Dalak granülomatöz tutulumu (sarkoidoz/TB)

Özet

Sarkoidoz ve tüberküloz dalağı diffüz büyüme ya da çoklu granülomatöz nodüllerle tutabilir; görünüm özellikle yaygın hastalıkta örtüşür. Portal faz kontrastlı BT küçük hipoenhans odakları gösterir ve toraks, karaciğer, lenf düğümleri gibi eşlik eden tutulum bölgelerini haritalar. BT dağılımı olasılıkları daraltır, ancak bu iki enfeksiyöz ve inflamatuvar nedeni tek başına kesin ayıramaz. Nodülleri metastaz, lenfoma veya apse diye yanlış sınıflamak gereksiz girişime ya da tedavi edilebilir enfeksiyonun gecikmesine yol açabilir.

Faz ve pencere

Portal tanısal

Miliyer splenik tüberkülozda rastgele dağılmış çok küçük hipodens lezyonlar görülebilir; makronodüler formda tek veya çoklu yuvarlak ya da oval nodüller izlenebilir ve kontrastlı MR’da periferik kontrastlanma görülebilir. Sarkoidoz da dalakta hipodens nodüller oluşturabilir; bu bulgu tüberkülozdan ayrım için tek başına özgül değildir. Kitle oluşturan TB'de santral nekroz ve çevresel kontrastlanma görülebilir.

Kontrastsız

Kronik granülomatöz hastalıkta noktasal veya kaba kalsifikasyonlar saptanabilir; aktif küçük nodüllerin ayrımı için tek başına sınırlıdır.

Önerilen pencereler: Batın (G 400 / M 50), Karaciğer (G 150 / M 30), Mediasten (G 350 / M 50).

BT bulguları

• Dalak boyutunda artış izlenebilir ve bu durum parankime dağılmış çoklu küçük nodüllerle birlikte bulunabilir.
• Sarkoidozda dalakta hipodens nodüller izlenir; makronodüler formda nodüller büyüyüp birleşebilir veya çevresel kontrastlanma gösterebilir.
• Miliyer tüberkülozda küçük nodüller dalak içinde rastgele dağılır; eşlik eden karaciğer ve akciğer miliyer odakları olasılığı artırır.
• Makronodüler tüberküloz tek veya çoklu yuvarlak lezyon yapabilir; nekrotik merkez ve periferik kontrastlanma görülebilir.
• Kronik evrede dalak ve lenf düğümlerinde kalsifikasyon gelişebilir; bu bulgu etkeni tek başına belirlemez.
• En sık tutulan lenf düğümü zincirleri mezenterik, çölyak, porta hepatis ve peripancreatik zincirlerdir; bu bölgeler ile birlikte karaciğerde eş odakları aynı incelemede değerlendirmek gerekir.

Normalde

Normal dalak portal fazda parankim boyunca karşılaştırılabilir kontrastlanma gösterir; granülomatöz tutulumda bu zemin üzerinde seçilen hipodens odaklar, birleşen alanlar veya diffüz büyüme aranır. Dalak hilusu, karaciğer parankimi ve üst batın lenf düğümlerini aynı düzeyde kıyaslayarak sistemik dağılımın tek organa sınırlı olup olmadığını belirle.

Ayırıcı tanı

Lenfoma

daha büyük veya birleşen odaklara yaygın lenfadenopati eşlik edebilir.

Metastaz

bilinen primer malignite ve diğer organlardaki benzer lezyonlar destekleyicidir.

Fungal enfeksiyonlar ve mikroapseler

immünsüpresyon varlığında dalakta çok sayıda lezyon görülebilir.

Piyojenik apse

sıvı yoğunluğu, çevresel kontrastlanma ve çevre yağ dokuda inflamasyon destekler.

Tuzaklar

• Sarkoidoz ve tüberküloz nodülleri BT’de birbirinden güvenilir biçimde ayrılamaz; toraks paterni, bağışıklık durumu ve mikrobiyolojik/histolojik kanıt gerekir.
• Miliyer tüberkülozda BT'de çok küçük hipodens splenik lezyonlar görülebilir.
• Kalsifikasyon kronik enfeksiyon veya eski granülom lehine olabilir ama aktif hastalığı kanıtlamaz.

Kendini dene

1. Sistemik hastalık öyküsü olan kişide portal fazda dalakta çok sayıda hafif hipoenhans nodül ve hiler lenf düğümleri görülüyor. Hangi hastalık grubu düşünülür?

   • Granülomatöz tutulum
   • Splenik hamartom
   • Basit kistler
   • Travmatik psödoanevrizma
   Cevabı göster

   Granülomatöz tutulum. Çoklu hipoenhans odaklar ve üst batın lenf düğümleri sistemik granülomatöz hastalıkla uyumludur; BT sarkoidoz ile tüberkülozu tek başına ayıramaz. Hamartom çoğunlukla tek solid kitle, kistler sıvı lezyon, psödoanevrizma ise damar fazında kontrastlanan kese oluşturur.

2. Miliyer splenik nodüllere akciğerlerde yaygın küçük rastgele nodüller eşlik ediyor; olası enfeksiyöz seçenek hangisidir?

   • Tüberküloz
   • Kistik ekinokok
   • Bakteriyel apse
   • Dalak enfarktı
   Cevabı göster

   Tüberküloz. Akciğer ve dalakta rastgele dağılmış miliyer nodüller dissemine tüberkülozu destekler. Kistik ekinokok kistik yapılar, apse koleksiyon ve inflamasyon, enfarkt ise kama biçimli perfüzyon kaybı oluşturur; sarkoidoz yine de klinik bağlamda ayırıcıda kalır.

İlgili konular

• Gamna–Gandy cisimcikleri

Kaynaklar

Bu sayfadaki 35 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 7 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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Eğitim amaçlıdır; hasta başında tanı ve tedavi kararının yerine geçmez. İçerik yapay zekâ destekli bir süreçle güncel literatüre göre cümle cümle kaynaklarla karşılaştırıldı, ancak uzman radyolog incelemesinden geçmedi. Klinik kararlarda güncel kılavuzları, kurum protokollerini ve radyoloji raporunu esas alın.