Dalak tüberkülozu BT bulguları

Özet

Dalak tüberkülozu çoğunlukla yaygın veya miliyer enfeksiyon sırasında ortaya çıkar; bağışıklığı baskılanmış kişilerde ve bilinen tüberküloz odağı olanlarda olasılık artar. Kontrastlı BT, dalaktaki küçük hipoattenüan nodülleri, nekrotik büyük tuberkülomları veya apse benzeri odakları ve eşlik eden karın içi hastalığı göstermede yararlıdır. Hiçbir BT bulgusu tek başına patognomonik değildir ve kesin tanı mikrobiyolojik ya da histopatolojik doğrulama gerektirebilir. Nodal, hepatik veya torasik yayılımın atlanması hastalığın dağılımının eksik değerlendirilmesine yol açar.

Faz ve pencere

Portal tanısal: Kontrastlı portal venöz fazda normal dalak parankimine göre hipoattenüan, dağınık mikronodüller veya daha büyük yuvarlak tuberkülomlar görülür; büyük odaklarda santral düzensiz nekroz ve heterojen çevresel kontrastlanma olabilir.
Kontrastsız: Kronik hastalıkta parankimal veya nodüler kalsifikasyon seçilebilir; kontrastsız görüntüler küçük hipoattenüan odakları ve aktif yumuşak doku kontrastlanmasını karakterize etmek için sınırlıdır.

Önerilen pencereler: Batın (G 400 / M 50), Yumuşak doku (G 400 / M 40), Akciğer (G 1500 / M -600).

BT bulguları

Miliyer dağılımda dalak boyunca serpiştirilmiş çok sayıda küçük hipoattenüan mikronodül
Makronodüler biçimde tek veya çok sayıda yuvarlak ya da oval hipoattenüan tuberkülom
Büyük tuberkülomda merkezî düzensiz nekroz ve heterojen kontrastlanan çevre parankim
Kontrastlı BT'de tüberküloz apsesi genellikle küçük, kötü sınırlı ve hafif çevre kontrastlanması gösteren bir lezyondur; ek splenik odaklar ve uygun enfeksiyon öyküsü tanıyı destekler.
İyileşmiş veya kronik odaklarda parankimal kalsifikasyon görülebilir
Karaciğerde benzer hipoattenüan granülomlar ve splenomegali eşlik edebilir
Eşlik eden hepatik nodüller ve hilus lenf nodlarında kazeifiye granülomlar tanıyı destekler.
Toraks görüntülerinde akciğer miliyer nodülleri ya da aktif tüberküloz bulguları eşlik edebilir

Ölçütler ve sınıflamalar

Mikronodüler splenik tüberküloz: Mikronodüler formda 10 mm'den küçük nodüller görülür.
Makronodüler splenik tüberküloz: 10 mm'den büyük nodüller
BT nodül boyutuna göre: Kontrastlı BT bulgularına göre splenik TB mikronodüler (10 mm'den küçük) ve makronodüler (10 mm'den büyük) olarak iki tipe ayrılır.

Normalde

Dalak dışındaki karın içi tüberküloz odaklarını değerlendir; inceleme toraksa uzanıyorsa göğüs içi tutulum açısından da görüntüleri gözden geçir.

Normal BT ile kıyasla

Aynı bölgenin, kaynak veri setinde patoloji içermediği belirtilen bir BT incelemesini kesit kesit kaydırın; organ sınırlarını açarak anatomiyi hasta görüntüsüyle karşılaştırın. Küçük rastlantısal bulgular tümüyle dışlanmamıştır.

Kaynak: TotalSegmentator v2.01 veri seti (Wasserthal ve ark., Radiology: Artificial Intelligence 2023), CC BY 4.0, vaka s0541; organ sınırları veri setinin otomatik segmentasyonundan, birleştirilerek sadeleştirildi. Görüntüler 2,5 mm kesit aralığına yeniden örneklendi.

Ayırıcı tanı

Kontrastlı BT'de fungal enfeksiyonlar, özellikle hematolojik malignite veya immünsupresyon gibi risk gruplarında ayırıcı tanıya girer.
Splenik lenfoma: solid nodüller veya diffüz infiltrasyon yapar; nekrotik lenf nodları ve enfeksiyon bulguları yoksa yine örtüşebilir.
Splenik sarkoidoz: çoklu hipoattenüan nodüller oluşturabilir; toraks içi lenfadenopati ve akciğer bulguları tanıyı destekler.
Piyojenik dalak apsesi: genellikle çevresel kontrastlanan koleksiyon, bazen gaz ve çevre inflamasyonuyla seyreder.
Dalak metastazı: bilinen primer tümör veya diğer organ metastazları vardır; merkezî nekroz tek başına tüberküloz ayrımı sağlamaz.
Dalak infarktı: periferik kama biçimli, kapsüle tabanı dayanan defekt beklenir; yuvarlak çoklu granülomlar tipik değildir.

Tuzaklar

Dalakta tek veya çok sayıda hipodens tüberküloz odağı bulunabileceğini göz önünde bulundur.
Santral nekroz gösteren hipodens splenik lezyonlar, TB dışında piyojenik enfeksiyonlar, mantar hastalıkları ve neoplastik süreçlerde de görülebilir; kesin ayırım için klinik ve patolojik değerlendirme gereklidir.
Dalakta küçük hipoattenüan nodüller görülebilir; BT bulguları tek başına splenik tüberküloz tanısını kesinleştirmez.
Dalak parankimi içindeki kalsifikasyonlar tüberkülozun önemli radyolojik özellikleri arasında yer alır.

Kendini dene

Uzamış ateş ve bilinen tüberküloz öyküsü olan kişide dalakta çok sayıda rastgele hipoattenüan nodül ve nekrotik abdominal nodlar var. En olası tanı nedir?
Cevabı göster
Dalak tüberkülozu. Miliyer splenik nodüller, nekrotik abdominal lenf nodları ve uygun klinik öykü birlikte tüberkülozu destekler; BT tek başına kesin tanı koymaz. Sarkoidozda toraks içi eşlikçiler; lenfoma ve metastazda tümöral dağılım ve klinik öykü aranır.
Portal venöz BT'de dalak boyunca küçük odaklar izleniyor. Hangi şekil daha çok splenik infarktı düşündürür?
Cevabı göster
Kapsüle dayanan periferik kama. İnfarkt tipik olarak periferik, kama biçimli ve kapsüle tabanı dayanan hipoattenüan defekt oluşturur. Rastgele yuvarlak mikronodüller miliyer enfeksiyonları; hedef benzeri mikroapseler mantar enfeksiyonunu; stellat kalsifikasyon IMT'yi akla getirir.

Kaynaklar

Bu sayfadaki 42 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 7 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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