PULMONARY

TUBERCULOSIS
Dr Prakash Sapkale
• Caused by infection with
“Mycobacterium Tuberculosis.”
• Accounts for 95 % of pulmonary mycobacterial infections.
Other mycobacteria- M.Avium-intracellulare complex,
M.kansasii.
 Predisposing factors
• Pregnancy
• Diabetes Mellitus
• Alcoholism
• Silicosis
• Malignancy
• Immune compromise – including HIV
infection
• Socio-economic factors- inner city
poverty, homelessness, immigration
trends
• Occupation- Nurses, vagrants, people in
closed institutions.
Two forms-

1)Primary Tuberculosis-
in previously unexposed individuals
especially in infants and children
hypersensitivity to tuberculoprotein is absent

2)Post-primary tuberculosis
(secondary,reactivation,reinfection,adult tuberculosis.)
In a patient who already possesses hypersensitivity to
tuberculoprotein.

# Progressive primary tuberculosis-

When the primary disease passes directly into the post-
primary form without a break.
 PRIMARY TUBERCULOSIS

• Clinical Features-

• Primary tuberculosis develops about 1-2

months after the exposure.
• Mainly infants and children.
• Usually occult.
• Occasionally it may result in a transient self
limited illness (pyrexia and erythema
nodosum)
• Very occasionally a clinically significant
illness in infants and children.
 PRIMARY TUBERCULOSIS
• Pathology-

• Small area of peripheral consolidation-

Ghon focus.
• Lymph node involvement and
complications due to lymphadenopathy due
to compression of adjacent airways, vessels,
and serosal membranes.
• Pleural effusion may be the only feature
• Healing is by fibrosis; with or without
calcification
• Tuberculoma -repeated episodes of arrest
 PRIMARY TUBERCULOSIS
Radiological findings-

• Radiographic patterns are related to

the competence or maturity of the
immune response and not to the
timing.
• 5 to 15% patients may have normal
chest films.
 PRIMARY TUBERCULOSIS
• Radiological findings-

3)Consolidation:
• Can occur in any lobe
• Ghon focus- small area of peripheral
consolidation.
• Homogenous consolidation which mimics
community acquired pneumonias
• Suspect tuberculosis if a consolidation is
indolent or associated with nodal
enlargement
• Multifocal involvement and cavitation rare
• Cavitation suggests progressive primary
 PRIMARY TUBERCULOSIS
• Radiological findings-

2) Lymphadenopathy:
• Most common manifestation of primary tuberculosis
• Sometimes may be obscured by a large consolidation
• Can occur -
With consolidation-nodes draining the consolidated area are
enlarged.
Without consolidation-
-unilateral hilar, unilateral hilar plus paratracheal
adenopathy, isolated paratracheal adenopathy
-mediastinal adenopathy
-bilateral hilar adenopathy is uncommon, when present , is
almost always asymmetrical

Features of complications due to lymphadenopathy may be

seen.
 PRIMARY TUBERCULOSIS
• Radiological findings-

• Features of complications due to

lymphadenopathy(pressure/erosion)-
d) Airways-
• Obstructive overinflation
• Segmental or lobar collapse-commonly anterior segment of
upper lobe and the middle lobe
• Segmental consolidation -bronchial perforation and aspiration of
caseous material in distal segment/hypersensitivity phenomenon.
• Bronchial perforation-
-scattered heterogeneous consolidation similar to
bronchopneumonia;
-It consists of acinar nodules, ipsilateral or contralateral
lung involved, segmental distribution
• Healing of bronchial or segmental lesions- bronchostenosis,
bronchiectasis, parenchymal fibrosis, volume loss, bulla
formation
 PRIMARY TUBERCULOSIS
• Radiological findings-

• Features of complications due to lymphadenopathy -

b)Blood vessels-
• Isolated lesion- e.g. soft tissue abscess
• Generalized- miliary tuberculosis
• May remain dormant for years to present later as bone,joint or
renal tuberculosis

c) Pericardium –
• Pericarditis(erosion by node; can also occur in miliary tuberculosis.
• Constrictive pericarditis and pericardial calcification- late sequelae

d) Pleura –pleural effusion

e) Others- esophageal involvement, phrenic and recurrent laryngeal

nerve paresis, SVC obstruction, fistula formation.
 PRIMARY TUBERCULOSIS
• Radiological findings-

3) Pleural effusion-
Usually unilateral except in miliary TB
• Seen in children, teenagers and young adults
• In teenagers and young adults large effusion-slow and painless
accumulation
• Pleural thickening or calcification uncommon –associated with
empyema

4)Miliary tuberculosis:
• Seen in both primary and secondary tuberculosis
• Multiple small (1-2 mm ) discrete nodules of soft tissue density,
scattered throughout both lungs. Characteristically very well
defined.
• Clear with therapy,slowly often over months,no residual
changes,no calcification.

5) Tuberculoma (described later)

 PRIMARY TUBERCULOSIS
• Radiological findings-

6)Inactive primary tuberculosis:

-Normal chest radiograph with positive
montoux reaction
-A well defined rounded or
irregular(linear) opacity with or without
calcification – Ghon focus
-Ghon focus with ipsilateral lymph node
calcification- Ranke complex.
 POST-PRIMARY
TUBERCULOSIS
• In contrast to primary tuberculosis,
lymphadenopathy is notably absent in
patients with postprimary tuberculosis, with
the exception of patients with HIV/AIDS
infection.
• Characterized by strong site preference,
chronicity, cavity formation and fibrosis
• Usually initial lesion in apicoposterior
segment of an upper lobe or the superior
segment of a lower lobe.
• The lesion consists of coarse nodular and
linear opacities
• Changes may be unilateral or bilatral
• Volume loss seen later when fibrosis occurs
 POST-PRIMARY
TUBERCULOSIS
Clinical Features-

• The findings of reactivation tuberculosis typically

become radiographically apparent within 2 years of
the initial infection or many years later, often as a
result of comorbid states: old age, malnutrition, and/or
neoplasm.
• lethargy,
• anorexia,
• weight loss,
• low-grade fever,
• cough,
• hoarseness,
• hemoptysis
 POST-PRIMARY
TUBERCULOSIS
• Radiological findings-

3)Cavitation-
-40-80% cases
-Common in apicoposterior segment of an upper lobe
or the superior segment of a lower lobe
-single or multiple, large or small, varying thickness of
wall from hairline to few millimeters
-smooth walled
-sometimes air fluid levels may be seen
-Rasmussen aneurysm- granulomatous weakening
of the pulmonary vessel wall.A life threatening
complication-hemoptysis
 POST-PRIMARY
TUBERCULOSIS
• Radiological findings-

2) Healing-
-healing occurs by fibrosis-scar formation
-cavities usually obliterated but may remain as
thin walled rings
-well defined upper lobe nodular and linear
opacities
-severe volume loss
-pleural thickening
-calcification less common han with primary
tuberculosis
-bronchiectasis
-cysts and bullae
 POST-PRIMARY
TUBERCULOSIS
• Radiological findings-

3) Endobronchial spread:
-with or without cavitation,
- ipsi- or contralateral
-segmental distribution
-results in bronchopneumonic consolidation-
nodular,with acinar lesions that may become
confluent

4) Endobronchial infection:
-tuberculous bronchitis
-may result in bronchostenosis, bronchiectasis
 POST-PRIMARY
TUBERCULOSIS
• Radiological findings-

5)Pleural effusion:
-usually an empyema
-results in pleural thickening and
calcification.
-occasionally directly involves the chest wall

6)Miliary tuberculosis:
-Cryptic,typically presenting in old men as
pyrexia of unknown origin with nonspecific
symptoms
-usually no evidence of known primary
 POST-PRIMARY
TUBERCULOSIS
• Radiological findings-

7)Tuberculoma:
-Localized parenchymal disease that alternately
activates and heals
-frequently remains stable for years but can anytime
reactivate and disseminate
-a nodule 10-15 mm size
-most common in right upper lobe but can be situated
in any lobe
-usually single, can be multiple, when multiple all may
be confined to single segment
-satellite lesions can be seen nearby
-calcification may occur
 POST-PRIMARY
TUBERCULOSIS
• Radiological findings-

8)Mycetma formation:
-colonization by fungus , usually Aspergillus
Fumigatus
-usually in cavities more than 25 mm in
diameter
-CT is more sensitive

9)Chest wall involvement:

-haematogenous seeding or direct spread
-usually associated with drug abuse
-can affect soft tissue, rib or costal cartilage
 PROGRESSIVE PRIMARY
TUBERCULOSIS
• Progressive primary tuberculosis
occurs in the setting of acute
infection in patients with minimal or
marked immune compromise.
Patients with progressive primary
tuberculosis become acutely ill, and
they may have extensive lung
parenchymal opacities and
cavitation. Hypoxia and death may
occur.
 Diagnostic approach

• Diagnosis is based on a combination of

tuberculin skin testing ,sputum examination,
and radiography. Bronchoscopy may be
required to obtain specimens.

• Chest Radiograph-
-cost efective
-less sensitive-may not show any findings in 5-
15% cases.
 Diagnostic approach
• CT scan-

-more sensitive but costly.Used especially in progressive primary or

postprimary tuberculosis
-helps confirm the presence of an ill-defined parenchymal infiltrate
-CT is the examination of choice for evaluating lymphadenopathy and
involvement of the tracheobronchial tree.
-Broncholiths may be identified in rare cases.
-Associated mediastinitis and even mediastinal abscesses
-Small pleural effusions are detected more readily on CT scans . Contrast
enhancement may be useful in identifying evolution into an empyema.
-Cavitation and mycetoma formation
-Tuberculomas
-The bronchogenic spread of tuberculosis
-Miliary tuberculosis
-Bronchial stenosis
-Bronchiectasis
-Empyema is visualized on contrast-enhanced CT scans with enhancement of
the parietal and visceral pleurae.
-Involvement of the pericardium and spine
 Diagnostic approach
• MRI-may be used to evaluate complications
of thoracic disease.

• USG-pleural effusion,soft tissue

involvement

• PET in tuberculosis –
-on pet tuberculosis may be
indistinguishable from malignancy
-can be used to assess response to therapy,
to distinguish active from inactive lesion
-costly, not widely available.
 ACTIVITY AND RESPONSE TO
THERAPY
• Active lesion-
-ill defined coalesced nodules.
-poorly marginated linear opacities
-thick walled cavity surrounded by consolidation.
• Inactive lesion-
-well defined small nodular and linear shadows
-calcification
• Compare with previous radiograph

• However exceptions exist, and many patients show

intermediate pattern and even inactive lesions can undergo
reactivation

• Response to therapy is suggested by

-resolution of abnormal opacities, a decrease in cavity size,
volume loss by fibrosis
END