Pediatric Primary Tuberculosis complicated by a Bronchopneumonia

Xing Liu, MD; Xi Zhao*, MD
Department of Radiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, P. R. China
*Siemens Healthineers China
|10/09/2019

An 11-year-old boy, complaining of paroxysmal cough with occasional phlegm, shortness of breath, chest tightness and pain within the past 10 days, was hospitalized. He was in poor physical health and had a history of hypertension, bronchopneumonia, idiopathic pulmonary fibrosis and primary tuberculosis. The physical examination revealed expiratory dyspnea with bilateral coarse breath sounds and extensive rale in the right lung. A CT chest examination was requested for further evaluation.

CT images revealed bilateral inhomogenous pulmonary densities showing geographical ground glass opacities (GGOs), areas of hyperinflation and bronchial wall thickening. An area of consolidation with blurred margins and an air bronchogram sign was revealed in the apical segment of the right upper lobe. Here a cavity measuring 0.8 × 0.5 mm in size, with peripheral calcifications, was found. Other calcified foci in both lungs were also visualized. Multiple enlarged lymph nodes were seen in the mediastinum. There was no sign of pleural effusion. A diagnosis of primary tuberculosis complicated by a bronchopneumonia was suspected and a treatment with antituberculous drugs and antibiotics was planned.

A chest CT was performed to further evaluate expiratory dyspnea with breath sounds and extensive rale in the right lung of 11-year old boy.
Courtesy of First Affiliated Hospital of Zhengzhou University, Zhengzhou, P. R. China

Fig. 1:
Axial views with mediastinum window show multiple enlarged lymph nodes (dotted arrows) and an area of consolidation in which a cavity, with peripheral calcifications, is found in the apical segment of the right upper lobe (arrow, Fig. 1b).

CT imaging plays a key role in pediatric pulmonary infections. A standard chest radiography lacks specificity. An initial scan is generally performed to make an accurate diagnosis and follow up scans are often required to monitor treatment results. Therefore, optimization of the radiation dose delivered in each scan is of particular importance. In this case, standard dose reduction techniques, such as CARE Dose 4D (automatic controlled tube current modulation) and ADMIRE (Advanced Modeled Iterative Reconstruction) were applied. Additionally, an advanced technique, Selective Photon Shield (SPS), featuring two special tin filters applied to both tubes, was adopted. The filters optimize the X-ray spectrum and significantly improve the air/soft tissue contrast. A total effective dose of only 0.026 mSv was achieved, this being within the dose range of a standard X-ray examination. Another highlight is the unique ultrafast scanning mode, the “Turbo Flash mode”. We used this to complete the chest scan, since the patient was unable to cooperate due to dyspnea, in only 0.43 s achiving excellent diagnostic image quality. The combination of SPS and “Turbo Flash mode” has great potential for routinely performed ultra-low dose pediatric CT scans of the lungs.

A chest CT was performed to further evaluate expiratory dyspnea with breath sounds and extensive rale in the right lung of 11-year old boy.
Courtesy of First Affiliated Hospital of Zhengzhou University, Zhengzhou, P. R. China

Fig. 2:
Axial (Figs. 2a–2d) and coronal (Figs. 2e–2f) views with lung window show bilateral geographical GGOs, areas of hyperinflation and bronchial wall thickening. An area of consolidation with air bronchogram sign is seen in the apical segment of the right upper lobe, in which a cavity, with peripheral calcifications, is found.

Scanner

Scan area

Thorax

Scan mode

Turbo Flash

Scan length

219 mm

Scan direction

Cranio-caudal

Scan time

0.43 s

Tube voltage

100 / Sn100 kV

Effective mAs

10 mAs

Dose modulation

CARE Dose4D

CTDIvol

0.04 mGy

DLP

0.9 mGy cm

Effective dose

0.026 mSv*

Rotation time

0.25 s

Pitch

2

Slice collimation

192 x 0.6 mm

Slice width

1 mm

Reconstruction increment

0.7 mm

Reconstruction kernel

BI57 / Br40 ADMIRE 3