Pulmonary Manifestations of Tuberculosis

5/8/13 Pulmonary manifestations of tuberculosis | Radiology Reference Article | Radiopaedia.
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Pulmonary manifestations of tuberculosis

Dr Yuranga Weerakkody and Dr Frank Gaillard et al. view revision history
The lungs are the most common site of primary infection by tuberculosis and are a major source of spread of the disease
and of individual morbidity and mortality.
general discussion of tuberculosis is found in the parent article: tuberculosis

discussion of other mycobacterial infections of the lungs is found here: pulmonary Mycobacterium avium complex
(MAC) infections
Clinical presentation
The primary infection is usually asymptomatic (majority of cases), although a small number go on to have symptomatic
haematological dissemination which may result in miliary tuberculosis. Only in 5% of patients, usually those with impaired
immunity, go on to have progressive primary tuberculosis.
Patients with post-primary pulmonary tuberculosis are often asymptomatic or have only minor symptoms, such as a
chronic dry cough. In symptomatic patients constitutional symptoms are prominent with fever, malaise and weight-loss.
Productive cough which is often blood stained may also be present 1.
Occasionally patients may present with massive haemoptysis due to erosion of a bronchial artery 1,3.
Clinical presentation in AIDS patients
Patients with AIDS demonstrate altered patterns of infection depending on their CD4 count. When CD4 count drops to
below 350 cells/mm3 pulmonary manifestations appear similar to run-of-the-mill post-primary infections (see below).
When CD4 counts drop below 200 cells/mm3 then the pattern of infection is more likely to resemble primary infection
or miliary tuberculosis 4. Nodal enlargement is also common at this stage.
Distribution
The location of infection within the lung varies with both the stage of infection and age of the patient.
radiopaedia.org/articles/pulmonary-manifestations-of-tuberculosis 1/12
5/8/13 Pulmonary manifestations of tuberculosis | Radiology Reference Article | Radiopaedia.org
primary infection can be anywhere in the lung in children, whereas there is a predilection for the upper or lower
zone in adults 1
post-primary infections have a strong predilection for the upper zones
miliary tuberculosis is evenly distributed throughout both lungs
Radiographic features
Radiographic features depend on the type of infection, and are discusses separately.
Primary tuberculosis
The initial focus of infection can be located anywhere within the lung and has non-specific appearances ranging from too
small to be detectable, to patchy areas or consolidation or even lobar consolidation. Radiographic evidence of
parenchymal infection is seen in 70% of children, and 90% of adults 1. Cavitation is uncommon in primary TB, seen only
in 10-30% of cases 2. In most cases the infection becomes localised and a caseating granuloma forms (tuberculoma)
which usually eventually calcifies, and is then known as a Ghon lesion 1-2.
The more striking finding, especially in children, is that of ipsilateral hilar and contiguous mediastinal (paratracheal)
lymphadenopathy, usually right sided 3. This pattern is seen in over 90% of cases of childhood primary TB, but only 10-
30% of adults 1. These nodes typically have low density centres with rim enhancement on CT 1-3. Occasionally these
nodes may be large enough to compress adjacent airways resulting in distal atelectasis 1.
Pleural effusions are more frequent in adults, seen in 30-40% of cases, whereas they are only present in 5-10% of
paediatric cases 1.
As the host mounts an appropriate immune response both the pulmonary and nodal disease resolves. Calcification of
nodes is seen in 35% of cases 2. When a calcified node and a Ghon lesion are present, the combination is known as a
Ranke complex.
Post-primary pulmonary tuberculosis
Post-primary TB, also known as reactivation TB or secondary TB occurs years later, frequently in the setting of a
decreased immune status. In the majority of cases, post-primary TB within the lungs develops in either 1-2:
1. posterior segments of the upper lobes

2. superior segments of the lower lobes
Typical appearance of post primary TB is that of patchy consolidation or poorly defined linear and nodular opacities 1.
Post-primary infections are far more likely to cavitate than primary infections, and are seen in 20-45 % of cases. In the
vast majority of cases they develop in the posterior segments of the upper lobes (85%)1. The development of an air-
fluid level implies communication with the airway, and thus the possibility of contagion. Endobronchial spread along
nearby airways is a relatively common finding, resulting in a relatively well-defined 2-4 mm nodules or branching
lesions tree-in-bud appearance on CT 1,3.
Hilar nodal enlargement is seen in only approximately a third of cases 1. Lobar consolidation, tuberculoma formation and
miliary TB are also recognised patterns of post-primary TB but are less common.
Tuberculomas account for only 5% of cases of post-primary TB and appear as a well defined rounded mass typically
located in the upper lobes. They are usually single (80%) and can measure up to 4 cm in size. Small satellite lesions are
seen in most cases 1. In 20-30% of cases superimposed cavitation may develop.
Miliary pulmonary tuberculosis
Miliary tuberculosis is uncommon but carries a poor prognosis. It represents haematogeneous dissemination of an
uncontrolled tuberculous infection. It is seen both in primary and post-primary tuberculosis. Although implants are seen
throughout the body, the lungs are usually the easiest location to image.
Miliary deposits appear as 1-3 mm diameter nodules, which are uniform in size and uniformly distributed 1-2. If
treatment is successful no residual abnormality remains.
Tracheal and bronchial involvement
Isolated tracheal infection by tuberculosis is rare, but reported and typically results in irregular circumferential mural
thickening. It is usually the result of contiguous inflammation from adjacent nodal involvement 3.
Broncholith
A relatively uncommon presentation is due to erosion of a calcified lymph node into a bronchus, resulting in calcified
material entering the lumen. Rarely this material can be coughed-up (known as lithoptysis) 2.
Treatment and prognosis
Treatment is usually only in the setting of progressive primary tuberculosis, miliary tuberculosis or post primary infection,
and in general primary infections are asymptomatic. For a general discussion please refer to the parent article:
tuberculosis.
Administration of protracted courses of multiple antibiotics tailored to the sensitivity of the infective strain is the
cornerstone of treatment.
Any patient with tuberculosis should be considered infective until sputum assessment is preformed, and patients should
be placed in respiratory isolation. In many countries it is a reportable disease, and contact tracing will be performed.
Additional targeted therapies may be necessary in the setting of empyema, mediastinal complications or haemoptysis.
Complications
Recognised complications include:
colonisation of cavities by fungus:, e.g. aspergilloma

bronchiectasis
arterial pseudoaneurysms
bronchial artery pseudoaneurysm
pulmonary artery psueduoaneurysm - Rasmussen aneurysm
empyema
fibrothorax
bronchopleural fistula
Differential diagnosis
The differential is dependent of the type of infection.
differential of miliary pulmonary opacities

differential of alveolar pulmonary consolidation
differential of a pulmonary cavity
References
Synonyms & Alternative Spellings
Article Information:
System: Chest
Tags: tb, lungs
Gross pathology - cavitating pulmonary tuberculosis

Drag here to reorder.
Case 1 - miliary tuberculosis

Gross pathology - miliary tuberculosis

Case 2 - with advanced cavitation

Case 3
Case 4 - primary progressive pulmonary tuberculosis

Case 5
Case 6

Case 8
Case 9
Case 10 - with calcified granulomata


Case 12
Case 13
Case 14
Case 15 - post primary tuberculosis


Case 17 - with tree in bud changes

Case 18 : Post-primary pulmonary tuberculosis

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general discussion of tuberculosis is found in the parent article: tuberculosis

Clinical presentation in AIDS patients

Post-primary pulmonary tuberculosis

1. posterior segments of the upper lobes

Tracheal and bronchial involvement

Treatment and prognosis

Recognised complications include:

colonisation of cavities by fungus:, e.g. aspergilloma

The differential is dependent of the type of infection.

differential of miliary pulmonary opacities

Gross pathology - cavitating pulmonary tuberculosis

Case 1 - miliary tuberculosis

Drag here to reorder.

Gross pathology - miliary tuberculosis

Case 2 - with advanced cavitation

Case 4 - primary progressive pulmonary tuberculosis

Case 7 - miliary tuberculosis

Case 10 - with calcified granulomata

Case 11 - miliary tuberculosis

Case 15 - post primary tuberculosis

Case 16 - miliary tuberculosis

Case 17 - with tree in bud changes

Case 18 : Post-primary pulmonary tuberculosis

Peripheral Nervous System

20052013 Radiopaedia.org Designed and developed by TrikeApps

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