Granülomatöz mediastinal ve hiler lenfadenopati

Özet

Mediastinal ve hiler lenf düğümlerinin granülomatöz tutulumu en sık tüberküloz, sarkoidoz ve bazı endemik fungal enfeksiyonlarla ilişkilidir. Toraks BT, nodların hangi istasyonlarda ve ne biçimde dağıldığını gösterir; etkeni tek başına kanıtlamaz. BT'de bilateral simetrik hiler ve mediastinal lenfadenopati sarkoidozla ilişkili tipik örüntülerdendir; tek taraflı veya asimetrik tutulum sarkoidozda daha az tipiktir ve tüberküloz, diğer enfeksiyonlar, lenfoma ve metastaz ayırıcı tanıda düşünülmelidir. Aktif nodal enfeksiyonun eski kalsifiye sekel sanılması ya da sarkoidozun yalnız nodal görünümle kesinleştirilmesi tanısal gecikmeye yol açabilir.

Faz ve pencere

Kontrastsız

İzlem BT’sinde nod içi kalsifikasyon görülebilir.

Venöz tanısal

Tüberküloz lenfadenitinde kontrastlı BT'de merkezî nekroz ve çevresel halka tarzı kontrastlanma görülebilir. Sarkoidozda büyümüş hiler ve mediastinal nodlar çoğu kez daha homojen, karşılıklı ve simetrik dağılımdadır; eşlik eden akciğer mikronodülleri de aynı incelemede aranır.

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

BT bulguları

• İki taraflı hiler ve mediastinal nod büyümesi — karşılıklı hiler istasyonların benzer tutulumu sarkoidozu destekleyen dağılımdır.
• Tüberküloz lenfadenitinde kontrastlı BT'de merkezî nekroz ve çevresel halka tarzı kontrastlanma görülebilir.
• Asimetrik veya tek taraflı hiler-mediastinal tutulum sarkoidoz olasılığını azaltır; metastatik hastalık veya enfeksiyöz süreçler açısından değerlendirilmeli, ancak görüntüleme tek başına etkeni tanımlamaz.
• Nod içi kalsifikasyon, tüberküloz lenfadenitinin iyileşme döneminde görülebilir.
• Periferik yumurta kabuğu biçimli kalsifikasyon — sarkoidozda görülebilir; silikoz ve kömür işçisi pnömokonyozu da benzer görünüm oluşturur.
• Fissür ve bronkovasküler demet boyunca küçük nodüller — perilenfatik dağılım sarkoidozla uyumlu akciğer bulgusudur.
• Üst loblarda fibrotik çekinti ve mimari bozulma — kronik granülomatöz akciğer hastalığına eşlik edebilir.
• Scadding evre IV, fibrotik pulmoner sarkoidoz olarak tanımlanır.

Normalde

Normal hiler, sağ paratrakeal ve subkarinal lenf düğümleri ayrı küçük yumuşak doku yapıları olarak seçilir; birbirine eklenen nodal kitle, merkezî nekroz halkası veya nod içinde kalsiyum beklenmez. Aynı kesitte sağ ve sol hilusları, subkarinal zinciri ve üst lob bronkovasküler demetlerini karşılaştırın; nodların simetrisi ile perilenfatik nodül dağılımı kıyasın odak noktasıdır.

Ayırıcı tanı

Sarkoidoz

iki taraflı simetrik hiler-mediastinal nodlar ve perilenfatik mikronodüller; nodal nekroz varsa enfeksiyon da araştırılmalıdır.

Tüberküloz lenfadeniti

çevresel kontrastlanan nekrotik nod, asimetrik dağılım ve eşlik eden akciğer enfeksiyonu bulguları görülebilir.

Histoplazmoz

nodal veya pulmoner granülomlar iyileşme döneminde kalsifiye olabilir; maruziyet ve coğrafi öykü görüntüyü tamamlar.

Silikoz

üst loblarda küçük nodüller ve nodal yumurta kabuğu kalsifikasyonu; mesleki toz maruziyeti ayırıcıdır.

Lenfoma

nodal istasyonları birleştiren yumuşak doku kitleleri yapabilir; nekroz ve kalsifikasyon özellikle tedavi öyküsü bağlamında yorumlanır.

Tuzaklar

• Merkezî nodal nekrozu yalnız tüberkülozla eşleştirme; fungal enfeksiyonlar ve nekrotik metastazlar da benzer halka görünümü oluşturabilir.
• Yumurta kabuğu kalsifikasyonunu sarkoidoza özgü sayma; silikozda da aynı periferik kalsiyum paterni görülür.
• Kalsifiye nod saptandığında komşu yumuşak doku bileşenini de incele; eski kalsifikasyon aktif nodal süreci dışlamaz.
• Simetrik hiler büyümeyi tek başına sarkoidoz tanısı kabul etme; akciğer dağılımı, klinik ve mikrobiyolojik bulgular tanıyı değiştirir.

Kendini dene

1. Hiler nodlar iki tarafta benzer dağılımda; fissürler boyunca ince nodüller uzanıyor. En olası tanı nedir?

   • Sarkoidoz
   • Tüberküloz
   • Lenfoma
   • Silikoz
   Cevabı göster

   Sarkoidoz. Simetrik hiler büyüme ve fissür boyunca perilenfatik nodüller sarkoidoz örüntüsünü destekler. Tüberkülozda asimetri veya nekrotik nod görülebilir; lenfoma daha çok birleşen nodal kitleler oluşturur; silikozda mesleki maruziyet ve nodal kalsifikasyon beklenir.

2. Büyümüş bir subkarinal nodda merkezî düşük yoğunluk ve çevresel kontrastlanma var. En olası neden hangisidir?

   • Tüberküloz lenfadeniti
   • Sarkoidoz
   • Castleman hastalığı
   • Silikoz
   Cevabı göster

   Tüberküloz lenfadeniti. Nekrotik merkez ve çevresel kontrastlanan nod dokusu aktif tüberküloz lenfadenitinde görülebilen bir paterndir. Sarkoidoz çoğunlukla homojen ve simetrik nodlarla seyreder; Castleman sınırlı hipervasküler nodal kitle olabilir; silikozda yumurta kabuğu kalsifikasyonu ve maruziyet öyküsü öne çıkar.

İlgili konular

• Mediastinal Castleman hastalığı

Kaynaklar

Bu sayfadaki 39 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla otomatik olarak karşılaştırıldı; 3 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.