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Pulmonary Nontuberculous Mycobacterial Infection: Radiologic Manifestations¹

¹ From the Department of Radiology, Duke University Medical Center, Erwin Rd, Durham, NC 27710. Presented as a scientific exhibit at the 1997 RSNA scientific assembly. Received February 11, 1999; revision requested March 16 and received June 7; accepted June 10. Address reprint requests to J.J.E.

View larger version (99K): [in a new window]   Figure 1a.   Pulmonary M avium-intracellulare infection in a 42-year-old woman with a chronic cough. Sputum cultures were negative; the diagnosis was made with bronchoscopy and transbronchial biopsy. (a) Posteroanterior chest radiograph shows scattered, poorly defined linear and nodular areas of increased opacity with cavitation (arrow) in the right upper lobe. (b) Close-up computed tomographic (CT) scan of the right upper lobe shows peripheral centrilobular nodules (arrows), a thin-walled cavity, and bronchial wall thickening (arrowhead).

View larger version (139K): [in a new window]   Figure 1b.   Pulmonary M avium-intracellulare infection in a 42-year-old woman with a chronic cough. Sputum cultures were negative; the diagnosis was made with bronchoscopy and transbronchial biopsy. (a) Posteroanterior chest radiograph shows scattered, poorly defined linear and nodular areas of increased opacity with cavitation (arrow) in the right upper lobe. (b) Close-up computed tomographic (CT) scan of the right upper lobe shows peripheral centrilobular nodules (arrows), a thin-walled cavity, and bronchial wall thickening (arrowhead).

View larger version (160K): [in a new window]   Figure 2a.   Pulmonary M avium-intracellulare infection in a 50-year-old woman with a chronic cough. (a) Posteroanterior chest radiograph shows heterogeneous areas of increased opacity in the right upper lobe with volume loss. The patient responded poorly to antimycobacterial therapy and underwent right upper lobe resection. (b) Posteroanterior chest radiograph obtained 3 years after resection shows consolidation in the upper aspect of the right lung and new areas of increased opacity in the left lung. The diagnosis of recurrent M avium-intracellulare infection was confirmed with transbronchial lung biopsy. The infection responded poorly to antimycobacterial therapy, and right pneumonectomy was performed. Persistent infection resulted in chronic empyema in the right pleural space. (c) Posteroanterior chest radiograph obtained 1 year later shows air in the right pleural space, a finding consistent with a bronchopleural fistula from chronic M avium-intracellulare infection. Note the scattered heterogeneous areas of increased opacity in the left lung.

View larger version (154K): [in a new window]   Figure 2b.   Pulmonary M avium-intracellulare infection in a 50-year-old woman with a chronic cough. (a) Posteroanterior chest radiograph shows heterogeneous areas of increased opacity in the right upper lobe with volume loss. The patient responded poorly to antimycobacterial therapy and underwent right upper lobe resection. (b) Posteroanterior chest radiograph obtained 3 years after resection shows consolidation in the upper aspect of the right lung and new areas of increased opacity in the left lung. The diagnosis of recurrent M avium-intracellulare infection was confirmed with transbronchial lung biopsy. The infection responded poorly to antimycobacterial therapy, and right pneumonectomy was performed. Persistent infection resulted in chronic empyema in the right pleural space. (c) Posteroanterior chest radiograph obtained 1 year later shows air in the right pleural space, a finding consistent with a bronchopleural fistula from chronic M avium-intracellulare infection. Note the scattered heterogeneous areas of increased opacity in the left lung.

View larger version (152K): [in a new window]   Figure 2c.   Pulmonary M avium-intracellulare infection in a 50-year-old woman with a chronic cough. (a) Posteroanterior chest radiograph shows heterogeneous areas of increased opacity in the right upper lobe with volume loss. The patient responded poorly to antimycobacterial therapy and underwent right upper lobe resection. (b) Posteroanterior chest radiograph obtained 3 years after resection shows consolidation in the upper aspect of the right lung and new areas of increased opacity in the left lung. The diagnosis of recurrent M avium-intracellulare infection was confirmed with transbronchial lung biopsy. The infection responded poorly to antimycobacterial therapy, and right pneumonectomy was performed. Persistent infection resulted in chronic empyema in the right pleural space. (c) Posteroanterior chest radiograph obtained 1 year later shows air in the right pleural space, a finding consistent with a bronchopleural fistula from chronic M avium-intracellulare infection. Note the scattered heterogeneous areas of increased opacity in the left lung.

View larger version (167K): [in a new window]   Figure 3a.   Pulmonary M avium-intracellulare infection in a 72-year-old woman with a chronic cough. M avium-intracellulare was cultured from the sputum. (a) Posteroanterior chest radiograph shows scattered, bilateral, pulmonary areas of increased opacity with focal consolidation in the lingula. There is right paratracheal adenopathy (arrows). (b) Posteroanterior chest radiograph obtained 5 years later after long-term antituberculous drug therapy shows progressive volume loss in the upper lobes, increased paratracheal adenopathy (arrow), and improvement in the areas of increased opacity in the right upper lobe and lingula. New areas of increased opacity have developed in the middle lobe (arrowhead).

View larger version (170K): [in a new window]   Figure 3b.   Pulmonary M avium-intracellulare infection in a 72-year-old woman with a chronic cough. M avium-intracellulare was cultured from the sputum. (a) Posteroanterior chest radiograph shows scattered, bilateral, pulmonary areas of increased opacity with focal consolidation in the lingula. There is right paratracheal adenopathy (arrows). (b) Posteroanterior chest radiograph obtained 5 years later after long-term antituberculous drug therapy shows progressive volume loss in the upper lobes, increased paratracheal adenopathy (arrow), and improvement in the areas of increased opacity in the right upper lobe and lingula. New areas of increased opacity have developed in the middle lobe (arrowhead).

View larger version (166K): [in a new window]   Figure 4a.   Pulmonary M avium-intracellulare infection in a 43-year-old man with chronic obstructive lung disease, digital clubbing, and a chronic productive cough. Bronchial washings were positive for M avium-intracellulare. (a) Posteroanterior chest radiograph shows heterogeneous linear and nodular areas of increased opacity in the left lung. There is marked destruction of the right lung with architectural distortion and an air-fluid level in the superior segment of the right lower lobe. The patient was poorly compliant with antituberculous therapy and presented 20 months later with progressive weight loss and hemoptysis. (b) Posteroanterior chest radiograph shows progressive destruction of the upper lobes with a large bulla in the right upper lobe. Heterogeneous areas of increased opacity are present in the left upper lobe (arrows), and there is associated architectural distortion and traction bronchiectasis (arrowheads). (c) Left bronchial arteriogram shows a bronchial artery-pulmonary artery fistula (arrows). The bronchial arteries were embolized with polyvinyl alcohol foam powder (Ivalon; M-Pact, Eudora, Kan). The patient died after massive hemoptysis.

View larger version (178K): [in a new window]   Figure 4b.   Pulmonary M avium-intracellulare infection in a 43-year-old man with chronic obstructive lung disease, digital clubbing, and a chronic productive cough. Bronchial washings were positive for M avium-intracellulare. (a) Posteroanterior chest radiograph shows heterogeneous linear and nodular areas of increased opacity in the left lung. There is marked destruction of the right lung with architectural distortion and an air-fluid level in the superior segment of the right lower lobe. The patient was poorly compliant with antituberculous therapy and presented 20 months later with progressive weight loss and hemoptysis. (b) Posteroanterior chest radiograph shows progressive destruction of the upper lobes with a large bulla in the right upper lobe. Heterogeneous areas of increased opacity are present in the left upper lobe (arrows), and there is associated architectural distortion and traction bronchiectasis (arrowheads). (c) Left bronchial arteriogram shows a bronchial artery-pulmonary artery fistula (arrows). The bronchial arteries were embolized with polyvinyl alcohol foam powder (Ivalon; M-Pact, Eudora, Kan). The patient died after massive hemoptysis.

View larger version (147K): [in a new window]   Figure 4c.   Pulmonary M avium-intracellulare infection in a 43-year-old man with chronic obstructive lung disease, digital clubbing, and a chronic productive cough. Bronchial washings were positive for M avium-intracellulare. (a) Posteroanterior chest radiograph shows heterogeneous linear and nodular areas of increased opacity in the left lung. There is marked destruction of the right lung with architectural distortion and an air-fluid level in the superior segment of the right lower lobe. The patient was poorly compliant with antituberculous therapy and presented 20 months later with progressive weight loss and hemoptysis. (b) Posteroanterior chest radiograph shows progressive destruction of the upper lobes with a large bulla in the right upper lobe. Heterogeneous areas of increased opacity are present in the left upper lobe (arrows), and there is associated architectural distortion and traction bronchiectasis (arrowheads). (c) Left bronchial arteriogram shows a bronchial artery-pulmonary artery fistula (arrows). The bronchial arteries were embolized with polyvinyl alcohol foam powder (Ivalon; M-Pact, Eudora, Kan). The patient died after massive hemoptysis.

View larger version (151K): [in a new window]   Figure 5.   Pulmonary M avium-intracellulare infection in a 58-year-old woman with a history of chronic cough and recent onset of shortness of breath and fatigue. Posteroanterior chest radiograph shows thin-walled cavities in the right upper lobe and a well-defined nodule in the left upper lobe (arrow). There are scattered heterogeneous and small nodular areas of increased opacity bilaterally.

View larger version (131K): [in a new window]   Figure 6a.   Pulmonary M avium-intracellulare infection in a 50-year-old man with a history of resected non-small cell lung cancer and recent onset of weight loss and hemoptysis. (a) Posteroanterior chest radiograph obtained 4 years before admission shows sutures (arrow) and scarring in the right upper lobe from partial pulmonary resection. (b) Posteroanterior chest radiograph obtained at admission shows progressive volume loss, more areas of increased opacity around the sutures, and adjacent pleural thickening. M avium-intracellulare was cultured from bronchial washings. No malignant cells were found, and the patient's condition improved with appropriate antimycobacterial therapy.

View larger version (142K): [in a new window]   Figure 6b.   Pulmonary M avium-intracellulare infection in a 50-year-old man with a history of resected non-small cell lung cancer and recent onset of weight loss and hemoptysis. (a) Posteroanterior chest radiograph obtained 4 years before admission shows sutures (arrow) and scarring in the right upper lobe from partial pulmonary resection. (b) Posteroanterior chest radiograph obtained at admission shows progressive volume loss, more areas of increased opacity around the sutures, and adjacent pleural thickening. M avium-intracellulare was cultured from bronchial washings. No malignant cells were found, and the patient's condition improved with appropriate antimycobacterial therapy.

View larger version (160K): [in a new window]   Figure 7a.   Pulmonary M avium-intracellulare infection in a 64-year-old man with a history of chronic weight loss, cough, and occasional hemoptysis. (a) Posteroanterior chest radiograph shows scattered nodular areas of increased opacity and volume loss in both upper lobes. Note the cavity in the right upper lobe with an air-fluid level and biapical pleural thickening. (b) Coronal 2-[fluorine-18]fluoro-2-deoxy-d-glucose (FDG) positron emission tomographic scan shows marked increased FDG uptake in the upper lobes and in the wall of the right upper lobe cavity. Although increased FDG uptake is usually indicative of malignancy, false-positive studies can occur with NTMB infection. C = normal cardiac activity, H = hepatic activity, M = mediastinal activity.

View larger version (156K): [in a new window]   Figure 7b.   Pulmonary M avium-intracellulare infection in a 64-year-old man with a history of chronic weight loss, cough, and occasional hemoptysis. (a) Posteroanterior chest radiograph shows scattered nodular areas of increased opacity and volume loss in both upper lobes. Note the cavity in the right upper lobe with an air-fluid level and biapical pleural thickening. (b) Coronal 2-[fluorine-18]fluoro-2-deoxy-d-glucose (FDG) positron emission tomographic scan shows marked increased FDG uptake in the upper lobes and in the wall of the right upper lobe cavity. Although increased FDG uptake is usually indicative of malignancy, false-positive studies can occur with NTMB infection. C = normal cardiac activity, H = hepatic activity, M = mediastinal activity.

View larger version (129K): [in a new window]   Figure 8a.   Pulmonary M avium-intracellulare infection in a 60-year-old asymptomatic woman. (a) Close-up posteroanterior chest radiograph of the right lung shows scattered, small, heterogeneous areas of increased opacity and a thin-walled cavity in the right upper lobe (arrowheads). (b) Close-up thin-section CT scan of the right lung shows the thin-walled cavity in the right upper lobe, as well as a communicating bronchus (arrowheads) and small centrilobular nodules (arrows).

View larger version (125K): [in a new window]   Figure 8b.   Pulmonary M avium-intracellulare infection in a 60-year-old asymptomatic woman. (a) Close-up posteroanterior chest radiograph of the right lung shows scattered, small, heterogeneous areas of increased opacity and a thin-walled cavity in the right upper lobe (arrowheads). (b) Close-up thin-section CT scan of the right lung shows the thin-walled cavity in the right upper lobe, as well as a communicating bronchus (arrowheads) and small centrilobular nodules (arrows).

View larger version (153K): [in a new window]   Figure 9a.   Pulmonary M kansasii infection in a 28-year-old woman with a history of surgically treated tricuspid atresia who presented with weight loss, fever, and a cough. (a) Posteroanterior chest radiograph shows heterogeneous areas of increased opacity in the right upper lobe. (b, c) CT scans show a large upper lobe cavity (b) and small, nodular, tree-in-bud areas of increased opacity (c) in the dependent portion of the right lung, which are due to endobronchial spread of infection.

View larger version (141K): [in a new window]   Figure 9b.   Pulmonary M kansasii infection in a 28-year-old woman with a history of surgically treated tricuspid atresia who presented with weight loss, fever, and a cough. (a) Posteroanterior chest radiograph shows heterogeneous areas of increased opacity in the right upper lobe. (b, c) CT scans show a large upper lobe cavity (b) and small, nodular, tree-in-bud areas of increased opacity (c) in the dependent portion of the right lung, which are due to endobronchial spread of infection.

View larger version (138K): [in a new window]   Figure 9c.   Pulmonary M kansasii infection in a 28-year-old woman with a history of surgically treated tricuspid atresia who presented with weight loss, fever, and a cough. (a) Posteroanterior chest radiograph shows heterogeneous areas of increased opacity in the right upper lobe. (b, c) CT scans show a large upper lobe cavity (b) and small, nodular, tree-in-bud areas of increased opacity (c) in the dependent portion of the right lung, which are due to endobronchial spread of infection.

View larger version (164K): [in a new window]   Figure 10a.   Chronic pulmonary M avium-intracellulare infection in a 51-year-old man treated with multiple antimycobacterial drugs, including ethambutol, pyrazinamide, isoniazid, rifampin, and clofazimine. (a) Posteroanterior chest radiograph shows heterogeneous areas of increased opacity and cavitation (arrowheads) in the right upper lobe. Small, poorly defined nodules in both lungs are suggestive of endobronchial spread of infection. (b) Posteroanterior chest radiograph obtained 4 years later shows volume loss and persistent cavitation (arrowheads) in the right upper lobe. Consolidation is now present in the left upper lobe. (c) Posteroanterior chest radiograph obtained 2 years later shows cavitation in both upper lobes (arrowheads); progressive volume loss in the right upper lobe with adjacent apical pleural thickening; and scattered, small, well-defined, nodular areas of increased opacity in regions of prior endobronchial infection.

View larger version (164K): [in a new window]   Figure 10b.   Chronic pulmonary M avium-intracellulare infection in a 51-year-old man treated with multiple antimycobacterial drugs, including ethambutol, pyrazinamide, isoniazid, rifampin, and clofazimine. (a) Posteroanterior chest radiograph shows heterogeneous areas of increased opacity and cavitation (arrowheads) in the right upper lobe. Small, poorly defined nodules in both lungs are suggestive of endobronchial spread of infection. (b) Posteroanterior chest radiograph obtained 4 years later shows volume loss and persistent cavitation (arrowheads) in the right upper lobe. Consolidation is now present in the left upper lobe. (c) Posteroanterior chest radiograph obtained 2 years later shows cavitation in both upper lobes (arrowheads); progressive volume loss in the right upper lobe with adjacent apical pleural thickening; and scattered, small, well-defined, nodular areas of increased opacity in regions of prior endobronchial infection.

View larger version (169K): [in a new window]   Figure 10c.   Chronic pulmonary M avium-intracellulare infection in a 51-year-old man treated with multiple antimycobacterial drugs, including ethambutol, pyrazinamide, isoniazid, rifampin, and clofazimine. (a) Posteroanterior chest radiograph shows heterogeneous areas of increased opacity and cavitation (arrowheads) in the right upper lobe. Small, poorly defined nodules in both lungs are suggestive of endobronchial spread of infection. (b) Posteroanterior chest radiograph obtained 4 years later shows volume loss and persistent cavitation (arrowheads) in the right upper lobe. Consolidation is now present in the left upper lobe. (c) Posteroanterior chest radiograph obtained 2 years later shows cavitation in both upper lobes (arrowheads); progressive volume loss in the right upper lobe with adjacent apical pleural thickening; and scattered, small, well-defined, nodular areas of increased opacity in regions of prior endobronchial infection.

View larger version (143K): [in a new window]   Figure 11a.   Pulmonary M avium-intracellulare infection in a 42-year-old woman with a chronic cough. Posteroanterior (a) and lateral (b) chest radiographs show poorly defined, heterogeneous areas of increased opacity with associated tubular lucencies representing bronchiectasis in the lingula and middle lobe and scattered nodular areas of increased opacity in the right upper lobe.

View larger version (136K): [in a new window]   Figure 11b.   Pulmonary M avium-intracellulare infection in a 42-year-old woman with a chronic cough. Posteroanterior (a) and lateral (b) chest radiographs show poorly defined, heterogeneous areas of increased opacity with associated tubular lucencies representing bronchiectasis in the lingula and middle lobe and scattered nodular areas of increased opacity in the right upper lobe.

View larger version (121K): [in a new window]   Figure 12a.   Pulmonary M avium-intracellulare infection in a 67-year-old woman. The infection was proved with resection of the lingula. Close-up CT scans of the right lung show mild cylindrical bronchiectasis (arrow) and small centrilobular nodules in the middle lobe (arrowhead in a).

View larger version (120K): [in a new window]   Figure 12b.   Pulmonary M avium-intracellulare infection in a 67-year-old woman. The infection was proved with resection of the lingula. Close-up CT scans of the right lung show mild cylindrical bronchiectasis (arrow) and small centrilobular nodules in the middle lobe (arrowhead in a).

View larger version (149K): [in a new window]   Figure 13a.   Pulmonary M avium-intracellulare infection in a 70-year-old white woman with a chronic cough, malaise, and weight loss. M avium-intracellulare was cultured from bronchial washings. Thin-section CT scans (1-mm collimation) show atelectasis and bronchiectasis bilaterally, more severe in the middle lobe and lingula. Note the small, peripheral, tree-in-bud areas of increased opacity (arrow in a) and the 1.5-cm-diameter nodule in the left lower lobe (arrow in b).

View larger version (144K): [in a new window]   Figure 13b.   Pulmonary M avium-intracellulare infection in a 70-year-old white woman with a chronic cough, malaise, and weight loss. M avium-intracellulare was cultured from bronchial washings. Thin-section CT scans (1-mm collimation) show atelectasis and bronchiectasis bilaterally, more severe in the middle lobe and lingula. Note the small, peripheral, tree-in-bud areas of increased opacity (arrow in a) and the 1.5-cm-diameter nodule in the left lower lobe (arrow in b).

View larger version (103K): [in a new window]   Figure 14.   Pulmonary M avium-intracellulare infection in a 42-year-old woman with a chronic cough. Sputum cultures were negative. M avium-intracellulare infection was diagnosed with transbronchial lung biopsy. Thin-section CT scan (1-mm collimation) shows cylindrical bronchiectasis, bronchial wall thickening, and tree-in-bud areas of increased opacity.

View larger version (142K): [in a new window]   Figure 15.   Pulmonary M chelonae infection in a 45-year-old asymptomatic woman. Close-up posteroanterior chest radiograph of the right lower lobe shows a well-defined, noncalcified, 1-cm-diameter nodule (arrow). M chelonae infection was diagnosed at resection.

View larger version (0K): [in a new window]   Figure 16a.   Permission to reprint this figure electronically was denied by the publisher. See print version.

View larger version (0K): [in a new window]   Figure 16b.   Permission to reprint this figure electronically was denied by the publisher. See print version.

View larger version (142K): [in a new window]   Figure 17a.   Disseminated M avium-intracellulare infection in a 33-year-old woman with AIDS and a CD4+ cell count of 55/mm3 (55 x 106/L) who presented with weight loss and diarrhea. (a) Posteroanterior chest radiograph shows paratracheal and aortopulmonary window adenopathy (arrows). The lungs are normal. (b) Chest CT scan also shows mediastinal adenopathy (arrows). The lung parenchyma is normal. A = transverse aorta, * = superior vena cava.

View larger version (110K): [in a new window]   Figure 17b.   Disseminated M avium-intracellulare infection in a 33-year-old woman with AIDS and a CD4+ cell count of 55/mm3 (55 x 106/L) who presented with weight loss and diarrhea. (a) Posteroanterior chest radiograph shows paratracheal and aortopulmonary window adenopathy (arrows). The lungs are normal. (b) Chest CT scan also shows mediastinal adenopathy (arrows). The lung parenchyma is normal. A = transverse aorta, * = superior vena cava.

View larger version (161K): [in a new window]   Figure 18.   Pulmonary M kansasii infection in a 29-year-old cachectic man with AIDS who presented with dyspnea and a nonproductive cough. Posteroanterior chest radiograph shows paratracheal adenopathy and poorly defined scattered areas of increased opacity with a more focal, nodular area of increased opacity in the left upper lobe (arrow).

View larger version (101K): [in a new window]   Figure 19.   Disseminated M avium-intracellulare infection in a 35-year-old man with AIDS who presented with a cough and fever. The CD4+ cell count was 10/mm3 (10 x 106/L). Sputum cultures were negative. M avium-intracellulare infection was diagnosed with bronchoscopy and transbronchial biopsy. Posteroanterior chest radiograph shows masslike areas of increased opacity and smaller, scattered, nodular areas of increased opacity in the upper lobes. There is no hilar or mediastinal adenopathy.

View larger version (118K): [in a new window]   Figure 20a.   Pulmonary M avium-intracellulare infection in a 29-year-old man with AIDS. (a) Close-up posteroanterior chest radiograph of the upper right lung shows a mass in the apex of the lung (arrows) without hilar or paratracheal adenopathy. (b) CT scan shows a heterogeneous soft-tissue mass (M) in the right upper lobe abutting the mediastinum and chest wall. Biopsy revealed granulomatous inflammation, and a culture was positive for M avium-intracellulare.

View larger version (145K): [in a new window]   Figure 20b.   Pulmonary M avium-intracellulare infection in a 29-year-old man with AIDS. (a) Close-up posteroanterior chest radiograph of the upper right lung shows a mass in the apex of the lung (arrows) without hilar or paratracheal adenopathy. (b) CT scan shows a heterogeneous soft-tissue mass (M) in the right upper lobe abutting the mediastinum and chest wall. Biopsy revealed granulomatous inflammation, and a culture was positive for M avium-intracellulare.

View larger version (144K): [in a new window]   Figure 21a.   Disseminated M avium-intracellulare infection in a 33-year-old man with AIDS who presented with weight loss, pyrexia, and back pain. (a) Posteroanterior chest radiograph shows diffuse small nodules with basal predominance. There is no hilar or mediastinal adenopathy. (b) Chest CT scan also shows small, discrete nodules. Transbronchial biopsy was positive for M avium-intracellulare. (c) CT scan of the abdomen shows a right psoas abscess (arrow). Needle aspiration was positive for M avium-intracellulare.

View larger version (105K): [in a new window]   Figure 21b.   Disseminated M avium-intracellulare infection in a 33-year-old man with AIDS who presented with weight loss, pyrexia, and back pain. (a) Posteroanterior chest radiograph shows diffuse small nodules with basal predominance. There is no hilar or mediastinal adenopathy. (b) Chest CT scan also shows small, discrete nodules. Transbronchial biopsy was positive for M avium-intracellulare. (c) CT scan of the abdomen shows a right psoas abscess (arrow). Needle aspiration was positive for M avium-intracellulare.

View larger version (145K): [in a new window]   Figure 21c.   Disseminated M avium-intracellulare infection in a 33-year-old man with AIDS who presented with weight loss, pyrexia, and back pain. (a) Posteroanterior chest radiograph shows diffuse small nodules with basal predominance. There is no hilar or mediastinal adenopathy. (b) Chest CT scan also shows small, discrete nodules. Transbronchial biopsy was positive for M avium-intracellulare. (c) CT scan of the abdomen shows a right psoas abscess (arrow). Needle aspiration was positive for M avium-intracellulare.