Postprimary Tuberculosis Lung Imaging

Updated: Oct 14, 2015 . Author: Anjali Agrawal, MD; Chief Editor: Eugene C Lin, MD
Tuberculosis (TB) has existed for millennia, and despite initial declines in its incidence
during the middle of the 20th century, the disease has been reemerging across the world. [1]
The radiologic diagnosis of TB started only about a century ago, after Roentgen's discovery
of x-rays. [2] Fluoroscopy was used in the early part of the 20th century to detect cavitary TB,
because experienced fluoroscopists could easily detect cavities. Over the years,
improvements in technology, coupled with extensive investigation into the radiologic patterns
of pulmonary TB, have resulted in diagnostic imaging being an essential adjunct to the
clinical and microbiologic diagnosis of this disease. These events contributed to the routine
practice of documenting cavitary disease and following up the disease on film. [3, 4, 5, 6, 7]
Images related to postprimary tuberculosis are provided below.

Posteroanterior chest radiograph from a 65-year-old man with a long history of smoking,
chronic obstructive pulmonary disease (COPD), and childhood tuberculosis. The patient
presented with a history of recent onset of coughing, as well as had a fever and night sweats.
This image shows right-upper lung (RUL) bullous disease and suggests a left-lower lung
(LLL) cavity. The LLL abnormality was new, appearing since his previous examination a
year earlier, which was performed before the onset of his recent symptoms.

Computed tomography scan, pulmonary window setting, in a 65-year-old man with a long
history of smoking, chronic obstructive pulmonary disease (COPD), and childhood

tuberculosis. This image shows a thick-walled, left-lower lung (LLL) cavity with an air-fluid
level; a smaller, more medial cavity; and some lung parenchymal opacities. Acid-fast
organisms were detected in the patient's sputum, and the culture results indicated the presence
of Mycobacterium tuberculosis.

Posteroanterior chest radiograph in an 83-year-old woman who was sent to the emergency
department from her nursing home because of a recent history of productive cough, weight
loss, and fatigue. Until recently, the woman was the social director at the nursing home. In
her younger years, the patient had tuberculosis during her first pregnancy; this illness
occurred before antibiotic therapy was used to treat tuberculosis. This image demonstrates
extensive bilateral lung nodules and a cavity in a partially collapsed right upper lung. Sputum
cultures were positive for tuberculosis. The nodules indicate endobronchial spread of the
tuberculosis.

Selective bronchial arteriogram in a patient with history of tuberculosis who presented with
massive hemoptysis. This image reveals a Rasmussen aneurysm (left) that was embolized
(right).

Posteroanterior chest radiograph from a young female patient who presented with a cough,
positive findings on skin testing with purified protein derivative of tuberculin (PPD), and a
pleural effusion that was positive for acid-fast bacilli. This image shows a left pleural
effusion and left lower-lobe consolidation.
Tuberculosis results from infection by any of the TB complex mycobacteria, including
Mycobacterium tuberculosis, M bovis, M africanum, M microti, and M canetti. [8]
TB can be divided into primary, progressive-primary, and postprimary forms on the basis of
the natural history of the disease. Postprimary TB results from either reactivation of a latent
primary infection or, less commonly, from the repeat infection of a previously sensitized host.
The term "postprimary" is preferred to "reactivation" when referring to the clinical diagnosis,

because firmly distinguishing recurrence from an antecedent infection is impossible in most

cases. Approximately 10% of all infected patients are likely to develop reactivation, and the
risk is highest within the first 2 years or during periods of immunosuppression. [9, 10, 11, 12]
No radiologic study shows findings that are specific for tuberculosis. A cavitary process that
is demonstrated on chest radiographs or computed tomography (CT) scans in the apical and
posterior segments of the upper pulmonary lobe or in the superior segments of the lower
lobes is likely to be TB; however, differential considerations include other diseases, such as
histoplasmosis and other fungal infections, bacterial abscesses, and necrotic neoplasms,
especially lung neoplasms. [13, 14, 15]
In immunocompromised patients, postprimary TB may mimic primary TB, and the condition
can appear with pleural effusion, lymphadenopathy, or miliary spread. The usual pattern of
cavitary upper-lobe disease is less common in immunocompromised hosts than in
immunocompetent hosts. [16]
Although the findings of currently active TB can often be differentiated from previous
scarring on radiologic images, the possibility of latent or temporarily quiescent infection
exists, and healed or inactive TB should not be diagnosed without adequate clinical
information and/or the finding of calcified lesions. Radiographic follow-up is recommended
in all cases of TB because it provides valuable information regarding the extent of the disease
and its progression.
Stout et al reviewed 241 radiographs from 99 patients with pulmonary tuberculosis to
determine reliability in predicting tuberculosis relapse. Agreement among 3 independent
readers was very good for the findings of bilateral disease and cavitation, but substituting a
consensus interpretation for the original interpretation increased the odds ratio for the
association between cavitation on early chest radiograph and subsequent tuberculosis relapse
from 4.97 to 8.97. According to the authors, improving the reliability of these findings could
improve the utility of chest radiographs for predicting tuberculosis relapse. [17]
Sant'Anna et al, in a Brazilian study, observed the radiographic features of young patients
with pulmonary TB and found cavitary lesions in 67 of 243 patients (27.6%) between the
ages of newborn and 15 years and in 116 of 321 patients (36.1%) in adolescents aged 16 to 19
years. The most common radiographic lesions were postprimary tuberculosis (53.3%),
tuberculous expansile pneumonia (27%), and primary complex with adenomegaly (1.8%). [18]
In a Japanese study, Nakanishi et al concluded that even in cases of negative sputum smears,
high-resolution computed tomography (HRCT) scanning can be used to predict the risk of
pulmonary TB with good reproducibility and to indicate which patients have a high
probability of pulmonary TB. The authors examined findings in 116 patients with suspected
pulmonary TB who had negative sputum smears for acid-fast bacilli. They found that large
nodules, tree-in-bud appearance, lobular consolidation, and the main lesion being located in
S1, S2, and S6 were significantly associated with an increased risk of pulmonary TB. [19]