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Imaging of Extrapulmonary Tuberculosis¹

(CME available in print version and on RSNA Link)

Gülgün Engin, MD, Bülent Acuna, MD , Gülden Acuna, MD and Mehtap Tunaci, MD

¹ From the Department of Radiology, Istanbul Faculty of Medicine, University of Istanbul, Millet Street, Çapa 34390, Istanbul, Turkey. Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received February 4, 1999; revision requested April 8 and received May 18; accepted May 18. Address reprint requests to G.E. (e-mail: istrady@escortnet.com).

View larger version (109K): [in a new window]   Figure 1a.   Tuberculous spondylitis in a 17-year-old girl with low back pain. (a, b) Anteroposterior (a) and lateral (b) plain radiographs of the lower lumbar spine show loss of vertebral body height (arrowhead in a), sclerosis of the end plates, and anterior scalloping (arrowheads in b). (c) Sagittal T1-weighted magnetic resonance (MR) image (repetition time msec/echo time msec = 360/15) shows focal decreased signal intensity (arrow). (d, e) Sagittal T2-weighted (4,300/112) (d) and contrast material-enhanced coronal T1-weighted (360/15) (e) MR images show increased signal intensity (arrow). Tuberculous disease was confirmed with bone biopsy.

View larger version (93K): [in a new window]   Figure 1b.   Tuberculous spondylitis in a 17-year-old girl with low back pain. (a, b) Anteroposterior (a) and lateral (b) plain radiographs of the lower lumbar spine show loss of vertebral body height (arrowhead in a), sclerosis of the end plates, and anterior scalloping (arrowheads in b). (c) Sagittal T1-weighted magnetic resonance (MR) image (repetition time msec/echo time msec = 360/15) shows focal decreased signal intensity (arrow). (d, e) Sagittal T2-weighted (4,300/112) (d) and contrast material-enhanced coronal T1-weighted (360/15) (e) MR images show increased signal intensity (arrow). Tuberculous disease was confirmed with bone biopsy.

View larger version (120K): [in a new window]   Figure 1c.   Tuberculous spondylitis in a 17-year-old girl with low back pain. (a, b) Anteroposterior (a) and lateral (b) plain radiographs of the lower lumbar spine show loss of vertebral body height (arrowhead in a), sclerosis of the end plates, and anterior scalloping (arrowheads in b). (c) Sagittal T1-weighted magnetic resonance (MR) image (repetition time msec/echo time msec = 360/15) shows focal decreased signal intensity (arrow). (d, e) Sagittal T2-weighted (4,300/112) (d) and contrast material-enhanced coronal T1-weighted (360/15) (e) MR images show increased signal intensity (arrow). Tuberculous disease was confirmed with bone biopsy.

View larger version (153K): [in a new window]   Figure 1d.   Tuberculous spondylitis in a 17-year-old girl with low back pain. (a, b) Anteroposterior (a) and lateral (b) plain radiographs of the lower lumbar spine show loss of vertebral body height (arrowhead in a), sclerosis of the end plates, and anterior scalloping (arrowheads in b). (c) Sagittal T1-weighted magnetic resonance (MR) image (repetition time msec/echo time msec = 360/15) shows focal decreased signal intensity (arrow). (d, e) Sagittal T2-weighted (4,300/112) (d) and contrast material-enhanced coronal T1-weighted (360/15) (e) MR images show increased signal intensity (arrow). Tuberculous disease was confirmed with bone biopsy.

View larger version (153K): [in a new window]   Figure 1e.   Tuberculous spondylitis in a 17-year-old girl with low back pain. (a, b) Anteroposterior (a) and lateral (b) plain radiographs of the lower lumbar spine show loss of vertebral body height (arrowhead in a), sclerosis of the end plates, and anterior scalloping (arrowheads in b). (c) Sagittal T1-weighted magnetic resonance (MR) image (repetition time msec/echo time msec = 360/15) shows focal decreased signal intensity (arrow). (d, e) Sagittal T2-weighted (4,300/112) (d) and contrast material-enhanced coronal T1-weighted (360/15) (e) MR images show increased signal intensity (arrow). Tuberculous disease was confirmed with bone biopsy.

View larger version (173K): [in a new window]   Figure 2a.   Tuberculous spondylitis with psoas abscess in a 21-year-old woman. (a) Midsagittal T1-weighted MR images (519/16) show loss of vertebral body height and decreased signal intensity at T4 (arrows). (b) Coronal T2-weighted MR image (5,000/36) of the upper dorsal spine shows bilateral paraspinal abscesses (arrows) with involvement of T4. (c, d) Axial T2-weighted (2,247/985) (c) and parasagittal T2-weighted (2,247/985) (d) MR images show a large, lobulated paraspinal mass with high signal intensity that extends to the posterior paravertebral region (arrows). The diagnosis was confirmed with biopsy of the abscess.

View larger version (171K): [in a new window]   Figure 2b.   Tuberculous spondylitis with psoas abscess in a 21-year-old woman. (a) Midsagittal T1-weighted MR images (519/16) show loss of vertebral body height and decreased signal intensity at T4 (arrows). (b) Coronal T2-weighted MR image (5,000/36) of the upper dorsal spine shows bilateral paraspinal abscesses (arrows) with involvement of T4. (c, d) Axial T2-weighted (2,247/985) (c) and parasagittal T2-weighted (2,247/985) (d) MR images show a large, lobulated paraspinal mass with high signal intensity that extends to the posterior paravertebral region (arrows). The diagnosis was confirmed with biopsy of the abscess.

View larger version (139K): [in a new window]   Figure 2c.   Tuberculous spondylitis with psoas abscess in a 21-year-old woman. (a) Midsagittal T1-weighted MR images (519/16) show loss of vertebral body height and decreased signal intensity at T4 (arrows). (b) Coronal T2-weighted MR image (5,000/36) of the upper dorsal spine shows bilateral paraspinal abscesses (arrows) with involvement of T4. (c, d) Axial T2-weighted (2,247/985) (c) and parasagittal T2-weighted (2,247/985) (d) MR images show a large, lobulated paraspinal mass with high signal intensity that extends to the posterior paravertebral region (arrows). The diagnosis was confirmed with biopsy of the abscess.

View larger version (111K): [in a new window]   Figure 2d.   Tuberculous spondylitis with psoas abscess in a 21-year-old woman. (a) Midsagittal T1-weighted MR images (519/16) show loss of vertebral body height and decreased signal intensity at T4 (arrows). (b) Coronal T2-weighted MR image (5,000/36) of the upper dorsal spine shows bilateral paraspinal abscesses (arrows) with involvement of T4. (c, d) Axial T2-weighted (2,247/985) (c) and parasagittal T2-weighted (2,247/985) (d) MR images show a large, lobulated paraspinal mass with high signal intensity that extends to the posterior paravertebral region (arrows). The diagnosis was confirmed with biopsy of the abscess.

View larger version (102K): [in a new window]   Figure 3a.   Tuberculous spondylitis and tuberculous osteomyelitis in a 21-year-old woman with sacral pain. (a) Computed tomographic (CT) scan (bone window) of L1 shows bone destruction and bilateral psoas abscesses with multiloculated pus collections surrounded by a rim-enhancing inflammatory capsule (arrows, arrowheads). (b) CT scan (bone window) of S2 shows a well-defined lytic lesion surrounded by a sclerotic margin (arrow). Tuberculous disease was confirmed with bone biopsy.

View larger version (100K): [in a new window]   Figure 3b.   Tuberculous spondylitis and tuberculous osteomyelitis in a 21-year-old woman with sacral pain. (a) Computed tomographic (CT) scan (bone window) of L1 shows bone destruction and bilateral psoas abscesses with multiloculated pus collections surrounded by a rim-enhancing inflammatory capsule (arrows, arrowheads). (b) CT scan (bone window) of S2 shows a well-defined lytic lesion surrounded by a sclerotic margin (arrow). Tuberculous disease was confirmed with bone biopsy.

View larger version (95K): [in a new window]   Figure 4a.   Tuberculous osteomyelitis in a 52-year-old woman with pain. (a, b) Anteroposterior plain radiograph of the pelvis (a) and magnified radiograph of the left proximal femur (b) show bone destruction with calcifications. (c) CT scan (soft-tissue window) shows destruction of medullary and cortical bone. There are also calcifications within the bone lesion and the perilesion soft tissue (arrow). (d) Fat-suppressed coronal T1-weighted MR image (640/15) of the proximal femur shows heterogeneous increased signal intensity with cortical destruction. Hyperintense soft-tissue infection is evident. (e) Contrast-enhanced fat-suppressed axial T1-weighted MR image (740/17) shows enhancement of affected soft tissues (arrowheads) and bone marrow (arrow). Tuberculous disease was confirmed with bone biopsy.

View larger version (131K): [in a new window]   Figure 4b.   Tuberculous osteomyelitis in a 52-year-old woman with pain. (a, b) Anteroposterior plain radiograph of the pelvis (a) and magnified radiograph of the left proximal femur (b) show bone destruction with calcifications. (c) CT scan (soft-tissue window) shows destruction of medullary and cortical bone. There are also calcifications within the bone lesion and the perilesion soft tissue (arrow). (d) Fat-suppressed coronal T1-weighted MR image (640/15) of the proximal femur shows heterogeneous increased signal intensity with cortical destruction. Hyperintense soft-tissue infection is evident. (e) Contrast-enhanced fat-suppressed axial T1-weighted MR image (740/17) shows enhancement of affected soft tissues (arrowheads) and bone marrow (arrow). Tuberculous disease was confirmed with bone biopsy.

View larger version (54K): [in a new window]   Figure 4c.   Tuberculous osteomyelitis in a 52-year-old woman with pain. (a, b) Anteroposterior plain radiograph of the pelvis (a) and magnified radiograph of the left proximal femur (b) show bone destruction with calcifications. (c) CT scan (soft-tissue window) shows destruction of medullary and cortical bone. There are also calcifications within the bone lesion and the perilesion soft tissue (arrow). (d) Fat-suppressed coronal T1-weighted MR image (640/15) of the proximal femur shows heterogeneous increased signal intensity with cortical destruction. Hyperintense soft-tissue infection is evident. (e) Contrast-enhanced fat-suppressed axial T1-weighted MR image (740/17) shows enhancement of affected soft tissues (arrowheads) and bone marrow (arrow). Tuberculous disease was confirmed with bone biopsy.

View larger version (166K): [in a new window]   Figure 4d.   Tuberculous osteomyelitis in a 52-year-old woman with pain. (a, b) Anteroposterior plain radiograph of the pelvis (a) and magnified radiograph of the left proximal femur (b) show bone destruction with calcifications. (c) CT scan (soft-tissue window) shows destruction of medullary and cortical bone. There are also calcifications within the bone lesion and the perilesion soft tissue (arrow). (d) Fat-suppressed coronal T1-weighted MR image (640/15) of the proximal femur shows heterogeneous increased signal intensity with cortical destruction. Hyperintense soft-tissue infection is evident. (e) Contrast-enhanced fat-suppressed axial T1-weighted MR image (740/17) shows enhancement of affected soft tissues (arrowheads) and bone marrow (arrow). Tuberculous disease was confirmed with bone biopsy.

View larger version (72K): [in a new window]   Figure 4e.   Tuberculous osteomyelitis in a 52-year-old woman with pain. (a, b) Anteroposterior plain radiograph of the pelvis (a) and magnified radiograph of the left proximal femur (b) show bone destruction with calcifications. (c) CT scan (soft-tissue window) shows destruction of medullary and cortical bone. There are also calcifications within the bone lesion and the perilesion soft tissue (arrow). (d) Fat-suppressed coronal T1-weighted MR image (640/15) of the proximal femur shows heterogeneous increased signal intensity with cortical destruction. Hyperintense soft-tissue infection is evident. (e) Contrast-enhanced fat-suppressed axial T1-weighted MR image (740/17) shows enhancement of affected soft tissues (arrowheads) and bone marrow (arrow). Tuberculous disease was confirmed with bone biopsy.

View larger version (95K): [in a new window]   Figure 5.   Tuberculous dactylitis in a 16-year-old boy. Lateral (left) and anteroposterior (right) radiographs show fusiform soft-tissue swelling of the proximal and middle phalanges of the middle finger and periostitis (arrowheads).

View larger version (95K): [in a new window]   Figure 6a.   Spina ventosa in a 22-year-old woman. Anteroposterior (a) and magnified (b) radiographs show extensive soft-tissue swelling with ballooning of the third metacarpal of the left hand. Findings of tuberculous arthritis are also seen in the adjacent joint (arrowheads).

View larger version (127K): [in a new window]   Figure 6b.   Spina ventosa in a 22-year-old woman. Anteroposterior (a) and magnified (b) radiographs show extensive soft-tissue swelling with ballooning of the third metacarpal of the left hand. Findings of tuberculous arthritis are also seen in the adjacent joint (arrowheads).

View larger version (111K): [in a new window]   Figure 7a.   Tuberculous arthritis in a 28-year-old man with pain. Anteroposterior (a) and magnified (b) radiographs show marginal osseous erosions of the femoral head (arrows) with relative preservation of the left hip joint space. There is also evidence of periarticular osteopenia. Tuberculous disease was confirmed with bone biopsy.

View larger version (114K): [in a new window]   Figure 7b.   Tuberculous arthritis in a 28-year-old man with pain. Anteroposterior (a) and magnified (b) radiographs show marginal osseous erosions of the femoral head (arrows) with relative preservation of the left hip joint space. There is also evidence of periarticular osteopenia. Tuberculous disease was confirmed with bone biopsy.

View larger version (159K): [in a new window]   Figure 8a.   Meningeal tuberculosis in a 28-year-old woman. (a) Contrast-enhanced sagittal T1-weighted MR image (433/16) shows abnormal meningeal enhancement in the basal cisterns (arrows). (b) Nonenhanced CT scan shows hydrocephalus and ependymal calcification (arrow), which represent sequelae of tuberculosis. A chronic infarct of the internal capsule secondary to prior tuberculous arteritis is also shown (arrowhead). (c) Contrast-enhanced sagittal T1-weighted MR image (433/16) shows large loculi of cerebrospinal fluid, which lead to spinal cord compression (long arrows) and enhancement of the meninges (short arrow). (d) Sagittal T2-weighted MR image (3,000/96) shows hyperintense syringomyelia involving the cervicothoracic spinal cord. The diagnosis was confirmed by isolating M tuberculosis in a culture of cerebrospinal fluid.

View larger version (147K): [in a new window]   Figure 8b.   Meningeal tuberculosis in a 28-year-old woman. (a) Contrast-enhanced sagittal T1-weighted MR image (433/16) shows abnormal meningeal enhancement in the basal cisterns (arrows). (b) Nonenhanced CT scan shows hydrocephalus and ependymal calcification (arrow), which represent sequelae of tuberculosis. A chronic infarct of the internal capsule secondary to prior tuberculous arteritis is also shown (arrowhead). (c) Contrast-enhanced sagittal T1-weighted MR image (433/16) shows large loculi of cerebrospinal fluid, which lead to spinal cord compression (long arrows) and enhancement of the meninges (short arrow). (d) Sagittal T2-weighted MR image (3,000/96) shows hyperintense syringomyelia involving the cervicothoracic spinal cord. The diagnosis was confirmed by isolating M tuberculosis in a culture of cerebrospinal fluid.

View larger version (123K): [in a new window]   Figure 8c.   Meningeal tuberculosis in a 28-year-old woman. (a) Contrast-enhanced sagittal T1-weighted MR image (433/16) shows abnormal meningeal enhancement in the basal cisterns (arrows). (b) Nonenhanced CT scan shows hydrocephalus and ependymal calcification (arrow), which represent sequelae of tuberculosis. A chronic infarct of the internal capsule secondary to prior tuberculous arteritis is also shown (arrowhead). (c) Contrast-enhanced sagittal T1-weighted MR image (433/16) shows large loculi of cerebrospinal fluid, which lead to spinal cord compression (long arrows) and enhancement of the meninges (short arrow). (d) Sagittal T2-weighted MR image (3,000/96) shows hyperintense syringomyelia involving the cervicothoracic spinal cord. The diagnosis was confirmed by isolating M tuberculosis in a culture of cerebrospinal fluid.

View larger version (114K): [in a new window]   Figure 8d.   Meningeal tuberculosis in a 28-year-old woman. (a) Contrast-enhanced sagittal T1-weighted MR image (433/16) shows abnormal meningeal enhancement in the basal cisterns (arrows). (b) Nonenhanced CT scan shows hydrocephalus and ependymal calcification (arrow), which represent sequelae of tuberculosis. A chronic infarct of the internal capsule secondary to prior tuberculous arteritis is also shown (arrowhead). (c) Contrast-enhanced sagittal T1-weighted MR image (433/16) shows large loculi of cerebrospinal fluid, which lead to spinal cord compression (long arrows) and enhancement of the meninges (short arrow). (d) Sagittal T2-weighted MR image (3,000/96) shows hyperintense syringomyelia involving the cervicothoracic spinal cord. The diagnosis was confirmed by isolating M tuberculosis in a culture of cerebrospinal fluid.

View larger version (147K): [in a new window]   Figure 9a.   Parenchymal tuberculosis in a 28-year-old woman. Contrast-enhanced CT scan (a) and contrast-enhanced axial T1-weighted MR image (433/16) (b) through the quadrigeminal bodies show multiple parenchymal and meningeal caseating tuberculomas (arrows). The diagnosis was confirmed by isolating M tuberculosis in a culture of cerebrospinal fluid.

View larger version (119K): [in a new window]   Figure 9b.   Parenchymal tuberculosis in a 28-year-old woman. Contrast-enhanced CT scan (a) and contrast-enhanced axial T1-weighted MR image (433/16) (b) through the quadrigeminal bodies show multiple parenchymal and meningeal caseating tuberculomas (arrows). The diagnosis was confirmed by isolating M tuberculosis in a culture of cerebrospinal fluid.

View larger version (127K): [in a new window]   Figure 10a.   Ileocecal tuberculosis in a 51-year-old man. (a) Anteroposterior image from an enteroclysis study shows thickened folds in the cecum and an irregular cecal contour. (b) CT scan shows minimal thickening of the cecum with pericecal inflammatory changes. Mesenteric lymph nodes are also evident (arrows). (c) CT scan shows circumferential thickening of the cecum and terminal ileum. (d) CT scan shows inflammation that extends through the peritoneum into the psoas muscle. The diagnosis was confirmed with endoscopic biopsy.

View larger version (107K): [in a new window]   Figure 10b.   Ileocecal tuberculosis in a 51-year-old man. (a) Anteroposterior image from an enteroclysis study shows thickened folds in the cecum and an irregular cecal contour. (b) CT scan shows minimal thickening of the cecum with pericecal inflammatory changes. Mesenteric lymph nodes are also evident (arrows). (c) CT scan shows circumferential thickening of the cecum and terminal ileum. (d) CT scan shows inflammation that extends through the peritoneum into the psoas muscle. The diagnosis was confirmed with endoscopic biopsy.

View larger version (89K): [in a new window]   Figure 10c.   Ileocecal tuberculosis in a 51-year-old man. (a) Anteroposterior image from an enteroclysis study shows thickened folds in the cecum and an irregular cecal contour. (b) CT scan shows minimal thickening of the cecum with pericecal inflammatory changes. Mesenteric lymph nodes are also evident (arrows). (c) CT scan shows circumferential thickening of the cecum and terminal ileum. (d) CT scan shows inflammation that extends through the peritoneum into the psoas muscle. The diagnosis was confirmed with endoscopic biopsy.

View larger version (102K): [in a new window]   Figure 10d.   Ileocecal tuberculosis in a 51-year-old man. (a) Anteroposterior image from an enteroclysis study shows thickened folds in the cecum and an irregular cecal contour. (b) CT scan shows minimal thickening of the cecum with pericecal inflammatory changes. Mesenteric lymph nodes are also evident (arrows). (c) CT scan shows circumferential thickening of the cecum and terminal ileum. (d) CT scan shows inflammation that extends through the peritoneum into the psoas muscle. The diagnosis was confirmed with endoscopic biopsy.

View larger version (104K): [in a new window]   Figure 11.   Peritoneal tuberculosis (wet type) in a 27-year-old woman with ileocecal tuberculosis. CT scan shows a high-attenuation, loculated fluid collection and mesenteric lymph nodes (arrow) with fine nodular irregularity of the mesenteric surface. Marked thickening of the cecum and terminal ileum is also shown. The diagnosis was confirmed with culture of peritoneal fluid.

View larger version (150K): [in a new window]   Figure 12a.   Hepatic tuberculosis (macronodular type) in a 19-year-old woman with peritoneal tuberculosis. (a) Coronal T1-weighted MR image (15/4) shows hypointense masses in the liver (arrows). (b) Contrast-enhanced coronal T1-weighted MR image (15/4) shows peripheral enhancement of the masses with a honeycomblike appearance (arrows). (c) Axial T2-weighted MR image (1,800/80) shows a hyperintense liver mass (arrow) and perihepatic fluid. The diagnosis was confirmed with ultrasonographically (US) guided biopsy.

View larger version (155K): [in a new window]   Figure 12b.   Hepatic tuberculosis (macronodular type) in a 19-year-old woman with peritoneal tuberculosis. (a) Coronal T1-weighted MR image (15/4) shows hypointense masses in the liver (arrows). (b) Contrast-enhanced coronal T1-weighted MR image (15/4) shows peripheral enhancement of the masses with a honeycomblike appearance (arrows). (c) Axial T2-weighted MR image (1,800/80) shows a hyperintense liver mass (arrow) and perihepatic fluid. The diagnosis was confirmed with ultrasonographically (US) guided biopsy.

View larger version (99K): [in a new window]   Figure 12c.   Hepatic tuberculosis (macronodular type) in a 19-year-old woman with peritoneal tuberculosis. (a) Coronal T1-weighted MR image (15/4) shows hypointense masses in the liver (arrows). (b) Contrast-enhanced coronal T1-weighted MR image (15/4) shows peripheral enhancement of the masses with a honeycomblike appearance (arrows). (c) Axial T2-weighted MR image (1,800/80) shows a hyperintense liver mass (arrow) and perihepatic fluid. The diagnosis was confirmed with ultrasonographically (US) guided biopsy.

View larger version (122K): [in a new window]   Figure 13a.   Adrenal tuberculosis in a 59-year-old man. In-phase (a) and out-of-phase (b) axial breath-hold gradient-echo MR images (126/6) show a right adrenal mass (arrow), which does not lose signal intensity on the out-of-phase image (b). The mass has nonspecific features but proved to be tuberculosis at biopsy.

View larger version (109K): [in a new window]   Figure 13b.   Adrenal tuberculosis in a 59-year-old man. In-phase (a) and out-of-phase (b) axial breath-hold gradient-echo MR images (126/6) show a right adrenal mass (arrow), which does not lose signal intensity on the out-of-phase image (b). The mass has nonspecific features but proved to be tuberculosis at biopsy.

View larger version (109K): [in a new window]   Figure 14.   Adrenal tuberculosis in a 57-year-old woman with adrenal insufficiency. Contrast-enhanced CT scan shows bilateral adrenal masses with low-attenuation centers and peripheral calcifications (arrows).

View larger version (146K): [in a new window]   Figure 15a.   Tuberculous pyonephrosis in a 48-year-old man. (a) Anteroposterior conventional urogram shows dilatation of the caliceal system without pelvic dilatation. The margins of the middle calices are irregular (moth-eaten calix), and there are multiple internal filling defects caused by caseous debris (arrow). (b) CT scan shows a high-attenuation debris collection within dilated upper pole calices as well as a calculus (arrow). (c) Fat-suppressed coronal T2-weighted MR urogram (6,800/119) shows marked dilatation of the left upper pole calices due to infundibular stenosis. There is minimal dilatation of the left lower pole calices due to a distal ureteral stricture. (d) Longitudinal US scan shows a short stricture and wall thickening of the left distal ureter (arrow) with proximal dilatation. The diagnosis was confirmed with biopsy of the left ureter.

View larger version (116K): [in a new window]   Figure 15b.   Tuberculous pyonephrosis in a 48-year-old man. (a) Anteroposterior conventional urogram shows dilatation of the caliceal system without pelvic dilatation. The margins of the middle calices are irregular (moth-eaten calix), and there are multiple internal filling defects caused by caseous debris (arrow). (b) CT scan shows a high-attenuation debris collection within dilated upper pole calices as well as a calculus (arrow). (c) Fat-suppressed coronal T2-weighted MR urogram (6,800/119) shows marked dilatation of the left upper pole calices due to infundibular stenosis. There is minimal dilatation of the left lower pole calices due to a distal ureteral stricture. (d) Longitudinal US scan shows a short stricture and wall thickening of the left distal ureter (arrow) with proximal dilatation. The diagnosis was confirmed with biopsy of the left ureter.

View larger version (99K): [in a new window]   Figure 15c.   Tuberculous pyonephrosis in a 48-year-old man. (a) Anteroposterior conventional urogram shows dilatation of the caliceal system without pelvic dilatation. The margins of the middle calices are irregular (moth-eaten calix), and there are multiple internal filling defects caused by caseous debris (arrow). (b) CT scan shows a high-attenuation debris collection within dilated upper pole calices as well as a calculus (arrow). (c) Fat-suppressed coronal T2-weighted MR urogram (6,800/119) shows marked dilatation of the left upper pole calices due to infundibular stenosis. There is minimal dilatation of the left lower pole calices due to a distal ureteral stricture. (d) Longitudinal US scan shows a short stricture and wall thickening of the left distal ureter (arrow) with proximal dilatation. The diagnosis was confirmed with biopsy of the left ureter.

View larger version (103K): [in a new window]   Figure 15d.   Tuberculous pyonephrosis in a 48-year-old man. (a) Anteroposterior conventional urogram shows dilatation of the caliceal system without pelvic dilatation. The margins of the middle calices are irregular (moth-eaten calix), and there are multiple internal filling defects caused by caseous debris (arrow). (b) CT scan shows a high-attenuation debris collection within dilated upper pole calices as well as a calculus (arrow). (c) Fat-suppressed coronal T2-weighted MR urogram (6,800/119) shows marked dilatation of the left upper pole calices due to infundibular stenosis. There is minimal dilatation of the left lower pole calices due to a distal ureteral stricture. (d) Longitudinal US scan shows a short stricture and wall thickening of the left distal ureter (arrow) with proximal dilatation. The diagnosis was confirmed with biopsy of the left ureter.

View larger version (112K): [in a new window]   Figure 16.   Bladder tuberculosis in a 38-year-old woman with renal tuberculosis. Anteroposterior cystogram shows reduced bladder capacity as well as a diverticulum (arrow). The diagnosis was confirmed with histopathologic analysis.

View larger version (106K): [in a new window]   Figure 17a.   Tuberculous tubo-ovarian abscess in a 21-year-old woman with lower abdominal pain and fever. (a) Contrast-enhanced CT scan shows a multiloculated mass with peripheral enhancement around centers of low, soft-tissue attenuation. The lesion extends to the iliac muscle (arrow). (b) Coronal T2-weighted MR image (7,200/90) shows the abscess (arrows). The diagnosis was confirmed with culture of a US-guided aspiration sample.

View larger version (102K): [in a new window]   Figure 17b.   Tuberculous tubo-ovarian abscess in a 21-year-old woman with lower abdominal pain and fever. (a) Contrast-enhanced CT scan shows a multiloculated mass with peripheral enhancement around centers of low, soft-tissue attenuation. The lesion extends to the iliac muscle (arrow). (b) Coronal T2-weighted MR image (7,200/90) shows the abscess (arrows). The diagnosis was confirmed with culture of a US-guided aspiration sample.

View larger version (108K): [in a new window]   Figure 18a.   Tuberculous prostatitis and orchitis in a 69-year-old man with diabetes mellitus. (a) Contrast-enhanced CT scan shows an amorphous calcification (arrowhead) and diffuse low-attenuation areas in the peripheral zone of the prostate (arrows). (b) Axial T2-weighted endorectal MR image (4,700/112) shows a focal, heterogeneous area of high signal intensity, which corresponds to an abscess (arrow). (c) Contrast-enhanced axial T1-weighted endorectal MR image (600/15) shows peripheral enhancement of the abscess (arrow). (d) Axial T2-weighted endorectal MR image (4,700/112) shows diffuse, radiating, streaky areas of low signal intensity in the peripheral zone of the prostate (watermelon skin sign) (arrowheads). (e) Coronal T2-weighted MR image (3,200/119) shows focal hypointense areas in the testicles. The diagnosis was confirmed with transrectal US-guided biopsy.

View larger version (101K): [in a new window]   Figure 18b.   Tuberculous prostatitis and orchitis in a 69-year-old man with diabetes mellitus. (a) Contrast-enhanced CT scan shows an amorphous calcification (arrowhead) and diffuse low-attenuation areas in the peripheral zone of the prostate (arrows). (b) Axial T2-weighted endorectal MR image (4,700/112) shows a focal, heterogeneous area of high signal intensity, which corresponds to an abscess (arrow). (c) Contrast-enhanced axial T1-weighted endorectal MR image (600/15) shows peripheral enhancement of the abscess (arrow). (d) Axial T2-weighted endorectal MR image (4,700/112) shows diffuse, radiating, streaky areas of low signal intensity in the peripheral zone of the prostate (watermelon skin sign) (arrowheads). (e) Coronal T2-weighted MR image (3,200/119) shows focal hypointense areas in the testicles. The diagnosis was confirmed with transrectal US-guided biopsy.

View larger version (104K): [in a new window]   Figure 18c.   Tuberculous prostatitis and orchitis in a 69-year-old man with diabetes mellitus. (a) Contrast-enhanced CT scan shows an amorphous calcification (arrowhead) and diffuse low-attenuation areas in the peripheral zone of the prostate (arrows). (b) Axial T2-weighted endorectal MR image (4,700/112) shows a focal, heterogeneous area of high signal intensity, which corresponds to an abscess (arrow). (c) Contrast-enhanced axial T1-weighted endorectal MR image (600/15) shows peripheral enhancement of the abscess (arrow). (d) Axial T2-weighted endorectal MR image (4,700/112) shows diffuse, radiating, streaky areas of low signal intensity in the peripheral zone of the prostate (watermelon skin sign) (arrowheads). (e) Coronal T2-weighted MR image (3,200/119) shows focal hypointense areas in the testicles. The diagnosis was confirmed with transrectal US-guided biopsy.

View larger version (112K): [in a new window]   Figure 18d.   Tuberculous prostatitis and orchitis in a 69-year-old man with diabetes mellitus. (a) Contrast-enhanced CT scan shows an amorphous calcification (arrowhead) and diffuse low-attenuation areas in the peripheral zone of the prostate (arrows). (b) Axial T2-weighted endorectal MR image (4,700/112) shows a focal, heterogeneous area of high signal intensity, which corresponds to an abscess (arrow). (c) Contrast-enhanced axial T1-weighted endorectal MR image (600/15) shows peripheral enhancement of the abscess (arrow). (d) Axial T2-weighted endorectal MR image (4,700/112) shows diffuse, radiating, streaky areas of low signal intensity in the peripheral zone of the prostate (watermelon skin sign) (arrowheads). (e) Coronal T2-weighted MR image (3,200/119) shows focal hypointense areas in the testicles. The diagnosis was confirmed with transrectal US-guided biopsy.

View larger version (139K): [in a new window]   Figure 18e.   Tuberculous prostatitis and orchitis in a 69-year-old man with diabetes mellitus. (a) Contrast-enhanced CT scan shows an amorphous calcification (arrowhead) and diffuse low-attenuation areas in the peripheral zone of the prostate (arrows). (b) Axial T2-weighted endorectal MR image (4,700/112) shows a focal, heterogeneous area of high signal intensity, which corresponds to an abscess (arrow). (c) Contrast-enhanced axial T1-weighted endorectal MR image (600/15) shows peripheral enhancement of the abscess (arrow). (d) Axial T2-weighted endorectal MR image (4,700/112) shows diffuse, radiating, streaky areas of low signal intensity in the peripheral zone of the prostate (watermelon skin sign) (arrowheads). (e) Coronal T2-weighted MR image (3,200/119) shows focal hypointense areas in the testicles. The diagnosis was confirmed with transrectal US-guided biopsy.

View larger version (97K): [in a new window]   Figure 19a.   Tuberculous lymphadenitis in a 30-year-old man with miliary tuberculosis. (a) Contrast-enhanced CT scan shows a lymph node with peripheral enhancement and a low-attenuation center (arrow). (b) Transverse US scan shows multiple tiny calcifications within the hypoechoic lymph node.

View larger version (144K): [in a new window]   Figure 19b.   Tuberculous lymphadenitis in a 30-year-old man with miliary tuberculosis. (a) Contrast-enhanced CT scan shows a lymph node with peripheral enhancement and a low-attenuation center (arrow). (b) Transverse US scan shows multiple tiny calcifications within the hypoechoic lymph node.

View larger version (56K): [in a new window]   Figure 20a.   Tuberculous mastitis in a 26-year-old woman with clinical findings of acute mastitis. (a) Axial T2-weighted MR mammogram (4,250/90) shows a hyperintense mass (arrow). (b) Axial T1-weighted MR mammogram (620/15) shows a hypointense mass (arrow), as well as diffuse skin thickening and parenchymal distortion. (c) Contrast-enhanced axial T1-weighted MR mammogram (786/15) shows significant enhancement of the mass (arrow), skin, and parenchyma. The diagnosis was confirmed with excisional biopsy.

View larger version (57K): [in a new window]   Figure 20b.   Tuberculous mastitis in a 26-year-old woman with clinical findings of acute mastitis. (a) Axial T2-weighted MR mammogram (4,250/90) shows a hyperintense mass (arrow). (b) Axial T1-weighted MR mammogram (620/15) shows a hypointense mass (arrow), as well as diffuse skin thickening and parenchymal distortion. (c) Contrast-enhanced axial T1-weighted MR mammogram (786/15) shows significant enhancement of the mass (arrow), skin, and parenchyma. The diagnosis was confirmed with excisional biopsy.

View larger version (69K): [in a new window]   Figure 20c.   Tuberculous mastitis in a 26-year-old woman with clinical findings of acute mastitis. (a) Axial T2-weighted MR mammogram (4,250/90) shows a hyperintense mass (arrow). (b) Axial T1-weighted MR mammogram (620/15) shows a hypointense mass (arrow), as well as diffuse skin thickening and parenchymal distortion. (c) Contrast-enhanced axial T1-weighted MR mammogram (786/15) shows significant enhancement of the mass (arrow), skin, and parenchyma. The diagnosis was confirmed with excisional biopsy.