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Tuberculosis (pulmonary manifestations)

Sumber: https://radiopaedia.org/articles/tuberculosis-pulmonary-manifestations-1

A.Prof Frank Gaillard et al.

Pulmonary manifestations of tuberculosis are varied and depend in part whether the infection
is primary or post-primary. 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.

A general discussion of tuberculosis is found in the parent article: tuberculosis; and a 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. A 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:

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 discussed separately.

Primary pulmonary tuberculosis

In primary pulmonary 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 of 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 pulmonary tuberculosis, also known as reactivation tuberculosis or secondary

tuberculosis 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%)1,7. 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 sign) 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 haematogenous

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 the image.

Miliary deposits appear as 1-3 mm diameter nodules, which are uniform in size and uniformly
distributed 1-2. If the 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 a contiguous inflammation from
adjacent nodal involvement 3.

Broncholith

A broncholith is a relatively uncommon presentation which 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
performed, 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

o bronchial artery pseudoaneurysm

o pulmonary artery pseudoaneurysm/Rasmussen aneurysm

empyema

fibrothorax

bronchopleural fistula

Differential diagnosis

The imaging differential is dependent on the type and pattern of infection; consider:

differential of miliary pulmonary opacities

differential of alveolar pulmonary consolidation

differential of a pulmonary cavity

Related articles

Tuberculosis

tuberculosis

o causative agent[+]

o tuberculoma (tuberculous granuloma)

o tuberculous abscess

o miliary tuberculosis

o pulmonary tuberculosis

primary pulmonary tuberculosis

Ghon focus

Ranke complex

post-primary pulmonary tuberculosis

o extrapulmonary tuberculosis[+]

References
Article Information
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Cases and Figures

Figure 1: gross pathology - cavitating pulmonary tuberculosis

Case 1: miliary tuberculosis

Figure 2: gross pathology - miliary tuberculosis

Case 2: with advanced cavitation

Case 3

Case 4: primary progressive pulmonary tuberculosis

Case 5

Case 6

Case 7: miliary tuberculosis


Case 8

Case 9

Case 10: with calcified granulomata

Case 11: miliary tuberculosis


Case 12

Case 13

Case 14

Case 15: post primary tuberculosis

Case 16: miliary tuberculosis

Case 17: with tree in bud changes

Case 18: post-primary pulmonary tuberculosis

Case 19

Case 20

Case 21

Case 22

Case 23: chronic

Case 24: tuberculous empyema


Case 25

Case 26

Case 27

Case 28

Case 29

Case 30: post primary pulmonary tuberculosis

Case 31: post primary TB PET/CT

Case 32

Imaging Differential Diagnosis


Upper zone changes in ankylosing spondylitis