Pulmonary Tuberculosis

Pathology. A knowledge of the gross and microscopic pathology of

tuberculosis and of the pathogenesis are fundamental to an understanding of the
radiographic appearances.
Once of the primary infection has occurred and the alveolar membrane has
been penetrated (Figure 17-8), the infection being sufficiently severe, certain typical
body reactions ensue. The primary lesion acctualy occurs in the interstitial tissues of
the lung and this primary focus is usually seen in infancy and childhood. There occurs
a focus of pneumonic consolidation a few millimeters in diameter, usually under the
pleura of the lung periphery or near the hilus. This lesion may undergo fibrosis and
ultimately calcification, or it may be the source of a widespread dissemination of the
disease. Usually the infection is picked up by the lymphatics and it spreads to the
homolateral hilar lymph nodes, where it may undergo fibrosis and calcification or it
may no be arrested and may undergo fibrocaseation and ulceration. The primary
parenchymal lesion is called the Ghon focus; the combination of the primary
parenchymal lesion plus the lymph node is called the primary or ranke complex
(Figure 17-9). The ranke hypothesis indicates that the primary complex may become
cicatrized or may give rise to a tuberculosis septicemia which in turn may either heal
or produce organ tuberculosis throughout the body. Ranke assumed three stages : (1)
the primary focus, (2) general spread of the bacillus, and (3) isolated organ
tuberculosis.
The primary arredsted complex may remain dormant, or in adult life
reinfection may occur by either an exogenous or endogenous source of the tubercle
infection. Reactivation in the adult gives rise to a new exudative response which
usually lies in the apical or subapical region. This may undergo fibrosis,
fibrocaseation, or outright caseation with ulceration. The area of ulceration or
cavitation may then be encapsulated, or it may rupture into adjoining blood vessels or
bronchi and become widespread. Occasionally an acute exudative pneumonia may be
part of any of these various phases.
Epituberculosis (possibly allergic), as described by Eliasberg and Neuland, is a
nonspecific reaction of the pulmonary tissue around a tuberculous lesion which in
itself is not directly related to the tubercle bacillus. Ordunarily this process clears up
rather rapidly and is sharply limited to one lobe. It resembles a lobar pneumonia.
If the primary infection should involve the bronchial mucosa (endobranchial
type, Figure 17-8), the following possible events may occur; A tuberculous bronchitis
will ensue which may undergo fibrosis, and if the fibrotic process is very extensive, it
will cause either complete or partial bronchial occlusion. This in turn may result in
atelectasis of the lung peripheral to this broncus or in an obstructive emphysema. On
the other hand, the tuberculous bronchitis may in turn give rise to parenchymal
infection which may follow any of pathways previous outlined. The tuberculous
bronchitis may extemd upward to inbolve the larynx; this is usually associated with
and endobronchial indection. On the other hand, tuberculous bronchitis may undergo
caseation, and the caseated area may in turn develop along certain lines. It may
become encapsulated and perhaps may even lie dormant; It may penetrate the
bronchus, giving rise to a tuberculous mediastinitis; or it may give rise to other foci
elsewhere iin the body by penetration into blood vessels, lymphatics, or air passages,
or by a military spread.
It is thus apparent that various type of lesions and apperances may ensure.