenacker FM. The kidneys may demonstrate unilateral calcification. toe. spread beyond the chest. nervous. Muttarak M. scarring results in Radiol 2003. including the cardiovascular. Acuas G. Tuberculosis from head to such as the ureteropelvic junction. A 30-year-old woman with bilateral salpingitis. Downloaded from ClinicalKey. and luminal filling defects due to central nervous system: overview of neuroradiological findings. and ves. most commonly at points of normal anatomic narrowing. Copyright ©2016. Eur Radiol 2001. [1] Burrill J. Katsaros M. Harkirat S. musculoskeletal. a rising incidence of AIDS. and peripherally enhancing masses [4]. The authors thank Drs Jonathon Leipsic and Dave Malfair Genitourinary System for their contribution to this article.11: necrosis. Bilateral enhancement of the tubo. involvement results in a reduced bladder volume with wall [6] Bernaerts A. All rights reserved.20:471e88. often with an irregular margin and culosis. Conclusion The worldwide incidence of TB is rising due to increased migration. TB may cause bilateral salpingitis. microabscesses. which causes deformity and obliteration [9] Leung A. likely representing E103e15. lactating women [4]. Acuas B. Similarly.13:1876e90. Tuberculosis of the thickening. Imaging of gastrointestinal and abdominal tuberculosis. Acknowledgement percutaneous biopsy is required [10]. MacLean et al. Lahanis S. multiparous. et al.210: of the endometrial cavity.