The Common Vein

• 55yo man with with
  • chronic hepatitis B infection (current HBsAg positive, HBeAg negative, HBeAb positive,
  •  disseminated TB with
  •  s/p INH x8mo i10 years prior  
    • pulmonary,
    • peritoneal and
    • hepatic involvement,

 

Chest CT Lymph Node Biopsy

 

• • b5929-03L-TB-lympadenopathy-lung-nodules-effusion-CT-US-IR.png

    Disseminated Tuberculosis
    A 55-year-old male with a history of rheumatoid arthritis presents with new onset dyspnea, abdominal pain, and swelling. Axial CT of the chest reveals a large left pleural effusion (pink asterisks b, d), lung nodules in the left upper lobe (c) and left lower lobe (d), and mediastinal adenopathy (green arrowheads a, b). Inguinal adenopathy is noted (e). Biopsy of an axillary lymph node under ultrasound guidance (f) yielded necrotizing granulomas, confirming disseminated tuberculosis.
    Comment: Disseminated tuberculosis often involves multiple organ systems, with common findings including pleural effusions, lung nodules, and lymphadenopathy. The presence of necrotizing granulomas on biopsy is highly suggestive of tuberculosis and helps differentiate it from other granulomatous conditions such as sarcoidosis. Imaging findings combined with histopathologic confirmation are critical for accurate diagnosis and management.
    Citation: Disseminated tuberculosis commonly presents with pulmonary, pleural, and lymphatic involvement, with necrotizing granulomas serving as a key histological feature. (Radiographics. 2000;20(4):1169-1173).
    Ashley Davidoff MD TheCommonVein.net b5929-03L (01Li)

     

     

            Omental Thickening and
    Ascites with Enhancing peritoneum

     

    b5929c-000-disseminated-TB-peritoneal-omentum-induration-thickening-abdomen-55M-CT-001Liver.jpg

     

Disseminated Abdominal Tuberculosis
A 55-year-old male with a history of rheumatoid arthritis presents with abdominal pain, swelling, and new onset ascites. A recent lymph node biopsy confirmed the diagnosis of necrotizing granulomas. CT of the abdomen (axial view at the level of the mid kidneys) shows mild peritoneal enhancement, peritoneal and omental induration, and thickening, consistent with disseminated abdominal tuberculosis. Differential diagnosis includes peritoneal carcinomatosis and peritoneal mesothelioma.
Comment: Disseminated abdominal tuberculosis commonly presents with peritoneal thickening, omental caking, and ascites, which can mimic peritoneal carcinomatosis. Confirmation through histological findings such as necrotizing granulomas aids in differentiating this infectious etiology from malignancy.
Citation: Peritoneal tuberculosis can present with peritoneal thickening, omental caking, and ascites, often mimicking peritoneal carcinomatosis. (Radiographics. 2000;20(4):1169-1173).
Ashley Davidoff MD TheCommonVein.net b5929c-000 (01Li)

b5929c01L-000-disseminated-TB-peritoneal-omentum-induration-thickening-abdomen-55M-CT-001Liver.png

Disseminated Abdominal Tuberculosis
A 55-year-old male with a history of rheumatoid arthritis presents with abdominal pain, swelling, and new onset ascites. A recent lymph node biopsy confirmed the diagnosis of necrotizing granulomas. CT of the abdomen (axial view at the level of the mid kidneys) shows new ascites (b, pink asterisks, mild peritoneal enhancement, (b orange arrowheads) peritoneal and omental induration, and thickening (b white arrowhead)  consistent with disseminated abdominal tuberculosis. Differential diagnosis includes peritoneal carcinomatosis and peritoneal mesothelioma.  Asci
Comment: Disseminated abdominal tuberculosis commonly presents with peritoneal thickening, omental caking, and ascites, which can mimic peritoneal carcinomatosis. Confirmation through histological findings such as necrotizing granulomas aids in differentiating this infectious etiology from malignancy.
Citation: Peritoneal tuberculosis can present with peritoneal thickening, omental caking, and ascites, often mimicking peritoneal carcinomatosis. (Radiographics. 2000;20(4):1169-1173).
Ashley Davidoff MD TheCommonVein.net b5929c01L-000 (01Li)

b5929-01L-TB-peritoneal-liver-spleen-abdomen-CT-.jpg

Disseminated Abdominal Tuberculosis
A 55-year-old male with a history of rheumatoid arthritis presents with abdominal pain, swelling, and new onset ascites. A recent lymph node biopsy confirmed the diagnosis of necrotizing granulomas. CT of the abdomen (axial image a and coronal image b) shows new ascites (pink asterisk) and mild enhancement of the peritoneum (orange arrowhead).
Focus on omental thickening and enhancement (white arrowheads) is evident on axial images a, magnified in d, and coronal image e, magnified in f. Image c (coronal) shows multiple nodules in the spleen (maroon arrowhead), consistent with disseminated abdominal tuberculosis. Differential diagnosis includes peritoneal carcinomatosis and peritoneal mesothelioma.
Comment: Disseminated abdominal tuberculosis commonly presents with peritoneal thickening, omental caking, and ascites, which can mimic peritoneal carcinomatosis. Confirmation through histological findings such as necrotizing granulomas aids in differentiating this infectious etiology from malignancy.
Citation: Peritoneal tuberculosis can present with peritoneal thickening, omental caking, and ascites, often mimicking peritoneal carcinomatosis. (Radiographics. 2000;20(4):1169-1173).
Ashley Davidoff MD TheCommonVein.net b5929-01L (01Li)

b5929-02L-TB-peritoneal-thickening-spleen-nodules-abdomen-MRI.png

A 55-year-old male with a history of rheumatoid arthritis presents with abdominal pain, swelling, and new onset ascites. A recent lymph node biopsy confirmed the diagnosis of necrotizing granulomas.
A follow-up MRI shows resolution of ascites and confirms the persistence of peritoneal thickening on axial T2-weighted images (white arrowheads a, b) and multiple splenic nodules (c, magnified in d), consistent with ongoing disseminated abdominal tuberculosis.
Comment: Disseminated abdominal tuberculosis commonly presents with peritoneal thickening, omental caking, and ascites, which can mimic peritoneal carcinomatosis. Confirmation through histological findings such as necrotizing granulomas aids in differentiating this infectious etiology from malignancy.
Citation: Peritoneal tuberculosis can present with peritoneal thickening, omental caking, and ascites, often mimicking peritoneal carcinomatosis. (Radiographics. 2000;20(4):1169-1173).
Ashley Davidoff MD TheCommonVein.net b5929-02L (01Li)

b5929-06b-disseminated-TB-nodules-spleen-abdomen-55-US.jpg

Disseminated Tuberculosis
A 55-year-old male with a history of rheumatoid arthritis with known disseminated TB.
US transverse view of the spleen shows innumerable heterogeneous splenic nodules.
Comment: Disseminated tuberculosis frequently involves the spleen, presenting as multiple splenic nodules, often due to hematogenous spread of the infection. Splenic involvement can mimic other conditions such as lymphoma or metastases, emphasizing the importance of histological confirmation.
Citation: Splenic involvement in disseminated tuberculosis is a well-recognized manifestation, typically presenting as multiple nodules. (Radiographics. 2000;20(4):1169-1173).
Ashley Davidoff MD TheCommonVein.net b5929-06b (01Li)

3 Months Later

b5929-04L-TB-cavitating-lung-nodules-peritoneal-abscesses-or-tuberculomas-CT-b.jpg

Disseminated Tuberculosis
A 55-year-old male with a history of rheumatoid arthritis presents 3 months later, non-compliant with medication. Axial CT of the chest reveals slightly enlarged apical nodules (blue arrowheads a, c). The new nodules in the left apex show punctate cavitation. Large necrotic masses are noted in the subcapsular region of the liver (yellow arrowheads, axial CT c, e; coronal d; sagittal f). A new intrahepatic nodule is noted in segment 5 (orange arrowhead, e).
Comment: Disseminated tuberculosis can present with progressive pulmonary and hepatic involvement, especially in cases of non-compliance with treatment. The presence of necrotic subcapsular hepatic lesions raises concern for ongoing infectious burden or possible evolving abscess formation. Close monitoring and potential drainage, along with optimized medical therapy, are essential to manage progressive disease and prevent further complications.
Citation: Disseminated tuberculosis commonly presents with progressive pulmonary and hepatic involvement, often characterized by necrotic nodules. (Radiographics. 2000;20(4):1169-1173).
Ashley Davidoff MD TheCommonVein.net b5929-04L (01Li)

b5929-012-disseminated-TB-10-mths-laterperihepatic-subcapsular-intrahepatic-55M-US-001Liver.jpg

Disseminated Tuberculosis
A 55-year-old male with a history of rheumatoid arthritis with known disseminated TB.
US transverse view of the spleen shows innumerable heterogeneous splenic nodules. Sagittal ultrasound of the right lobe of the liver reveals multiple large necrotic lesions in the subcapsular region of the liver.
Comment: Disseminated tuberculosis frequently involves the spleen and liver, presenting as multiple nodules often due to hematogenous spread of the infection. Splenic involvement can mimic other conditions such as lymphoma or metastases, emphasizing the importance of histological confirmation. The presence of necrotic hepatic lesions raises concern for ongoing infectious burden and possible evolving abscess formation, warranting continued surveillance and medical management.
Citation: Splenic and hepatic involvement in disseminated tuberculosis is a well-recognized manifestation, typically presenting as multiple nodules. (Radiographics. 2000;20(4):1169-1173).
Ashley Davidoff MD TheCommonVein.net b5929-12 (01Li)

The progression from omental disease with ascites to predominantly subcapsular hepatic involvement in disseminated tuberculosis can be attributed to the disease’s pathophysiology and modes of spread.

Initial Presentation: Omental Disease and Ascites

Peritoneal tuberculosis is a common manifestation of abdominal TB, occurring in 31?58% of cases. It primarily results from hematogenous spread from a pulmonary focus, but can also arise from contiguous spread from adjacent organs or rupture of infected lymph nodes.

Progression to Subcapsular Hepatic Involvement

As the disease advances, Mycobacterium tuberculosis can disseminate hematogenously, leading to hepatic involvement. Hepatic tuberculosis often presents as multiple hypodense lesions in the subcapsular region of the liver, with a thickened capsule.

The predominance of subcapsular lesions over diffuse parenchymal involvement may be due to the bacteria’s localization in the peritoneal cavity, leading to direct seeding of the liver surface. This pattern has been observed in cases where peritoneal tuberculosis manifests as subcapsular hepatic lesions.

Clinical Implications

The shift from peritoneal to subcapsular hepatic involvement underscores the importance of early detection and consistent treatment of tuberculosis. Non-compliance with anti-tuberculous therapy can lead to disease progression and the development of complications such as necrotic hepatic lesions, which may mimic other conditions like abscesses or malignancies. Imaging studies, including ultrasound and CT, play a crucial role in identifying these changes, but histopathological confirmation remains essential for accurate diagnosis.

In summary, the transition from omental disease with ascites to predominantly subcapsular hepatic involvement in disseminated tuberculosis reflects the pathogen’s dissemination pathways and highlights the need for vigilant monitoring and adherence to treatment protocols to prevent disease progression and associated complications.

 

Can disseminated TB occur with limited active lung disease?