(Radiographics. 2001;21:859-860.)
© RSNA, 2001
Invited Commentary
Douglas S. Katz, MD
Department of Radiology, Winthrop University Hospital, Mineola, NY
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Commentary
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Tuberculosis has affected humans since the development of civilization (1,2). Descriptions of M tuberculosis infection have been attributed to Hippocrates, and tuberculosis may have caused more morbidity and mortality in humans than any other single infectious disease (2). Unfortunately, in developing nations, tuberculosis remains the most common cause of death in adults from an infectious disease (2,3). Intrathoracic as well as extrathoracic complications of tuberculosis are particularly common in the developing world but may occur in the industrialized world as well, due to delayed diagnosis, incomplete or inadequate therapy, and multidrug-resistant strains of M tuberculosis (1,2,4).
In the preceding article
, Kim and colleagues systematically describe and illustrate the broad spectrum of intrathoracic sequelae and complications of M tuberculosis infection. Such sequelae, which are much more commonly the result of postprimary tuberculosis as opposed to primary tuberculosis, may involve any portion of the thorax, including the pulmonary parenchyma, the central and peripheral airways, the pulmonary vasculature, the pleura and chest wall, the mediastinum, and the vertebral bodies. Although multiple articles in the radiology literature in the past several years have reviewed the thoracic sequelae of tuberculosis (2,5–9), the current article nicely summarizes this important topic and will be of interest to the readership of RadioGraphics throughout the world. With numerous examples and an appropriate emphasis on CT, Kim and co-workers demonstrate the host of complications, from relatively common conditions such as pulmonary fibrosis and bronchiectasis to uncommon and rare complications including broncholithiasis, esophagomediastinal fistula, and pneumothorax.
The authors correctly stress the important role of CT of the thorax in identifying these thoracic complications of tuberculosis, in clarifying plain radiographic findings, and in determining disease activity. CT is particularly useful in assessment and characterization of bronchiectasis, lymphadenopathy, tracheobronchial stenosis, and pericardial disease (2,8–10). The authors also demonstrate the role of intravenous contrast material, which can be given in selected cases. Intravenous contrast material assists in the evaluation of lymphadenopathy, pleural disease, and tracheal and central bronchial disease.
Although in general the current review nicely summarizes the recent literature on thoracic complications of primary and postprimary tuberculosis, several subjects discussed in the article require further clarification. First, tuberculomas are most often encountered in asymptomatic adults, are usually the result of healed primary tuberculosis, and most often remain stable in size over time (7). Second, massive hemoptysis in patients with tuberculosis is much more commonly related to hypertrophied bronchial arteries than to the rare Rasmussen aneurysm, but the initial treatment of choice for either entity is percutaneous catheter embolization (4,11). Third, esophagomediastinal fistula, a rare complication of tuberculosis, has a good prognosis and closes after antituberculosis drug therapy (12). Fourth, pseudochylous pleural effusion, with fat-fluid or fat-calcium levels evident at CT, is a very recently described rare complication of tuberculosis. Although the authors cite a potential explanation for this finding from the article by Song et al (13), its origin is actually uncertain. Fifth, bronchoscopy and biopsy may be required to distinguish tuberculosis from cancer when central airway disease is present at CT, since the imaging findings are variable and bronchial wall thickening, with or without associated hilar and mediastinal lymphadenopathy, may simulate bronchogenic carcinoma (8,10). Sixth, there are a few rare thoracic complications not discussed in the current article, including the development of adult respiratory distress syndrome following miliary tuberculosis and involvement of the larynx by tuberculosis (5,7). Seventh, the authors do not discuss in detail the endobronchial spread of tuberculosis, which is the most common complication of cavitary tuberculosis (7). Finally, the authors state that bronchogenic carcinoma and tuberculosis "often" coexist. Although they are correct that carcinoma may be obscured by tuberculosis or misinterpreted as progression of tuberculosis, this relationship is controversial and may be a coincidence (7). The association of malignancy and chronic tuberculous empyema, which is mentioned at the end of the article, is also not well established and may be similarly coincidental.
In conclusion, Kim and co-workers have both demonstrated and discussed the spectrum of various important common, uncommon, and rare thoracic sequelae and complications of primary and postprimary tuberculosis. Their article will further increase awareness of these complications in the international radiology community as well as in the general medical community at large.
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References
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Santelli ED, Katz DS, Goldschmidt AM, Thomas HA. Embolization of multiple Rasmussen aneurysms as a treatment of hemoptysis. Radiology 1994; 193:396-398.[Abstract/Free Full Text]
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Im JG, Kim JH, Han MC, Kim CW. Computed tomography of esophagomediastinal fistula in tuberculous mediastinal lymphadenitis. J Comput Assist Tomogr 1990; 14:89-92.[Medline]
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Song JW, Im JG, Goo JM, Kim HY, Song CS, Lee JS. Pseudochylous pleural effusion with fat-fluid level: report of six cases. Radiology 2000; 216:478-480.[Abstract/Free Full Text]
Related Article
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Thoracic Sequelae and Complications of Tuberculosis
- Hyae Young Kim, Koun-Sik Song, Jin Mo Goo, Jin Seong Lee, Kyoung Soo Lee, and Tae-Hwan Lim
RadioGraphics 2001 21: 839-858.
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