Imaging of tuberculosis of the abdominal viscera: beyond the intestines

Abstract

There is an increasing incidence of both intra- and extra-thoracic manifestations of tuberculosis, in part due to the AIDS epidemic. Isolated tubercular involvement of the solid abdominal viscera is relatively unusual. Cross-sectional imaging with ultrasound, multidetector computed tomography (CT), and magnetic resonance imaging (MRI) plays an important role in the diagnosis and post treatment follow-up of tuberculosis. Specific imaging features of tuberculosis are frequently related to caseous necrosis, which is the hallmark of this disease. However, depending on the type of solid organ involvement, tubercular lesions can mimic a variety of neoplastic and nonneoplastic conditions. Often, cross-sectional imaging alone is insufficient in reaching a conclusive diagnosis, and image-guided tissue sampling is needed. In this article, we review the pathology and cross-sectional imaging features of tubercular involvement of solid abdominopelvic organs with a special emphasis on appropriate differential diagnoses.

Keywords: Abdomen; computed tomography; magnetic resonance imaging; tuberculosis.

Figure 1

42-year-old man with hepatic, splenic, and renal tuberculosis. (a-c) Axial contrast-enhanced computed tomography images of the abdomen demonstrate coalescent hypodense lesions (macronodular) in the liver (white arrows in a), tiny hypodense lesions (micronodular or miliary) in the spleen (black arrows in a, b), and the kidneys (double-lined white arrows in c). Note the conglomeration of some of the splenic (black arrowheads in b) and renal lesions (double-lined black arrow in c) resulting in macronodular appearance.

Figure 2

38-year-old man with renal tuberculosis. Axial CECT image of the abdomen in the excretory phase reveals a hypodense parenchymal mass (arrow) in the upper pole of left kidney with perinephric extension. Biopsy of the lesion revealed tubercular abscess.

Figure 3

43-year-old woman with renal tuberculosis. (a, b) Coronal reformatted CECT urography images demonstrate infundibular stricture (white arrow) with a calyceal diverticulum (arrowhead).

Figure 4

51-year-old woman with renal tuberculosis. (a) Coronal T2-weighted (T2W) and (b) heavily T2W (long TR) magentic resonance (MR) images reveal grossly hydronephrotic right kidney (arrow) due to chronic upper ureteric tubercular stricture.

Figure 5

62-year-old man with hepatic tubercular abscess. Axial CECT images of the liver in (a) arterial and (b) portal venous phases reveal a solitary well-defined hypodense lesion (arrow) with peripheral rim of enhancement in the caudate lobe. Ultrasound guided fine needle aspiration biopsy (not shown) of the lesion revealed caseous necrosis with tubercle bacillus and epithelioid giant cells.

Figure 6

28-year-old man with HIV associated hepatic tuberculosis. (a) Transverse ultrasound image of the liver demonstrates well-defined hypoechoic lesions (arrows) in the right lobe. (b) Axial T2W MR image of the liver reveals high-signal intensity of the lesions (arrows). (c, d) Axial dual-echo in- and out-of-phase T1- weighted (T1W) MR images reveal the lesions (arrows) to be iso- to hypointense with peripheral hypointense rim. Note that the larger lesion has greater signal loss on the longer TE (in-phase) sequence which is most likely explained by the caseous necrosis. (e) Axial T1W fat suppressed postgadolinium MR image in the venous phase demonstrates heterogeneous enhancement of the lesions (arrows). Ultrasound-guided biopsy of the lesions revealed granulomatous inflammation with acid-fast bacilli consistent with tuberculosis.

Figure 7

45-year-old woman with pulmonary tuberculosis complicated by adrenal involvement. (a, b) Axial dual echo in- and out-of-phase T1W MR images reveal bilateral adrenal nodules (arrows) with no significant intravoxel lipid. Note the preserved contour of the adrenal glands. (c, d) Axial T1W fat suppressed postgadolinium MR image in the venous and delayed phases demonstrate peripheral rim enhancement of the right adrenal nodule and heterogeneous enhancement of the left adrenal nodule in the venous phase (arrows in c) with progressive increase in enhancement of both the nodules in delayed phase (arrows in d). CT-guided biopsy of the right adrenal lesion revealed granulomatous inflammation.

Figure 8

23-year-old-woman with pancreatic tuberculosis and previous history of pulmonary tuberculosis. (a, b) Axial CECT images of the upper abdomen demonstrate hypodense mass with nonenhancing necrotic areas (white arrows) in the pancreatic head and uncinate process region causing portal vein thrombosis with cavernous transformation (black arrow). The radiological picture is indistinguishable from pancreatic cancer. Note the absence of arterial encasement. Ultrasound guided fine needle aspiration biopsy revealed granulomatous inflammation. The patient was treated with standard antitubercular therapy with marked improvement.

Figure 9

31-year-old man with tubercular orchitis. (a, b) Longitudinal ultrasound images of the testis demonstrate enlarged, markedly heterogeneous hypoechoic appearance of the testis (arrows) with an ill-defined collection (arrowhead, b) in the lower pole.

Figure 10

26-year-old woman with chronic tubercular salpingo-oophoritis. (a) Transverse ultrasound image of the pelvis reveals hypoechoic masses (arrow) in both the adnexae. (b) Axial CECT image through the pelvis demonstrates bilateral tubo-ovarian masses with calcification (arrows).

Figure 11

38-year-old woman with chronic tubercular hydrosalpinges. (a) Axial T2W MR image reveals bilateral (asterisk) multi-loculated high signal intensity (arrows) adnexal lesions with intercommunicating loculi owing to incomplete septae suggestive of hydrosalpinges. (b) Coronal T1W fat suppressed postgadolinium (arrows) MR image demonstrates heterogeneous enhancement of the septations with no nodules. Note the compressed uterus in the midline (arrowhead).