JOURNAL READING

Comparison of Chest X-Ray Findings of Smear Positive and Smear Negative Patients
with Pulmonary Tuberculosis

Pembimbing :

dr. Markus B. Rahardjo, Sp.Rad (K)

Disusun oleh:
Faraida Jilzani

1410221045

Kiki Sri Rejeki A

1410221041

SMF RADIOLOGI
FAKULTAS KEDOKTERAN UPN VETERAN JAKARTA
RSUD PROF. DR. MARGONO SOEKARJO
PURWOKERTO
2015

LEMBAR PENGESAHAN
JOURNAL READING

Comparison of Chest X-Ray Findings of Smear Positive and Smear Negative Patients
with Pulmonary Tuberculosis

Disusun oleh :
Faraida Jilzani

1410221045

Kiki Sri Rejeki A

1410221041

Referat ini telah dipresentasikan dan disahkan sebagai salah satu persyaratan mengikuti ujian
kepaniteraan klinik di bagian radiologi RSUD Prof. Dr. Margono Soekarjo

Purwokerto, Januari 2015

Mengetahui,
Pembimbing

dr. Markus B. Raharjo, Sp.Rad (K)

Comparison of Chest X-Ray Findings of Smear Positive and Smear Negative Patients
with Pulmonary Tuberculosis

Abstrak
a. Latar belakang
Tuberkulosis merupakan penyakit infeksi kronis paru yang telah menyerah sepertiga
penduduk di dunia. Setiap tahunnya timbul sembilan juta kasus tuberkulosis baru dan
menyebabkan dua juta kematian per tahun. Pemeriksaan radiografi toraks dan
pewarnaan basil tahan asam Ziehl-Neelsen secara signifikan membantu diagnosis
tuberkulosis paru. Radiografi toraks dapat membantu diagnosis tuberkulosis pada
pasien dengan hasil pewarnaan negatif yang pada umumnya sering terlambat
didiagnosis.
b. Objek penelitian
Pada penelitian ini, hasil temuan radiografi toraks dibandingkan pada dua grup yaitu
grup pewarnaan negatif dan pewarnaan positif.
c. Pasien dan metode
Pada studi deskriptif-analitik retrospektif ini, 376 pasien yang telah dikonfirmasi
menderita tuberkulosis paru diteliti oleh Birjand Health Care Center sejak tahun 2001
hingga 2006. Dari 376 pasien, dipilih 100 pasien berdasarkan kriteria WHO dengan
hasil pewarnaan positif. Sebagai tambahan, dari pasien dengan hasil pewarnaan
negatif dipilih 100 pasien yang memiliki karakteristik demografi mirip dengan pasien
pewarnaan positif. Seluruhnya telah dilakukan pemeriksaan radiografi toraks yang
diinterpretasikan oleh dua orang spesialis radiologi secara independen. Disamping itu,
semua pasien juga dilakukan pemeriksaan laboratorium sputum. Data yang terkumpul
kemudian dianalisis berdasarkan tabel distribusi frekuensi rata-rata dan statistik
deskriptif menggunakan SPSS (versi 15) dan uji statistik chi square.
d. Hasil
Selain gambaran infiltrat retikulo-nodular, ditemukan frekuensi relatif gambaran lain
pada radiografi toraks pasien pewarnaan positif ternyata lebih banyak daripada pasien
dengan pewarnaan negatif. Hanya ditemukan perbedaan pada variabel kalsifikasi,
pelebaran mediastinum, infiltrat berbentuk patch, dan adenopati hilus yang bermakna
secara statistik (P<0,05)
e. Kesimpulan
Berdasarkan hasil studi ini, walaupun pemeriksaan radiografi bukan merupakan suatu
modalitas diagnostik pada tuberkulosis paru, namun pemeriksaan ini dapat
membenatu dalam diagnosis bersama-sama dengan pewarnaan sputum dan gejala
klinis.
Latar Belakang
Tuberkulosis adalah infeksi paru kronik yang disebabkan oleh bakteri
Mycobacterium. Penyakit ini menyebabkan lebih dari 30% dari seluruh angka kematian pada
abad ke 19 dan abad ke 20 dan baru-baru ini menginfeksi sepertiga penduduk dunia. Setiap
tahunnya timbul sembilan juta kasus baru dan dua juta kematian. Tuberkulosis adalah agen

infeksi kedua paling fatal di dunia kedua setelah AIDS. 80% dari seluruh pasien tuberkulosis
bertempat tinggal di 22 negara terutama negara berkembang. Telah diiperkirakan lebih dari
satu miliar orang yang terinfeksi tuberkulosis pada tahun 2020 dan jumlah pasien akan
mencapai 200 juta. Selain itu, satu juta kematian akan terjadi akibat tuberkulosis. Saat ini, 30
juta orang telah terinfeksi tuberkulosis dan diperkirakan hampir 300 juta orang telah
terkontaminasi dan sekitar 90 juta orang akan terjangkit tuberkulosis dalam 10 tahun
berikutnya.
Prevalensi tuberkulosis menurun sampai 5% hingga tahun 1995 namun lima tahun
berikutnya prevalensi ini meningkat mencapai 15,8%. Saat ini tuberkulosis yang berkaitan
dengan AIDS merupakan masalah kesehatan masyarakat yang paling penting di Asia, Afrika,
dan Amerika latin. Sejak itu, penyakit ini disebut sebagai kegawatdaruratan oleh WHO pada
tahun 1993.
Metode terbaik dan paling definitif dalam mendiagnosis tuberkulosis paru adalah
pulasan sputum dan pewarnaan Ziehl-Neelsen dengan beberapa uji berturut-turut. Dalam
beberapa dekade terakhir, terkait adanya perbedaan dan peningkatan jumlah teknik diagnosis,
tuberkulosis paru dengan pulasan positif meningkat. walaupun tuberkulosis negatif telah
berkurang secara signifikan, sejumlah besar kasus masih berada pada grup ini. Sebagai
contoh di Iran, tuberkulosis dengan pulasan positif meningkat dari 3980 menjadi 5430 kasus
dari tahun 1992 sampai 1996 (7 per 100.000 banding 8,9 per 100.000) dan tuberkulosis
pulasan negatif berkurang dari 13182 kasus menjadi 6081 kasus (2,31 per 100.000 banding
10 per 100.000).
Dalam studi yang dilakukan di Iran pada 1996, 11,25 per 100.000 tuberkulosis
pulasan positif dan 6,62 per 100.000 pulasan negatif dan 2,72 per 100.000 tuberkulosis
ekstrapulmoner ditemukan di Birjand, Khroasan selatan, yang berada pada posisi ketiga
setelah Systan-baluchestan dan Provinsi Golestan. Sejak ditemukan masing-masing
tuberkulosis pulasan negatif dapat mengkontaminasi dua orang setiap tahunnya, diagnosis
tuberkulosis secara cepat menjadi sama pentingnya dengan tuberkulosis pulasan positif. Pada
tuberkulosis pulasan negatif bahkan pulasan positif , perubahan radiologis dari foto toraks
sangat membantu dalam menentukan diagnosis. Walaupun beberapa temuan gambaran
radiografi toraks, termasuk infiltrat bentuk noduler atau bercak (patchy) pada pars posterior
lobus superior atau pada segmen anterior lobus inferior khususnya pada keterlibatan segmen
bilateral paru dan terkait dengan kavitas, bukan merupakan temuan spesifik untuk pada
tuberkulosis paru.manifestasi klinik dan penemuan epidemiologis lebih merupakan suatu
penentu diagnostik. Secara umum, temuan radiografi toraks pada pasien tuberkulosis paru
sekunder adalah sebagai berikut; bronkiektasis, konsolidasi, bercak, kavitas, dan TB miliar.

Objektif

Penelitian ini dilakukan untuk membandingkan temuan radiografi toraks yang terlihat
pada pasien tuberkulosis dengan pulasan positif dan pasien tuberkulosis dengan pulasan
negatif
Subjek penelitian dan metode
Pada penelitian deskriptif analitik retrospektif, sebanyak 376 pasien yang telah
dikonfirmasi tuberkulosis paru berada di rumah sakit Birjand health care center dari tahun
2001 sampai 2006. Selain dari 376 pasien tersebut, sebanyak 100 pasien dengan BTA positif
ditentukan berdasarkan kriteria who. Selain itu, diantara pasien dengan BTA negatif, 100
pasien dipilih sebagai grup kontrol, dimana pasien-pasien ini memiliki kemiripan
karakteristik demografi dengan pasien BTA positif.
Berdasarkan kriteria who, BTA positif didefinisikan dengan minimal 2 hasil tes
sputum yang positif atau 1 BTA positif yang disertai dengan salah satu kultur sputum positif
atau gambaran radiografi yang sesuai dengan tb paru. Negatif smear PTB adalah
dikonfirmasi perubahan radiografi ketika positif yang kompatibel untuk PTB telah terdeteksi
dan terlepas dari 10-14 terapi antibiotik spektrum yang luas hari, tidak ada perubahan dalam
keadaan umum pasien tercatat dari siapa dua negatif BTA seri diambil dengan setidaknya dua
minggu interval dan di setiap sesi, tiga sampel diperiksa dan semua sampel negatif untuk
asam bacillus cepat. Selain itu, BTA negatif PTB didefinisikan ketika seorang pasien yang
sakit parah dengan perubahan radiografi di mendukung lesi PTB (keterlibatan jaringan
interstitial atau milier TB) menunjukkan dua sampel negatif untuk bacillus cepat asam.
Dokter kemudian memutuskan untuk memulai pengobatan anti-TB pada pasien dengan BTA
negatif awalnya dan dahak yang positif. Semua dari para pasien menjalani radiographies
dada yang kemudian ditafsirkan oleh dua ahli radiologi ahli independen. Selain itu, dahak
semua pasien 'diperiksa oleh seorang teknisi laboratorium ahli di referensi laboratorium dari
pusat kesehatan. Data yang diperoleh adalah dianalisis dengan cara dari tabel distribusi
frekuensi dan statistik deskriptif menggunakan SPSS versi 15 for Windows (SPSS Inc,
Chicago, Ill, USA) dan uji Chi-square digunakan untuk analisis statistik. P-nilai-nilai kurang
dari 0,05 dianggap signifikan secara statistik.
Hasil
Dari 200 pasien yang diteliti, kebanyakan merupakan penduduk Iran (97%), 63,5%
adalah wanita dan 59% kasus terdapat di daerah urban. Distribusi umur yaitu 15,5%, 45%,
dan 39,5% dengan kelompok umur 1-13 tahun, 14-55 tahun, dan >55 tahun. Usia rata-rata
pada pasien wanita adalah 50,88 22,22 tahun dan pada pasien pria adalah 49,11 22,82
tahun (P=0,57), 48,31 22,41 tahun pada pasien dengan pulasan positif dan 51,66 21,52
tahun pada pasien dengan pulasan negatif (P=0,28).
Empat puluh persen dari pasien pulasan positif dan 25% pasien pulasan negatif
memiliki ESR > 50 (P<0,001). Berdasarkan hasil penelitian ini, gambaran radiografi yang
paling umum ditemukan pada pasien dengan pulasan positif adalah kalsifikasi (56%),
adenopati (53%), bronkiektasis (40%), infiltrat noduler (36%), dan infiltrat bentuk bercak
(30%).

Keterlibatan apikal, kavitas, destruksi pulmoner inkomplit, efusi pleura, pelebaran

mediastinum, dan fibrosis merupakan temuan radiologis yang umum ditemukan selanjutnya.
Sementara pada pasien dengan pulasan negatif, kalsifikasi (27%), infiltrat retikulo-noduler
(41%), fibrosis (23%), adenopati (21%), dan infiltrat bercak (14%) merupakan temuan
radiografi toraks yang paling umum. Demikian juga, keterlibatan apikal, bronkiektasis, efusi
pleura, kavitas, pelebaran mediastinum, merupakan temuan radiologis yang paling umum
ditemukan berikutnya. Frekuensi ditemukannya infiltrat bentuk bercak, kalsifikasi, pelebaran
mediastinum, dan adenopati hilus pulmoner lebih tinggi pada pasien dengan pulasan positif
(P=0,006, P<0,001, P=0,02 dan P<0,001 berturut-turut). Walaupun frekuensi efusi pleura,
destruksi pulmoner komplit, TB miliar, fibrosis pulmoner, dan keterlibatan apikal merupakan
temuan umum pada pasien dengan pulasan positif dan infiltrat retikulonoduler pada pasien
pulasan negatif, namun tidak menunjukkan perbedaan yang signifikan secara statistika.
Jadi, frekuensi kalsifikasi, adenopati hilus pulmoner, ddestruksi pulmoner inkomplit,
kavitas, pelebaran mediastinum, bronkiektasis, dan infiltrat bentuk bercak merupakan
gambaran yang lebih sering ditemukan pada pasien dengan pulasan positif dibandingkan
dengan pulasan negatif yang signifikan secara statistika (semua P<0,05). Frekuensi fibrosis
pulmoner, infiltrat apikal, efusi pleura, destruksi komplit pulmoner, dan TB miliar lebih
tinggi namun perbedaannya tidak signifikan secara statistik (semua P>0,05). Dalam kontras,
infiltrat retikulo-noduler lebih sering terlihat pada gambaran radiografi toraks pasien dengan
pulasan negatif dibandingkan dengan pulasan positif namun tidak memiliki perbedaan yang
signifikan secara statistik (P>0,05).
Gambaran
radiologi
Kalsifikasi
Adenopati
hilus
Destruksi
inkomplit
Infiltrasi
apeks
Pelebaran
mediastinum
Bronchiecta
sis
Infiltrasi
Reticulo-nodular
Bercak
infiltrasi
Fibrosis
paru
Kavitas
Efusi pleura
Destruksi
komplit
Tuberkulosis

Pulasan
negatif, %
27
21

Pulasan
positif, %
56
53

P Value
P < 0,001
P < 0,001

16

P = 0,005

P = 0,09

10

P = 0,02

12

40

P = 0,001

41

36

P = 0,47

14

30

P = 0,006

23

30

P = 0,26

22
10
4

53
11
9

P = 0,001
P =0,82
P = 0,15

10

P = 0,30

miliar

Diskusi
Meskipun pencegahan dan terapi memiliki keuntungan yang sangat besar, tb paru
masih tetap menjadi masalah kesehatan yang penting di Iran seperti di banyak daerah yang
endemis. Oleh sebab itu diagnosis yang tepat dan evaluasi pasien merupakan hal yang sangat
diperlukan sementara karena besar wilayah geografis, dan tingkat akses yang berbeda untuk
kesehatan layanan, mendekati lebih mudah diakses dan pencitraan lebih murah dan teknik
laboratorium menyambut (14). Sehubungan Dengan Itu, dalam penelitian deskriptif ini,
pasien yang telah dikonfirmasikan dengan PTB dibandingkan dalam hal radiologis dan
manifestasi laboratorium dan di sini temuan kami dibandingkan dengan literatur.
Dalam penelitian yang dilakukan oleh Rathman et al., Dari 1389 kasus yang
mencurigakan untuk TB, 34% adalah BTA positif dan 66% adalah BTA negatif. perubahan
radiografi dinilai dalam dua kelompok. Cavity tercatat dalam kasus BTA positif lebih dari
BTA yang negative (40% vs 25%), (P <0,001). Demikian juga, kalsifikasi secara signifikan
lebih sering terjadi pada positif smear dibandingkan smear negatif (P <0.001) (15).
Dalam studi yang dilakukan oleh van Cleef et al. BTA negatif dan pasien TB BTA
positif yang diikuti up selama sepuluh tahun dan dada perubahan radiografi dibangkitkan dari
1% sampai 10% dalam kasus negatif smear. Generalized retikulo-nodular infiltrasi (55%);
rongga (30%) dan efusi pleura (15%) lebih sering terjadi pada smear negatif daripada kasus
BTA positif (P <0,001). sementara, infiltrasi merata (45%), kalsifikasi (45%), adenopathy
(30%), dan bronkiektasis (22%) lebih sering di positif smear dibandingkan dengan kelompok
negatif smear (P = 0.001) (16). Dalam penelitian yang dilakukan oleh Miller et al. temuan
paru kompatibel dengan BTA positif infiltrasi merata, kavitasi dan kalsifikasi (17). Di
disebutkan. Penelitian, lesi paru BTA positif yang kompatibel dengan PTB, infiltrasi merata,
kavitasi dan kalsifikasi yang lebih sering, sedangkan dalam penelitian yang dilakukan oleh
Gatner et al. lesi paru kompatibel dengan BTA negatif. PTB, hilus atau mediastinum
adenopati, reticulonodular difus infiltrasi dan efusi pleura yang lebih umum (18).
Dalam penelitian kami, mirip dengan penelitian lain, beberapa paru. Perubahan
terlihat lebih sering dengan statistik perbedaan yang signifikan antara smear positif dan. BTA
negatif pasien seperti infiltrasi merata, kalsifikasi, dan adenopati di BTA positif dan
reticulonodular infiltrasi dalam yang negatif smear. Hal ini mungkin membantu diagnosis
penyakit dan harus disimpan dalam keberatan oleh dokter, maka, menurut studi yang
dilakukan. Jones et al. di penjara, 20% dari pasien dengan. BTA negatif PTB mungkin telah
terjawab saat. Perubahan radiografi diabaikan (19). Demikian juga, di. Penelitian lain pada
518 pasien PTB, 14,8% dari BTA negatif. pasien memiliki temuan paru khas kompatibel
dengan PTB (20).
Dalam penelitian yang dilakukan oleh Razaghi et al. 100 pasien TB di Kashan, Iran,
radiologis yang paling umum temuan itu infiltrasi retikulo-nodular (18%), bronkiektasis
(13%) dan atelektasis (3%) (21). Dalam studi yang dilakukan oleh Rajabzadeh di Ghouchan,

Iran, pada pasien TB yang berusia lebih tua dari 50 tahun, infiltrasi segmental terlihat pada
40% kasus dan terutama infiltrasi paru unilateral (83%) adalah yang paling. Temuan umum
yang diikuti oleh keterlibatan apikal (30%), efusi pleura (26%), rongga (20%) dan adenopati
(16%) (22). Dalam penelitian kami, baik smear positif dan pasien negatif smear dievaluasi
dan khas. Perubahan paru seperti keterlibatan apikal dan rongga lebih umum, kemungkinan
besar karena usia yang lebih tinggi berbagai kasus kami dibandingkan dengan penelitian lain.
Dalam penelitian yang dilakukan oleh Bakhshayeshkaram et al. pada tanggal. Pasien
TB positif 100 smear dari Teheran, yang paling paru keterlibatan adalah: infiltrasi retikulonodular (98%), rongga (60%), penebalan pleura (45%), adenopathy (36%) dan fibrosis (30%)
(23). Dalam studi lain pada smear positif (n = 50), infiltrasi dengan atau tanpa rongga di
segmen paru bagian atas (78%), dan hilar adenopati mediastinum (65%), dan efusi pleura
(45%) adalah manifestasi radiologis yang paling umum (24). Persentase yang sangat tinggi
retikulo-nodular infiltrasi dalam penelitian yang dilakukan oleh Bakhshayeshkaram et al.
mungkin karena atribusi paru kronis dan penyakit akibat kerja dalam studi menyebutkan
bahwa tidak dikecualikan. Demikian juga, dalam penelitian yang dilakukan oleh. Cohen et al,
12 dari 50 kasus PTB bertepatan dengan keganasan; Oleh karena itu, frekuensi yang lebih
tinggi dari adenopati dan rongga dicatat (24).
Dalam penelitian kami, mirip dengan penelitian lain, beberapa paru. Perubahan
terlihat lebih sering dengan signifikan secara statistik perbedaan antara smear positif dan
negatif smear pasien. Memperhatikan perbedaan ini dengan dokter akan mengakibatkan
diagnosis yang lebih baik dari penyakit. Selain itu, mengingat fakta bahwa radiologi umum.
Temuan dapat dilihat pada TB serta paru keganasan, abses paru dan paru kronis penyakit,
pendekatan terbaik adalah untuk menyingkirkan penyakit ini dalam diagnosis diferensial
sebelum intervensi medis.
Berdasarkan temuan dan hasil penelitian kami, klinis manifestasi dan dahak dalam
terang radiografi. Perubahan adalah alat yang sangat berguna dalam diagnosis. PTB dan
karenanya bantuan yang luar biasa untuk pengobatan PTB pasien.
Ucapan terimakasih
Dengan ini, penulis mengucapkan terima kasih kepada Dr. Mohammad M.
Mohammadifard atas dukungannya, melaporkan hasil radiografi dan untuk para kolega yang
bekerja di unit Tuberkulosis Birjand Health Care Center. Penulis juga memberikan apresiasi
kepada para pasien yang bersedia menjadi subjek penelitian ini untuk kerjasamanya.
Dukungan
Penelitian ini mendapat dukungan dari fakultas kedokteran dan departemen penelitian
Mashhad University of Medical Research.
Daftar Pustaka

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Iran J Radiol. 2014 November; 11(4): e13575. DOI: 10.5812/iranjradiol.13575

Published online 2014 September 23. Research Article

Comparison of Chest X-Ray Findings of Smear Positive and Smear Negative Patients with Pulmonary
Tuberculosis
Azadeh Ebrahimzadeh 1; Mahyar Mohammadifard 2,*; Ghodratallah Naseh 3
1Department of Internal Medicine, Faculty of Medicine, Birjand University of Medical Sciences,
Birjand, Iran
2Department of Radiology, Imam Reza Hospital, Birjand University of Medical Sciences, Birjand,
Iran
3Department of Surgery, Imam Reza Hospital, Birjand University of Medical Sciences, Birjand, Iran
*Corresponding author: Mahyar Mohammadifard, Imam Reza Hospital, School of Medicine, Birjand
University of Medical Sciences, Birjand, Iran. Tel: +98-5118414499, Fax: +98-5612226898, E-mail:
mahyarmohammadifard@yahoo.com
Received: July 13, 2013; Revised: April 20, 2014; Accepted: June 1, 2014

ABSTRACT
Background: Tuberculosis is a chronic pulmonary infectious disease that has affected one-third of the
people in the world. It causes nine million new cases and two million deaths per year. Chest
radiography associated with Ziehl-Neelsen acid-fast staining procedure significantly helps the
diagnosis of pulmonary tuberculosis (PTB). Chest radiography can help the diagnosis of tuberculosis
in patients with a negative smear sample result that is mainly diagnosed with delay.
Objectives: In this study, chest X-ray findings of PTB were compared in two groups of smear
positive and smear negative patients.
Patients and Methods: In this retrospective descriptive-analytical study, 376 patients who had been
confirmed with PTB were referred to Birjand Health Care Center from 2001 to 2006. Out of the 376
patients, 100 patients with a positive smear based on WHO criteria were selected. In addition, among
negative smear patients, 100 were selected in whom similar demographic characteristics with positive
smear patients were seen. All of them had undergone chest radiographies that were then interpreted by
two expert radiologists independently. Moreover, all patients sputa were examined by an expert
laboratory technician at the reference laboratory of the health center. The obtained data were analyzed
by means of frequency distribution table and descriptive statistics using SPSS (version 15) and Chisquare statistical test.
Results: Except reticulo-nodular infiltration, the relative frequency of other radiographic findings in
positive smear patients were more than negative smear patients; and only differences in calcification
variables, mediastinal widening, patchy infiltration and hilar adenopathy were statistically significant
(P < 0.05).
Conclusions: Based on the results of this study, although radiographic findings are not diagnostic in
PTB, they are helpful if the assessment associates with the view of clinical manifestations and sputum
smears.
Keywords: Pulmonary Tuberculosis; Smear Positive; Smear Negative; Radiological Findings

1. Background
Tuberculosis is a chronic lung
infection that is caused by mycobacterium
germs. This disease caused more than 30% of
all deaths in the 19th and 20th centuries and
has currently infected one-third of all people
worldwide. It causes nine million new cases
and two million deaths annually (1-3). TB is
the second most fatal infectious agent after
AIDS. Eighty percent of all tuberculosis
patients reside in 22 countries primarily in the
third-world (1, 2). It has been estimated that
over one billion people will be infected by
tuberculosis by 2020 and the number of
patients will reach 200 million. In addition,
one million deaths will occur due to
tuberculosis. At present, 30 million people are
infected by tuberculosis, while it is estimated
that almost 300 million people are
contaminated and about 90 million would be
involved with tuberculosis within the next ten
years (1, 4, 5).
The prevalence of tuberculosis
reduced to 5% annually until 1995 (6), but
within the next five years, the prevalence
increased to 15.8%. Currently, tuberculosis in
association with acquired immunodeficiency
syndrome (AIDS) is the most important public
health problem in Asia, Africa and Latin
America. Hence, it was called an emergency
by WHO in 1993 (6, 7).
The best and most definitive method
in the diagnosis of pulmonary tuberculosis
(PTB) is sputum smear and Ziehl-Neelsen
staining with several consecutive tests (1-3). In
the recent decades, due to the increase in
diversity and number of diagnostic techniques,
smear positive tuberculosis has raised (2, 3).
Although smear negative tuberculosis has
significantly reduced, still a considerable
number of cases fall at this group. For
example, in Iran, smear positive tuberculosis
increased from 3980 to 5430 cases from 1992
to 1996 (7 per 100,000 vs. 8.9 per 100,000);
and smear negative tuberculosis reduced from
13182 cases to 6081 (23.1 per 100,000 vs. 10
per 100,000) (8).

In a study done in Iran in 1996, 11.25

per 100,000 smear positive and 6.62 per
100,000 smear negative and 2.72 per 100,000
extra-pulmonary tuberculosis were detected
in Birjand, South Khorasan, which ranked
third place after Systan-Baluchestan and
Golestan provinces (9). Since each smear
negative patient can contaminate two people
each year, rapid diagnosis of tuberculosis is
as essentially important as the smear positive
patient.
In smear negative and even smear
positive cases, radiographic changes are
helpful in disease diagnosis. Although some
chest X-ray findings, including nodular or
patchy infiltration in the posterior parts of the
superior lobes or anterior segments of the
inferior lobes particularly in bilateral
involvement and associated with cavity, are
not specific for pulmonary tuberculosis,
clinical manifestations and epidemiologic
findings are very diagnostic (10, 11).
Generally, common radiologic findings in
secondary PTB are demonstrated as follows:
bronchiectasis, consolidation, patchy, cavitary,
and miliary TB (12, 13).
2. Objectives
This study has been done to compare
chest X-ray changes
seen in smear positive and smear negative
tuberculosis
patients.
3. Patients and Methods
In this retrospective descriptiveanalytical study, 376 patients who had been
confirmed with PTB were referred to Birjand
Health Care Center from 2001 to 2006. Out of
the 376 patients, 100 patients with a positive
smear based on WHO criteria were selected. In
addition, among negative smear patients, 100
patients were selected as the control group, in
whom similar demographic characteristics
with positive smear patients were seen.
Based on WHO criteria, positive
smear PTB is defined with at least two positive
sputum smears of acid-fast bacillus or one

positive sputum smear associated either with

one positive sputum culture or chest
radiographic findings compatible with PTB.
Negative smear PTB was confirmed when
positive radiographic changes compatible for
PTB have been detected and in spite of a 1014 day wide spectrum antibiotic therapy, no
change in the patients general condition was
noted from whom two negative serial sputum
smears were taken with at least two weeks
interval and in each session, three samples
were examined and all samples were negative
for acid fast bacillus. In addition, smear
negative PTB is defined when a severely ill
patient with radiographic changes in favour of
PTB lesions (interstitial tissue involvement or
miliary TB) shows two negative samples for
acid fast bacillus.
The physician then decided to start
anti-TB treatment in a patient with initially
negative sputum smears and a positive sputum
culture. All of the patients underwent chest
radiographies that were then interpreted by
two expert radiologists independently.
Moreover, all patients sputa were examined
by an expert laboratory technician at the
reference laboratory of the health center. The
obtained data were analyzed by means of
frequency distribution table and
descriptive statistics using SPSS version 15 for
Windows (SPSS Inc., Chicago, Ill, USA) and
Chi-square test was used for statistical
analysis. P-values less than 0.05 were
considered statistically significant.
4. Results
Out of the 200 patients who were
studied, most of them were Iranian citizens
(97%), 63.5% were female and 59% of the
cases were from urban areas. The age
distribution was 15.5%, 45%, and 39.5% in the
age groups of 1-13, 14-55, and above 55 years
old, respectively. The mean age in the females
was 50.88 22.22 years and 49.11 22.82
years in the males (P=0.57), 48.31 22.41
years in the positive smear group and 51.66
21.52 years in the negative smear group (P =
0.28). Forty six percent of the smear positive

and 25% of the smear negative patients had

ESR > 50 (P < 0.001).
Based on the results of this study, the
most common radiographic manifestations in
smear positive cases were calcification (56%),
adenopathy (53%), bronchiectasis (40%),
reticulonodular infiltration (36%), and patchy
infiltration (30%). Apical involvement, cavity,
incomplete pulmonary destruction, pleural
effusion, mediastinal widening and fibrosis
were the next common findings, while in
smear negative patients, calcification (27%),
reticulo-nodular infiltration (41%), fibrosis
(23%), adenopathy (21%), and patchy
infiltration (14%) were the most common
findings.
Likewise,
apical
involvement,
bronchiectasis, pleural effusion, cavity,
mediastinal widening were the next common
findings. The frequency of patchy infiltration,
calcification, mediastinal widening, and hilar
pulmonary adenopathy was higher in smear
positive patients (P = 0.006, P < 0.001, P =
0.02 and P < 0.001, respectively). Although the
frequency of pleural effusion, complete
pulmonary destruction, miliary TB, pulmonary
fibrosis and apical involvement were common
in smear positive cases and reticulo-nodular
infiltration in smear negative ones, but neither
showed any significant statistical difference.
So, the frequency of calcification, pulmonary
hilar adenopathy, incomplete pulmonary
destruction, cavity, mediastinal widening,
bronchiectasis, and patchy infiltration were
more common in the smear positive groups
compared to smear negative groups that were
statistically
significant (all Ps < 0.05). The frequency of
pulmonary fibrosis, apical infiltration, pleural
effusions, complete pulmonary destruction and
miliary TB were higher but with no significant
statistical difference (all Ps > 0.05). In
contrast, reticulo-nodular infiltration was seen
more commonly in smear negative groups
rather than in smear positive groups with no
significant statistical difference (P > 0.05)
(Table 1).

Table 1. Radiological Changes in Smear

Positive and Smear Negative Groups
Radiologic Finding
Smear
Negative, %
Calcification
27
Hilar adenopathy

21

Incomplete
destruction
Apical infiltration

Widening of
mediastinum
Bronchiectasis

Reticulo-nodular
infiltration
Patchy infiltration

41

12

14

Lung fibrosis

23

Cavity

22

Pleural effusion

10

Complete
destruction
Miliary tuberculosis

4
6

5. Discussion
Despite great advantages in prevention
and treatment, PTB is still an important health
problem in Iran as well as many other endemic
areas (4, 8). So, proper diagnosis and followup of the patients is essential while due to
large geographic areas, and different access
levels to health services, approaching more
accessible and cheaper imaging and laboratory
techniques is welcome(14). Therefore, in this
descriptive study, the patients who had been
confirmed with PTB were compared in term of
radiologic and laboratory manifestations and
here our findings are compared with the
literature.
In the study conducted by Rathman et
al., of the 1389 cases suspicious for

tuberculosis, 34% were smear positive and

66% were smear negative. Radiographic
changes were assessed in the two groups.
Cavity was noted in smear positive cases more
than smear negative ones (40% vs. 25%), (P <
0.001).
Likewise,
calcification
was
significantly more common in smear positives
than smear negatives (P < 0.001) (15).
In the study performed by van Cleef et al.
smear negative and smear positive tuberculosis
patients were followed up for ten years and the
chest radiographic changes raised from 1% to
10% in the smear negative cases. Generalized
reticulo-nodular infiltration (55%); cavity
(30%) and pleural effusion (15%) were more
frequent in smear negative than smear positive
cases (P < 0.001). Whilst, patchy infiltration
(45%), calcification (45%), adenopathy (30%),
and bronchiectasis (22%) were more frequent
in smear positives compared to the smear
negative group (P = 0.001) (16).
In the study carried out by Miller et al.
pulmonary findings compatible with smear
positive were patchy infiltration, cavitation
and calcification (17). In the mentioned study,
pulmonary lesions compatible with smear
positive PTB, patchy infiltration, cavitation
and calcification were more frequent, while in
the study conducted by Gatner et al.
pulmonary lesions compatible with smear
negative PTB, hilar or mediastinal adenopathy,
diffuse reticulonodular infiltration and pleural
effusion were more common (18).
In our study, similar to other studies,
some pulmonary changes were seen more
frequently with a statistically significant
difference between the smear positive and
smear negative patients such as patchy
infiltration, calcification, and adenopathy in
smear positive and reticulonodular infiltration
in smear negative ones. This might help the
diagnosis of the disease and should be kept in
mind by physicians, hence, according to the
study performed by Jones et al. in jail, 20% of
the patients with smear negative PTB might
have been missed when the radiographic
changes were neglected (19). Likewise, in
another study on 518 PTB patients, 14.8% of

smear negative patients had typical pulmonary

findings compatible with PTB (20). In the
study carried out by Razaghi et al. on 100 TB
patients in Kashan, Iran, the most common
radiologic findings were reticulo-nodular
infiltration (18%), bronchiectasis (13%) and
atelectasis (3%) (21).
In the study performed by Rajabzadeh
in Ghouchan, Iran, on TB patients who were
older than 50 years old, segmental infiltration
was seen in 40% of the cases and primarily
unilateral lung infiltration (83%) was the most
common finding which was followed by apical
involvement (30%), pleural effusion (26%),
cavity (20%) and adenopathy (16%) (22). In
our study, both smear positive and smear
negative patients were evaluated and typical
pulmonary changes such as apical involvement
and cavity were more common, most likely
due to the higher age range of our cases
compared to other studies.
In
the
study
conducted
by
Bakhshayeshkaram et al. on 100 smear
positive TB patients from Tehran, the most
pulmonary involvements were: reticulonodular infiltration (98%), cavity (60%),
pleural thickening (45%), adenopathy (36%)
and fibrosis (30%) (23). In another study on
smear positive patients (n = 50), infiltration
with or without cavity in the upper pulmonary
segments (78%), hilar and mediastinal
adenopathy (65%), and pleural effusion (45%)
were
the
most
common
radiologic
manifestations (24).
The very high percentage of reticulonodular infiltration in the study carried out by
Bakhshayeshkaram et al. is probably due to the
attribution of chronic pulmonary and
occupational diseases in the mentioned study
that were not excluded. Likewise, in the study
performed by Cohen et al., 12 out of 50 PTB
cases coincided with malignancy; therefore, a
higher frequency of adenopathy and cavity
were noted (24).
In our study, similar to other studies,
some pulmonary changes were seen more
frequently with statistically significant
differences between smear positive and smear

negative patients. Paying attention to these

differences by physicians would lead to better
diagnosis of the disease. Moreover, in view of
the fact that common radiologic findings can
be seen in tuberculosis as well as pulmonary
malignancy, pulmonary abscess and chronic
pulmonary diseases, the best approach is to
rule out these diseases in the differential
diagnosis before any medical intervention.
Based on the findings and results of our study,
clinical manifestations and sputum smear in
the light of radiographic changes are very
useful tools in the diagnosis of PTB and hence
a remarkable help for the treatment of PTB
patients.
Acknowledgements
Hereby
we
acknowledge
Dr.
Mohammad M. Mohammadifard for his great
support, reporting the radiographs and our
colleagues working at the TB unit of Birjand
Health Care Center. We also appreciate our
valued patients for their cooperation.
Funding/Support
This study was supported by the
Faculty of Medicine and the Chancellery for
Research of Mashhad University of Medical
Sciences.
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