Tüberküloz dışı mikobakteri akciğer hastalığı

Özet

Tüberküloz dışı mikobakteriler, özellikle yapısal akciğer hastalığı olanlarda kronik nodüler-bronşektatik ya da fibrokaviter akciğer hastalığı oluşturabilir. İnce kesit BT, nodüler-bronşektatik formun küçük nodüller ve bronşektazi gibi karakteristik bulgularını göstermede akciğer grafisine göre daha yararlıdır; fibrokaviter form ise grafiyle değerlendirilebilir. Bu dağılım NTM için ipucu verir, fakat tüberkülozdan veya diğer bronşiolit nedenlerinden tek başına ayırt ettirmez; klinik ve kültür verisi gerekir. Kavite ve yaygın bronşiolit bulgularının BT'de değerlendirilmesi, tutulumun yaygınlığını ortaya koymaya yardımcı olur.

Faz ve pencere

Kontrastsız tanısal

İnce kesit akciğer algoritmalı inspiryum görüntülerinde sağ orta lob ve lingulada silindirik/variköz bronş genişlemesi, bronş duvarı kalınlaşması, mukus tıkaçları ve dallanan sentrilobüler tomurcuklanan ağaç opasiteleri aranır. Üst lob fibrokaviter formda kavite, çevresinde fibrozis ve ağır fibrozise bağlı hacim kaybı görülebilir; kavite görünümü tüberküloz veya malign lezyonlarla örtüşebilir.

Önerilen pencereler: Akciğer (G 1500 / M -600), Mediasten (G 350 / M 50).

BT bulguları

• Orta lob-lingula nodüler bronşektazi paterni — multifokal bronş genişlemesi, küçük sentrilobüler nodüller ve bronş çevresi duvar kalınlaşması birlikte bulunur.
• Tomurcuklanan ağaç — BT'de küçük sentrilobüler nodüller ve dallanan opasiteler biçiminde görülür; bu görünüm etkeni tek başına belirlemez.
• Mukus tıkacı ve distal atelektazi — bronş içi yumuşak doku yoğunluğu, distal segmentte hacim kaybıyla eşleşebilir.
• Üst lob fibrokaviter değişiklik — üst loblarda kavite, çevresinde fibrozis ve ağır fibrozise bağlı hacim kaybı görülebilir.
• Kavite duvarı ve çevre nodüller — NTM'de kavite duvarı kalın veya ince olabilir ve çevresinde nodüler ya da çizgisel opasiteler görülebilir; bu görünüm tüberküloz veya malign lezyonlarla örtüşebilir.
• Mozaik atenüasyon/hava hapsi — küçük hava yolu tıkanıklığını düşündürür; ekspirasyon görüntüsü varsa belirginleşebilir.
• Plevral kalınlaşma veya efüzyon — plevral kalınlaşma fibrokaviter formda sık eşlik edebilir; plevral efüzyon ise seyrektir.

Ölçütler ve sınıflamalar

NTM akciğer hastalığı için balgam kültürü

Klinik ve görüntüleme ölçütlerine uygunluk ve diğer tanıların dışlanması yanında, en az 2 ayrı balgam örneğinde aynı NTM türünün (M. abscessus için aynı alttürün) kültürde üremesi gerekir; tek başına kültür sonucu hastalık tanısı koydurmaz.

NTM akciğer hastalığı için bronş yıkama/BAL kültürü

Klinik ve görüntüleme ölçütlerine uygunluk ve diğer tanıların dışlanması yanında, en az 1 bronş yıkama/lavaj kültüründe NTM üremesi gerekir; tek başına kültür sonucu hastalık tanısı koydurmaz.

NTM akciğer hastalığı için biyopsi temelli mikrobiyoloji

Transbronşiyal veya başka akciğer biyopsisinde mikobakteriyel histolojik bulgu (granülomatöz inflamasyon veya aside dirençli basil) ile NTM kültür pozitifliği; ya da aynı histolojik bulgularla birlikte en az 1 balgam veya bronş yıkama kültüründe NTM üremesi.

Normalde

Normal bronşlarla karşılaştırmada bronşektaziyi düşündüren bulgular arasında çok odaklı bronş genişlemesine eşlik eden küçük sentrilobüler nodüller ve dallanan opasiteler yer alır. Aynı düzeyde karşılaştırma yaparken bronşektazi, bronş duvarı kalınlaşması, mukus tıkaçları ve tomurcuklanan ağaç görünümündeki nodülleri değerlendirin.

Ayırıcı tanı

Postprimer tüberküloz

apikal kavite ve tomurcuklanan ağaç örtüşür; eşlik eden üst lob fibrozisi benzer olabilir, etkeni görüntüleme belirlemez.

Kronik aspirasyonda tekrarlayan mikroaspirasyon, oral mikroorganizmaların alt solunum yollarına taşınmasına katkıda bulunabilir.

Bakteriyel enfeksiyon

NTM-PD'ye bakteriyel eş enfeksiyonlar eşlik edebilir; bu nedenle yeni konsolidasyonun nedeni yalnız BT görünümüyle belirlenemez.

Kistik fibrozis veya primer siliyer diskinezi

NTM izolasyonu sık görülmektedir; özellikle primer siliyer diskinezide hastaların çok azı NTM akciğer hastalığı tanı kriterlerini karşılar, görüntüleme bulguları klinik öykü ile birlikte değerlendirilir.

Kaviteli malignite

NTM hastalığı nadiren (%3,6) tek nodül veya kitle şeklinde ortaya çıkarak akciğer kanserini taklit edebilir; PET-BT'de belirgin FDG tutulumu maligniteyle örtüşebilir.

Tuzaklar

• Orta lob-lingula bronşektazisini tek başına NTM tanısı saymayın; tanı için klinik, radyolojik ve mikrobiyolojik ölçütlerin birlikte karşılanması gerekir.
• Tomurcuklanan ağaç NTM'ye özgü değildir; tüberkülozda da görülebilir.
• Fibrokaviter NTM ile tüberküloz BT'de güvenilir biçimde ayırt edilemeyebilir; kavite morfolojisi etkeni kanıtlamaz.
• Bronşektaziyi değerlendirirken genişlemiş bronşlara eşlik eden küçük sentrilobüler nodülleri ve dallanan opasiteleri birlikte inceleyin.

Kendini dene

1. Kronik öksürükte orta lob-lingula bronşektazisi ve tomurcuklanan ağaç var. BT hangi tanıyı destekler?

   • Tüberküloz dışı mikobakteri hastalığı
   • Akut pulmoner emboli
   • Kardiyojenik ödem
   • Aspergilloma
   Cevabı göster

   Tüberküloz dışı mikobakteri hastalığı. Nodüler bronşektatik patern NTM için tipik bir dağılım ipucudur; yine de kültürle doğrulama gerekir. Nodüler-bronşektatik NTM formunda bronşektaziye küçük nodüller ve tomurcuklanan ağaç görünümü eşlik edebilir; tanı klinik, radyolojik ve mikrobiyolojik ölçütlerle konur.

2. Üst lob kavitesi ve komşu tomurcuklanan ağaç görülen hastada görüntüleme hangi ayrımı yapamaz?

   • NTM ile tüberküloz
   • Efüzyon ile pnömotoraks
   • Bronşektazi ile amfizem
   • Atelektazi ile nodül
   Cevabı göster

   NTM ile tüberküloz. Fibrokaviter NTM tüberküloza çok benzeyebilir; BT etkeni kesin olarak ayırmaz ve balgam testleri gerekir. Üst lob fibrokaviter NTM formu tüberkülozdan BT ile güvenilir biçimde ayrılamayabilir; kavite görünümü etkeni kanıtlamaz ve mikrobiyolojik değerlendirme gerekir.

Kaynaklar

Bu sayfadaki 40 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla otomatik olarak karşılaştırıldı; 21 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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Eğitim amaçlıdır; hasta başında tanı ve tedavi kararının yerine geçmez, tıbbi tavsiye değildir. Metinler yapay zekâ desteğiyle yazıldı ve otomatik bir adımda kaynak alıntılarıyla karşılaştırıldı; bu bir tıbbi doğrulama değildir ve içerik uzman radyolog incelemesinden geçmedi. Klinik kararlarda güncel kılavuzları, kurum protokollerini ve radyoloji raporunu esas alın.