Pulmonary Tuberculosis: Parenchymal Disease

Pulmonary Tuberculosis
Historically, pulmonary tuberculosis has been divided into primary and postprimary
tuberculosis, with primary tuberculosis being considered a disease of childhood and postprimary
tuberculosis a disease of adulthood. However, a reduction in the prevalence of tuberculosis in
most Western countries (1,2) owing to effective treatment and public health measures has
resulted in large unexposed adult populations who are at risk for contracting primary
tuberculosis. As a result, primary tuberculosis now accounts for 23%34% of all adult cases of
tuberculosis (27).
It can sometimes be difficult to differentiate between primary and postprimary
tuberculosis both clinically and radiologically, since their features can overlap. However,
confirming the diagnosis is more important than identifying the subtype because it allows
initiation of correct clinical management.
Primary Tuberculosis
Primary tuberculosis is seen in patients not previously exposed to M tuberculosis. It is
most common in infants and children and has the highest prevalence in children under 5 years of
age. The prevalence of primary tuberculosis in adults is increasing for the reasons outlined
earlier; however, because primary tuberculosis is perceived to be a disease of childhood, it is
often not suspected in adults, resulting in misdiagnosis (28). Chest radiography remains the
mainstay of diagnosis; however, normal radiographic findings may be seen in up to 15% of
patients with proved tuberculosis (29).
At radiology, primary tuberculosis manifests as four main entities: parenchymal disease,
lymphadenopathy, miliary disease, and pleural effusion.
Parenchymal Disease.Typically, parenchymal disease manifests as dense, homogeneous

parenchymal consolidation in any lobe; however, predominance in the lower and middle lobes is
suggestive of the disease, especially in adults. Its appearance is often indistinguishable from that
of bacterial pneumonia; however, it can be differentiated from bacterial pneumonia on the basis
of radiographic evidence of lymphadenopathy and the lack of response to conventional
antibiotics (Fig 1). In children under 2 years of age, lobar or segmental atelectasis is frequently
seen, most often involving the anterior segment of an upper lobe or the medial segment of the
middle lobe.
In approximately two-thirds of cases, the parenchymal focus resolves without sequelae at
conventional radiography; however, this resolution can take up to 2 years. In the remaining
cases, a radiologic scar persists that can calcify in up to 15% of cases, an entity that is known as
a Ghon focus. Other calcified foci can also be seen, and persistent masslike opacities called
tuberculomas are seen in approximately 9% of cases. Tuberculomas can cavitate and undergo
calcification.
Lymphadenopathy.Radiographic evidence of lymphadenopathy is seen in up to 96% of
children and 43% of adults. Lymphadenopathy is typically unilateral and right sided, involving
the hilum and right paratracheal region (Fig 2), although it is bilateral in about one-third of cases.
Any nodes greater than 2 cm in diameter generally have a low-attenuation center secondary to
necrosis at CT and are highly suggestive of active disease (30). Although
lymphadenopathy is usually associated with other manifestations of tuberculosis, it can be the
sole radiographic feature, a finding that is more common in infants and decreases in frequency
with age. CT is more sensitive than chest radiography for assessing lymphadenopathy. The
combination of calcified hilar nodes and a Ghon focus is called a Ranke complex and is
suggestive of previous tuberculosis, although it can also result from histoplasmosis.
With treatment, there is usually slower resolution of the lymphadenopathy than of the
parenchymal disease, and nodal calcification may develop. However, this calcification usually
occurs 6 months or more after the initial infection.
Figure 1. Parenchymal Figure 2. Lymphadenopathy in a

primary tuberculosis in an patient with primary tuberculosis.
adult. Radiograph of the Chest radiograph shows a bulky left
left lung demonstrates hilum and a right paratracheal mass,
extensive findings that are consistent with
lymphadenopathy and are typical in
pediatric patients.
Figure 3. Miliary
tuberculosis. (a)
Radiograph
of the left lung shows
diffuse
23-mm nodules, findings
that are typically
Miliary Disease.Clinically significant military disease affects between 1% and 7% of patients
with all forms of tuberculosis. It is usually seen in the elderly, infants, and immunocompromised
persons, manifesting within 6 months of initial exposure. Chest radiography is usually normal at
the onset of symptoms, and hyperinflation may be the earliest feature. The classic radiographic
findings of evenly distributed diffuse small 23-mm nodules, with a slight lower lobe
predominance, are seen in 85% of cases (Fig 3). High-resolution CT is more sensitive than
conventional radiography, with nodules seen in a random distribution. The nodules usually
resolve within 26 months with treatment, without scarring or calcification; however, they may
coalescence to form focal or diffuse consolidation.
Pleural Effusion.A pleural effusion is seen in approximately one-fourth of patients with

proved primary tuberculosis (29). The effusion is often the sole manifestation of tuberculosis and
usually manifests 37 months after initial exposure. Pleural effusion is a very uncommon finding
in infants. The effusion is usually unilateral, and complications (eg, empyema formation,
fistulization, bone erosion) are rare. Residual pleural thickening and calcification can result.
Ultrasonography (US) often demonstrates a complex septated effusion.
Postprimary Tuberculosis
Postprimary tuberculosis remains primarily a disease of adolescence and adulthood. It occurs in

patients previously sensitized to M tuberculosis. The term postprimary tuberculosis is generally
used to refer to both reinfection with and reactivation of tuberculosis. Primary tuberculosis is
usually self-limiting, whereas postprimary tuberculosis is progressive, with cavitation as its
hallmark, resulting in hematogenous dissemination of the disease as well as disease spread
throughout the lungs. Healing usually occurs with fibrosis and calcification
The features of primary and postprimary tuberculosis may overlap; however, the
distinguishing features of postprimary tuberculosis include a predilection for the upper lobes, the
absence of lymphadenopathy, and cavitation. At radiology, postprimary tuberculosis may
manifest as parenchymal disease, airway involvement, and pleural extension.
Parenchymal Disease.The earliest finding in parenchymal disease is patchy, poorly defined

consolidation, particularly in the apical and posterior segments of the upper lobes (28). In the
majority of cases, more than one pulmonary segment is involved, with bilateral disease seen in
onethird to two-thirds of cases.
Cavitation, the hallmark of postprimary tuberculosis, affects about 50% of patients. The
cavities typically have thick, irregular walls, which become smooth and thin with successful
treatment. Cavities are usually multiple and occur within areas of consolidation (Figs 4, 5).
Resolution can result in emphysematous change or scarring. A minority of cavities demonstrate
air-fluid levels; however, these findings can indicate the presence of superinfection.
If there is airway disease and, in particular, endobronchial spread of infection, tree-in-bud
opacities may develop. These findings, which are usually visible in the lung periphery and
resemble a branching tree with buds at the tips of the branches, are indicative of active
tuberculosis (Fig 6). Lymphadenopathy and pneumothoraces are seen in only about 5% of
patients (27).
Figure 4. Parenchymal
postprimary tuberculosis.
Chest radiograph
demonstrates the
characteristic bilateral
upper lobe fibrosis
associated with
postprimary
tuberculosis.
Airway Involvement.Airway involvement is characterized by bronchial stenosis, leading to

lobar collapse or hyperinflation, obstructive pneumonia, and mucoid impaction. Bronchial
stenosis is seen in 10%40% of patients with active tuberculosis (27) and is best demonstrated
with CT, which usually shows long segment narrowing with irregular wall thickening, luminal
obstruction, and extrinsic compression (30). It also results in tree-in-bud opacities and traction
bronchiectasis, particularly of the upper lobes.
Pleural Extension.Pleural effusions occur most often in primary tuberculosis but are seen in
approximately 18% of patients with postprimary tuberculosis; they are usually small and
associated with parenchymal disease. The effusions are typically septated and can remain stable
in size for many years (Fig 7). The pleura may become thickened, which can result in a
tuberculous empyema and an associated risk of developing a bronchopleural fistula. Residual
pleural thickening and calcification may also occur.
Burrill JB. Tuberculosis: A Radiologic Review. RSNA. RadioGraphics 2007; 27:12551273

Published online 10.1148/rg.275065176

Pulmonary Tuberculosis: Parenchymal Disease

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Pulmonary Tuberculosis

Parenchymal Disease.Typically, parenchymal disease manifests as dense, homogeneous

Figure 1. Parenchymal Figure 2. Lymphadenopathy in a

Pleural Effusion.A pleural effusion is seen in approximately one-fourth of patients with

Postprimary tuberculosis remains primarily a disease of adolescence and adulthood. It occurs in

Parenchymal Disease.The earliest finding in parenchymal disease is patchy, poorly defined

Airway Involvement.Airway involvement is characterized by bronchial stenosis, leading to

Burrill JB. Tuberculosis: A Radiologic Review. RSNA. RadioGraphics 2007; 27:12551273

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