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*Biopsy of the lung  
*Biopsy of the lung  
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{| class="wikitable"
|+Differentiating brain tubercloma from other brain cystic lesions
!Disease
!Prominent clinical features
!Lab findings
!Radiological findings
|-
|Neurocysticercosis
|
* Presenting symptoms differ according to the site of the cysticerci. 
* [[Parenchymal]] neurocysticercosis causes all the symptoms and signs of [[Space occupying lesion|space occupying lesions]].
* Extraparenchymal neurocysticercosis causes manifestations of [[increased intracranial pressure]] if cysts are present in the [[subarachnoid space]] or in the [[ventricles]], manifestations of [[spinal cord compression]] if present in the spinal cord or causes eye disease if cysts are present in the [[orbit]].
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* [[Immunoblot|CDC's immunoblot]] is based on detection of [[antibody]] to one or more of [[Glycoprotein|7 lentil-lectin purified structural glycoprotein]] [[antigens]] from the larval cysts.
* It is 100% [[Specificity (tests)|specific]] and has a [[sensitivity]] superior to that of any other test yet evaluated
|
* [[Computed tomography|Computerized tomography (CT)]] is superior to [[magnetic resonance imaging|magnetic resonance imaging (MRI)]] for demonstrating small [[calcification]]s.
* However, [[MRI]] shows [[cysts]] in some locations (cerebral convexity, [[Ependyma|ventricular ependyma]]) better than [[CT]], is more [[Sensitivity|sensitive]] than CT to demonstrate surrounding [[cerebral edema|edema]], and may show internal changes indicating the death of cysticerci.
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|[[Brain abscess]]
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* [[Headaches]] are the most common symptom. Usually, [[headaches]] occur on the same side of the [[Abscesses|abscess]] and tend to be severe (not responding to [[analgesics]]).
* [[Fever]] is not  a reliable sign.<ref name="pmid25075836">{{cite journal |vauthors=Brouwer MC, Tunkel AR, McKhann GM, van de Beek D |title=Brain abscess |journal=N. Engl. J. Med. |volume=371 |issue=5 |pages=447–56 |year=2014 |pmid=25075836 |doi=10.1056/NEJMra1301635 |url=}}</ref>
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*[[Lumbar puncture]] is contraindicated but when done, it was variable between patients.
*Culture from the CT-guided aspirated lesion helps in identifying the causative agent.
|
* [[Contrast enhanced CT]] provides rapid assessment of the size and number of the abscesses.
* [[MRI|MRI:]] [[Diffusion-weighted imaging|Diffusion-weighted imaging (DWI)]] [[MRI]] can differentiate [[brain abscesses]] from [[Brain cyst|cystic brain lesions]] with [[Sensitivity|sensitivit]]<nowiki/>y and [[specificity]] of 96%.<ref name="urlBrain Abscess — NEJM">{{cite web |url=http://www.nejm.org/doi/full/10.1056/NEJMra1301635 |title=Brain Abscess — NEJM |format= |work= |accessdate=}}</ref>
|-
|[[Brain tumors]]
|
* Most common presenting symptom is [[Headache|dull aching headache]].
* Usually, it's associated with other symptoms of [[Increased intracranial pressure|increased intracranial pressure (ICP)]] as [[Seizure|seizures]], [[Visual disturbance|visual disturbances]], [[Nausea and vomiting|nausea, and vomiting]].<ref name="urlPrimary Brain Tumors in Adults - American Family Physician">{{cite web |url=http://www.aafp.org/afp/2008/0515/p1423.html |title=Primary Brain Tumors in Adults - American Family Physician |format= |work= |accessdate=}}</ref>
|
|
* [[CT]] may be used in localizing the [[tumor]] and getting a rough estimate on the dimensions.
* [[MRI]]: [[MRI|Gadolinium-enhanced MRI]] is the preferred imaging modality for assessing the extension of the tumor and its exact location.<ref name="urlPrimary Brain Tumors in Adults - American Family Physician">{{cite web |url=http://www.aafp.org/afp/2008/0515/p1423.html |title=Primary Brain Tumors in Adults - American Family Physician |format= |work= |accessdate=}}</ref>
|-
|[[Tuberculoma|Brain tuberculoma]]
|
* [[Tuberculoma|Brain tuberculomas]] has insidious onset of symptoms as compared to [[tuberculous meningitis]].
* Presentations are usually due to the pressure effect, not the [[Bacilli|T.B. bacilli]].
* Presenting symptoms and signs in order of occurrence:<ref name="urlThe Journal of Association of Chest Physicians - Tuberculoma of the brain - A diagnostic dilemma: Magnetic resonance spectroscopy a new ray of hope : Download PDF">{{cite web |url=http://www.jacpjournal.org/downloadpdf.asp?issn=2320-8775;year=2015;volume=3;issue=1;spage=3;epage=8;aulast=Mukherjee;type=2 |title=The Journal of Association of Chest Physicians - Tuberculoma of the brain - A diagnostic dilemma: Magnetic resonance spectroscopy a new ray of hope : Download PDF |format= |work= |accessdate=}}</ref>
# Episodes of [[focal seizures]]
# Signs of [[increased intracranial pressure]]
# [[Focal neurologic signs|Focal neurologic deficits]].
|
* [[TB|T.B.]] should be investigated everywhere else in the body (e.g. [[Lymphadenopathy|peripheral lymphadenopathy]], [[Sputum culture|sputum]] and [[blood culture]])
|
* [[CT]]: [[Contrast enhanced CT|Contrast-enhanced CT]] scan shows a ring enhancing lesion surrounded by an area of hypodensity ([[cerebritis]]) and the resulting [[mass effect]].
* [[MRI]]: Better than [[CT]] scan in assessing the site and size of the [[tuberculoma]]. Gadolinium-enhanced MRI shows a ring enhancing lesion between 1-5 cm in size (In NCC, the wall is thicker, [[Calcification|calcifications]] are eccentric and the diameter is less than 2 cm)
|-
|Neurosarcoidosis
|
* 70% of the patients present with the neurological symptoms rather than the presentation of systemic disease. Common presentations are:<ref name="urlNeurosarcoidosis">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3975794/ |title=Neurosarcoidosis |format= |work= |accessdate=}}</ref>
# Cranial nerve neuropathies: [[Facial palsy]] is the most common presentation.
# [[Meningeal]] involvement: diffuse [[Meningitis|meningeal inflammation]] can cause diffuse [[Polyneuropathy|basilar polyneuropathy]] in 40% of the patients. with [[neurosarcoidosis]].
# Inflammatory [[spinal cord]] disease: Inflammatory span usually more than 3 spinal cord segments which helps to differentiate it from [[Multiple sclerosis|Multiple Sclerosis]].
# [[Peripheral neuropathy]]: [[Polyneuropathy|Asymmetric polyneuropathy]] or [[mononeuritis multiplex]]. It may also manifest as [[Guillain-Barré syndrome|Guillain-Barré syndrome (GBS)]] like presentation.
# [[Hypothalamic pituitary adrenal axis|HPO axis]] involvement: may present as [[diabetes insipidus]]. More than 50% of the cases have no radiological signs.
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* [[Noninvasive test|Noninvasive tests]] have low [[sensitivity]] and [[specificity]].
* Serum [[ACE|ACE levels]] are elevated in 25% of the cases
* [[Lumbar puncture]] shows elevated [[CSF]] proteins together with mild-moderate [[pleocytosis]]. It is usually accompanied by [[oligoclonal bands]].<ref name="urlNeurosarcoidosis">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3975794/ |title=Neurosarcoidosis |format= |work= |accessdate=}}</ref>
|
* [[Magnetic resonance imaging|MRI]] with [[contrast]] shows enhancement of the inflamed areas (i.e. [[cranial nerves]], [[meninges]] or [[Hypothalamic pituitary adrenal axis|HPO axis]])
|}
{| class="wikitable"
![[Image:cerebral-absceses.jpg|center|300px|thumb|MRI brain showing brain abscess - Case courtesy of A.Prof Frank Gaillard, https://radiopaedia.org/ From the case https://radiopaedia.org/cases/4933"]]
![[Image:butterfly1802.jpg|center|300px|thumb|MRI brain showing Glioblastoma multiforme - Case courtesy of A.Prof Frank Gaillard, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/28272">rID: 28272</a> ]]
![[Image:intracranial-tuberculoma-mri-brain.jpg|center|300px|thumb|MRI brain showing tuberculoma - Case courtesy of Dr G Balachandran, https://radiopaedia.org/ From the case https://radiopaedia.org/cases/5489"]]
![[Image:neurosarcoidosis-and-chiari-i-malformation.jpg|center|300px|thumb|MRI brain showing Neurosarcoidosis - Case courtesy of A.Prof Frank Gaillard, https://radiopaedia.org/ From the case https://radiopaedia.org/cases/4364S]]
|}
|}


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
{{WH}}
{{WS}}
[[Category:Bacterial diseases]]
[[Category:Disease]]
[[Category:Infectious disease]]
[[Category:Pulmonology]]
[[Category:Needs content]]
[[Category:Primary care]]

Revision as of 20:22, 22 August 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]

Overview

Pulmonary tuberculosis must be differentiated from other diseases that cause cough, fever, night sweats, hemoptysis and weight loss, such as: brucellosis, bronchogenic carcinoma, Hodgkin lymphoma, bacterial pneumonia, sarcoidosis, mycoplasmal pneumonia.

Differential Diagnosis

Pulmonary Tuberculosis
Disease Findings
Bacterial pneumonia Sudden onset of symptoms, such as high fever, cough, purulent sputum, chest pain. Consolidation on chest X-ray, leukocytosis.
Bronchogenic carcinoma Can be asymptomatic, usually at older ages (> 50 years old), cough, hemoptysis, weight loss
Brucellosis Fever, anorexia, night sweats, malaise,back pain , headache, and depression. History of exposure to infected animal
Hodgkin lymphoma Fever, night sweats, pruritus, painless adenopathy, mediastinal mass
Mycoplasmal pneumonia Gradual onset of dry cough, headache, malaise, sore throat. Diffuse bilateral infiltrates in chest X-ray.
Sarcoidosis Non-caseating granulomas in lungs and other organs, bilateral hiliar adenopathy, predominantly in African American females.
Adapted from Mandell, Douglas, and Bennett's principles and practice of infectious diseases 2010 [1]

Extra-Pulmonary Tuberculosis
Extra-Pulmonary Location Differential Diagnosis
Tuberculous Lymphadenitis Lymphoma, squamous cell carcinoma, papillary thyroid cancer, pyogenic infection
Skeletal Tuberculosis Multiple myeloma, bone metastasis, spinal cord abscess, osteoporosis
Tuberculous Arthrits Bacterial septic arthritis, pseudogout
Central Nervous System Tuberculosis Bacterial meningitis, viral meningitis, encephalitis
Tuberculosis Peritonitis Bacterial peritonitis, chronic peritoneal dialysis
Adapted from Asian Spine J. Feb 2014; 8(1): 97–111[2]; Handbook of Clinical Neurology[3]; Circulation Dec 2005 vol.112 no.23 3608-3616[4]; Am J Trop Med Hyg 2013 vol. 88 no. 1 54-64[5] Clin Infect Dis.(2011)53(6):555-562.[6]


Causes of

lung cavities

Differentiating Features Differentiating radiological findings Diagnosis

confirmation

  • CXR and CT demonstrates cavities in the upper lobe of the lung
  • Sputum smear positive for acid-fast bacilli and nucleic acid amplification tests (NAAT) is used on sputum or any sterile fluid for rapid diagnosis and is positive for mycobacteria.
  • Any age group
  • Acute, fulminant life threating complication of prior infection
  • >100.4F fever, with hemodynamic instability
  • Worsening pneumonia-like symptoms
  • CBC is positive for causative organism
  • Children and elderly are at risk
  • Empyema appears lenticular in shape and has a thin wall with smooth luminal margins
  • Pulmonary nodules with cavities and infiltrates are a frequent manifestation on CXR
  • Elderly females of 40-50 age group
  • Manifestation of rheumatoid arthritis
  • Presents with other systemic symptoms including symmetric arthritis of the small joints of the hands and feet with morning stiffness are common manifestations.
  • Pulmonary nodules with cavitation are located in the upper lobe (Caplan syndrome) on Xray.
  • On CXR bilateral adenopathy and coarse reticular opacities are seen.
  • CT of the chest demonstrates extensive hilar and mediastinal adenopathy
  • Additional findings on CT include fibrosis (honeycomb, linear, or associated with bronchial distortion), pleural thickening, and ground-glass opacities.[13]
  • Common appearance on CT is patchy consolidation,often accompanied by ground-glass opacities and nodules.[17]
  • Exclusively afflicts smokers, with a peak age of onset of between 20 and 40 years.
  • Clinical presentation varies, but symptoms generally include months of dry cough, fever, night sweats and weight loss.
  • Skin is involved in 80% of the cases, scaly erythematous rash is typical.
  • Thin-walled cystic cavities are the usual radiographic manifestation, observed in over 50% of patients by either CXR or CT scans.[19]
  • Biopsy of the lung
Differentiating brain tubercloma from other brain cystic lesions
Disease Prominent clinical features Lab findings Radiological findings
Neurocysticercosis
Brain abscess
  • Lumbar puncture is contraindicated but when done, it was variable between patients.
  • Culture from the CT-guided aspirated lesion helps in identifying the causative agent.
Brain tumors
  • CT may be used in localizing the tumor and getting a rough estimate on the dimensions.
  • MRI: Gadolinium-enhanced MRI is the preferred imaging modality for assessing the extension of the tumor and its exact location.[22]
Brain tuberculoma
  • Presentations are usually due to the pressure effect, not the T.B. bacilli.
  • Presenting symptoms and signs in order of occurrence:[23]
  1. Episodes of focal seizures
  2. Signs of increased intracranial pressure
  3. Focal neurologic deficits.
  • CT: Contrast-enhanced CT scan shows a ring enhancing lesion surrounded by an area of hypodensity (cerebritis) and the resulting mass effect.
  • MRI: Better than CT scan in assessing the site and size of the tuberculoma. Gadolinium-enhanced MRI shows a ring enhancing lesion between 1-5 cm in size (In NCC, the wall is thicker, calcifications are eccentric and the diameter is less than 2 cm)
Neurosarcoidosis
  • 70% of the patients present with the neurological symptoms rather than the presentation of systemic disease. Common presentations are:[24]
  1. Cranial nerve neuropathies: Facial palsy is the most common presentation.
  2. Meningeal involvement: diffuse meningeal inflammation can cause diffuse basilar polyneuropathy in 40% of the patients. with neurosarcoidosis.
  3. Inflammatory spinal cord disease: Inflammatory span usually more than 3 spinal cord segments which helps to differentiate it from Multiple Sclerosis.
  4. Peripheral neuropathy: Asymmetric polyneuropathy or mononeuritis multiplex. It may also manifest as Guillain-Barré syndrome (GBS) like presentation.
  5. HPO axis involvement: may present as diabetes insipidus. More than 50% of the cases have no radiological signs.
MRI brain showing brain abscess - Case courtesy of A.Prof Frank Gaillard, https://radiopaedia.org/ From the case https://radiopaedia.org/cases/4933"
MRI brain showing Glioblastoma multiforme - Case courtesy of A.Prof Frank Gaillard, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/28272">rID: 28272</a>
MRI brain showing tuberculoma - Case courtesy of Dr G Balachandran, https://radiopaedia.org/ From the case https://radiopaedia.org/cases/5489"
MRI brain showing Neurosarcoidosis - Case courtesy of A.Prof Frank Gaillard, https://radiopaedia.org/ From the case https://radiopaedia.org/cases/4364S

References

  1. ↑ Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
  2. ↑ Moon, Myung-Sang (2014). "Tuberculosis of Spine: Current Views in Diagnosis and Management". Asian Spine Journal. 8 (1): 97. doi:10.4184/asj.2014.8.1.97. ISSN 1976-1902.
  3. ↑ Garcia-Monco, Juan Carlos (2014). "Tuberculosis". 121: 1485–1499. doi:10.1016/B978-0-7020-4088-7.00100-0. ISSN 0072-9752.
  4. ↑ Mayosi, B. M. (2005). "Tuberculous Pericarditis". Circulation. 112 (23): 3608–3616. doi:10.1161/CIRCULATIONAHA.105.543066. ISSN 0009-7322.
  5. ↑ Daher, E. D. F.; da Silva Junior, G. B.; Barros, E. J. G. (2013). "Renal Tuberculosis in the Modern Era". American Journal of Tropical Medicine and Hygiene. 88 (1): 54–64. doi:10.4269/ajtmh.2013.12-0413. ISSN 0002-9637.
  6. ↑ Fontanilla, J.-M.; Barnes, A.; von Reyn, C. F. (2011). "Current Diagnosis and Management of Peripheral Tuberculous Lymphadenitis". Clinical Infectious Diseases. 53 (6): 555–562. doi:10.1093/cid/cir454. ISSN 1058-4838.
  7. ↑ 7.0 7.1 Chaudhuri MR (1973). "Primary pulmonary cavitating carcinomas". Thorax. 28 (3): 354–66. PMC 470041. PMID 4353362.
  8. ↑ Mouroux J, Padovani B, Elkaïm D, Richelme H (1996). "Should cavitated bronchopulmonary cancers be considered a separate entity?". Ann. Thorac. Surg. 61 (2): 530–2. doi:10.1016/0003-4975(95)00973-6. PMID 8572761.
  9. ↑ Onn A, Choe DH, Herbst RS, Correa AM, Munden RF, Truong MT, Vaporciyan AA, Isobe T, Gilcrease MZ, Marom EM (2005). "Tumor cavitation in stage I non-small cell lung cancer: epidermal growth factor receptor expression and prediction of poor outcome". Radiology. 237 (1): 342–7. doi:10.1148/radiol.2371041650. PMID 16183941.
  10. ↑ 10.0 10.1 Langford CA, Hoffman GS (1999). "Rare diseases.3: Wegener's granulomatosis". Thorax. 54 (7): 629–37. PMC 1745525. PMID 10377211.
  11. ↑ Lee KS, Kim TS, Fujimoto K, Moriya H, Watanabe H, Tateishi U, Ashizawa K, Johkoh T, Kim EA, Kwon OJ (2003). "Thoracic manifestation of Wegener's granulomatosis: CT findings in 30 patients". Eur Radiol. 13 (1): 43–51. doi:10.1007/s00330-002-1422-2. PMID 12541109.
  12. ↑ Baughman RP, Teirstein AS, Judson MA, Rossman MD, Yeager H, Bresnitz EA, DePalo L, Hunninghake G, Iannuzzi MC, Johns CJ, McLennan G, Moller DR, Newman LS, Rabin DL, Rose C, Rybicki B, Weinberger SE, Terrin ML, Knatterud GL, Cherniak R (2001). "Clinical characteristics of patients in a case control study of sarcoidosis". Am. J. Respir. Crit. Care Med. 164 (10 Pt 1): 1885–9. doi:10.1164/ajrccm.164.10.2104046. PMID 11734441.
  13. ↑ Brauner MW, Grenier P, Mompoint D, Lenoir S, de Crémoux H (1989). "Pulmonary sarcoidosis: evaluation with high-resolution CT". Radiology. 172 (2): 467–71. doi:10.1148/radiology.172.2.2748828. PMID 2748828.
  14. ↑ Murphy J, Schnyder P, Herold C, Flower C (1998). "Bronchiolitis obliterans organising pneumonia simulating bronchial carcinoma". Eur Radiol. 8 (7): 1165–9. doi:10.1007/s003300050527. PMID 9724431.
  15. ↑ 15.0 15.1 Al-Ghanem S, Al-Jahdali H, Bamefleh H, Khan AN (2008). "Bronchiolitis obliterans organizing pneumonia: pathogenesis, clinical features, imaging and therapy review". Ann Thorac Med. 3 (2): 67–75. doi:10.4103/1817-1737.39641. PMC 2700454. PMID 19561910.
  16. ↑ Cordier JF, Loire R, Brune J (1989). "Idiopathic bronchiolitis obliterans organizing pneumonia. Definition of characteristic clinical profiles in a series of 16 patients". Chest. 96 (5): 999–1004. PMID 2805873.
  17. ↑ Lee KS, Kullnig P, Hartman TE, Müller NL (1994). "Cryptogenic organizing pneumonia: CT findings in 43 patients". AJR Am J Roentgenol. 162 (3): 543–6. doi:10.2214/ajr.162.3.8109493. PMID 8109493.
  18. ↑ Suri HS, Yi ES, Nowakowski GS, Vassallo R (2012). "Pulmonary langerhans cell histiocytosis". Orphanet J Rare Dis. 7: 16. doi:10.1186/1750-1172-7-16. PMC 3342091. PMID 22429393.
  19. ↑ Moore AD, Godwin JD, Müller NL, Naidich DP, Hammar SP, Buschman DL, Takasugi JE, de Carvalho CR (1989). "Pulmonary histiocytosis X: comparison of radiographic and CT findings". Radiology. 172 (1): 249–54. doi:10.1148/radiology.172.1.2787035. PMID 2787035.
  20. ↑ Brouwer MC, Tunkel AR, McKhann GM, van de Beek D (2014). "Brain abscess". N. Engl. J. Med. 371 (5): 447–56. doi:10.1056/NEJMra1301635. PMID 25075836.
  21. ↑ "Brain Abscess — NEJM".
  22. ↑ 22.0 22.1 "Primary Brain Tumors in Adults - American Family Physician".
  23. ↑ "The Journal of Association of Chest Physicians - Tuberculoma of the brain - A diagnostic dilemma: Magnetic resonance spectroscopy a new ray of hope : Download PDF".
  24. ↑ 24.0 24.1 "Neurosarcoidosis".
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