Tuberculosis chest x ray

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mashal Awais, M.D.[2]; Alejandro Lemor, M.D. [3]


X-ray is a main diagnostic method for pulmonary tuberculosis. Chest X-ray may show parenchymal infiltrates, hilar adenopathy, cavitation, nodules and pleural effusion. Pulmonary tuberculosis is often present in the upper lobes.

Chest X-Ray

An anteroposterior chest X-ray is one of the main imaging tests to be done in a patient with tuberculosis or suspected tuberculosis.[1]

Primary Tuberculosis

Secondary Tuberculosis

  • In the majority of cases the consolidation involves more than one lobe.[7]
Chest X-Ray Images in Pulmonary Tuberculosis

Common Findings of Miliary Tuberculosis on Chest X-Ray

  • Fine, pinpoint approximately 1-2mm in size, discrete, uniform distribution, soft mottlings.
  • Commonly found throughout both lungs.
Chest X-Ray Images in Miliary Tuberculosis

CDC Guidelines for Evaluating Chest X-Ray[8]

A medical examination is obligatory for all refugees traveling to the U.S. and all applicants outside the U.S. applying for an immigrant visa. The aim of the medical examination is to detect applicants with inadmissible health-related conditions such as active tuberculosis. Outside the U.S., medical examinations are done by about 400 physicians (panel physicians) who are selected by United States Department of State consular officials. In the U.S., medical examinations are done by about 3,000 physicians (civil surgeons) selected by district directors of the U.S. Citizenship and Immigration Services. Centers for Disease Control and Prevention (CDC) has been responsible for establishing the guidelines.

The chest X-ray and classification system is structured to collect findings into categories according to their probability of being related to TB or non-TB conditions requiring medical follow-up.

Abnormal Findings

Chest X-Ray Findings that Can Suggest Active TB

This category consists of all findings typically associated with active pulmonary TB. An applicant with any of the following findings must perform an examination of sputum specimens.

Chest X-ray Findings Description
Infiltrate or consolidation Opacificaties within the lung parenchyma. Consolidation or infiltrate may be dense or patchy and has irregular, ill-defined, or hazy borders.
Any cavitary lesion Lucency (darkened area) within the lung parenchyma, with or without irregular margins that may be surrounded by an area of airspace consolidation or infiltrates, or by nodular or fibrotic (reticular) densities, or both. The walls around the lucent area may be thick or thin. Calcification may also exist surrounding a cavity.
Nodule with poorly defined margins Round density within the lung parenchyma, also known as a tuberculoma. Nodules included in this category are those with margins that are poorly defined. The surrounding haziness may be either subtle or readily obvious and indicates coexisting airspace consolidation.
Pleural effusion Presence of a high amount of fluid within the pleural space. This finding must be differentiated from blunting of the costophrenic angle, which may or may not represent a small amount of fluid within the pleural space (except in children when even minor blunting of the costophrenic angle is considered a finding suggestive of active TB).
Hilar or mediastinal lymphadenopathy (bihilar lymphadenopathy) Enlargement of lymph nodes in one or both hila or within the mediastinum, with or without associated consolidation or atelectasis.
Linear, interstitial disease (in children only) Prominence of linear, interstitial (septal) markings.
Other Any other finding indicating active TB, such as miliary TB. Miliary findings are nodules of millet size (1 to 2 millimeters) distributed throughout the parenchyma.
Adpated from CDC[8]

Chest X-Ray Findings that Can Suggest Inactive TB

These findings can be suggestive of prior TB, that is inactive. It is not possible to diagnose active TB based on only a single radiograph. If a diagnosis active TB is in doubt, sputum smears examination must be performed. Additionally, if there are any signs or symptoms of TB, examination of sputum smears must be performed then. Consequently, any applicant may have findings grouped in this category, but still have active TB as suggested by:

Chest X-ray Findings Description
Discrete fibrotic scar or linear opacity Discrete reticular densities within the lung with distinct edges and without suggestion of airspace opacification or haziness between or around the densities. Calcification may be seen within the lesion and then the it is called a fibrocalcific scar.
Discrete nodule(s) without calcification One or multiple nodular densities with distinct borders and without any surrounding airspace opacification. Nodules are generally round or have rounded edges. These characteristics allow them to be differentiated from infiltrates or airspace opacities. These nodules must be noncalcified to be included in this category.
Discrete fibrotic scar with volume loss or retraction Discrete linear densities with reduction in the space occupied by the upper lobe. Usually upward deviation of the hilum on the corresponding side with asymmetry of the volumes of the two thoracic cavities are present as associated signs.
Discrete nodule(s) with volume loss or retraction One or multiple nodular densities with distinct borders and no surrounding airspace opacification with reduction in the space occupied by the upper lobe. Nodules are mainly rounded.
Other Any other finding indicating previous TB, such as upper lobe bronchiectasis.
Adpated from CDC[8]

Other Chest X-Ray Findings


This category includes findings that require a follow-up evaluation for non-TB conditions either at the time of the chest X-ray or after resettlement of the applicant in the U.S.

Chest X-ray Findings Description
Musculoskeletal abnormalities New bony fractures or bony abnormalities present on radiographs that require follow-up.
Cardiac abnormalities Cardiac or vascular abnormalities, or any other cardiovascular abnormality of significant nature present on radiographs to require follow-up.
Pulmonary abnormalities Pulmonary finding that is not suggestive of TB, such as a mass, that requires follow-up.
Other Any other finding that the panel physician believes needs follow-up, but is not one of the above.
Adpated from CDC[8]

Follow-up Not Required

This includes findings that are minor and do not suggest TB disease. This does not need follow-up evaluation after the applicant resettlement.

Chest X-ray Findings Description
Pleural thickening Irregularity of the pleural margin, including apical capping (thickening of the pleura in the apical region). Pleural thickening may be calcified.
Diaphragmatic tenting A localized accentuation of the normal convexity of the hemidiaphragm as if 'pulled upwards by a string'.
Blunting of costophrenic angle (in adults) Blunting or loss of sharpness of one or both costophrenic angles. Blunting can be related to a small amount of fluid in the pleural space or to pleural thickening and, by itself, is a non-specific finding (except in children, when even minor blunting is considered an indication of active TB). In contrast a large pleural effusion, or the presence of a significant amount of fluid in the pleural space, may be a sign of active TB at any age.
Solitary calcified nodules or granuloma Discrete calcified nodule or granuloma, or calcified lymph node. The calcified nodule may be present within the lung, hilium, or mediastinum. The borders must be sharp and well defined. Formerly, it was considered a Class B3 TB; however, Class B3 has been excluded from the classification scheme because it has not been reported to be associated with active TB.
Adpated from CDC[8]

X-Ray Findings in Complications of Tuberculosis

Complication X-Ray Findings
Thin-walled cavity
  • Present in both active and inactive tuberculosis
  • May regress with treatment
  • Air-filled cysts may persist[10]
  • Maybe misidentified as an emphysematous bulla or pneumatocele.
  • Mobile mass ringed by an air shadow.
  • Calcifications
Fibrosing mediastinitis
Tuberculous spondylitis (Pott's disease)
  • Vertebral endplate irregularities
  • Reduction of the intervertebral disk space
  • Adjacent bone sclerosis
  • In advanced stages of the disease, kyphosis can occur as a result of anterior compression of the vertebral bodies, and paravertebral abscesses.


  1. Riccardo Piccazzo, Francesco Paparo & Giacomo Garlaschi (2014). "Diagnostic accuracy of chest radiography for the diagnosis of tuberculosis (TB) and its role in the detection of latent TB infection: a systematic review". The Journal of rheumatology. Supplement. 91: 32–40. doi:10.3899/jrheum.140100. PMID 24788998. Unknown parameter |month= ignored (help)
  2. 2.0 2.1 Cardinale, L.; Parlatano, D.; Boccuzzi, F.; Onoscuri, M.; Volpicelli, G.; Veltri, A. (2014). "The imaging spectrum of pulmonary tuberculosis". Acta Radiologica. doi:10.1177/0284185114533247. ISSN 0284-1851.
  3. Kim, Hyae Young; Song, Koun-Sik; Goo, Jin Mo; Lee, Jin Seong; Lee, Kyoung Soo; Lim, Tae-Hwan (2001). "Thoracic Sequelae and Complications of Tuberculosis1". RadioGraphics. 21 (4): 839–858. doi:10.1148/radiographics.21.4.g01jl06839. ISSN 0271-5333.
  4. Woodring JH, Vandiviere HM, Fried AM, Dillon ML, Williams TD, Melvin IG (1986). "Update: the radiographic features of pulmonary tuberculosis". AJR Am J Roentgenol. 146 (3): 497–506. doi:10.2214/ajr.146.3.497. PMID 3484866.
  5. Patel, AnandK; Rami, KiranC; Ghanchi, FerozD (2011). "Radiological presentation of patients of pulmonary tuberculosis with diabetes mellitus". Lung India. 28 (1): 70. doi:10.4103/0970-2113.76308. ISSN 0970-2113.
  6. Padyana, Mahesha; Bhat, RaghavendraV; Dinesha, M; Nawaz, Alam (2012). "HIV-Tuberculosis: A Study of Chest X-Ray Patterns in Relation to CD4 Count". North American Journal of Medical Sciences. 4 (5): 221. doi:10.4103/1947-2714.95904. ISSN 1947-2714.
  7. Burrill, Joshua; Williams, Christopher J.; Bain, Gillian; Conder, Gabriel; Hine, Andrew L.; Misra, Rakesh R. (2007). "Tuberculosis: A Radiologic Review1". RadioGraphics. 27 (5): 1255–1273. doi:10.1148/rg.275065176. ISSN 0271-5333.
  8. 8.0 8.1 8.2 8.3 8.4 "CDC Medical Examination of Immigrants and Refugees".
  9. Kim HY, Song KS, Goo JM, Lee JS, Lee KS, Lim TH (2001). "Thoracic sequelae and complications of tuberculosis". Radiographics. 21 (4): 839–58, discussion 859-60. doi:10.1148/radiographics.21.4.g01jl06839. PMID 11452057.
  10. Fraser, Richard (1994). Synopsis of diseases of the chest. Philadelphia: W.B. Saunders. ISBN 0721636691.
  11. Galdermans D, Verhaert J, Van Meerbeeck J, de Backer W, Vermeire P (1990). "Broncholithiasis: present clinical spectrum". Respir Med. 84 (2): 155–6. PMID 2371439.
  12. Minami M, Kawauchi N, Yoshikawa K, Itai Y, Kokubo T, Iguchi M; et al. (1991). "Malignancy associated with chronic empyema: radiologic assessment". Radiology. 178 (2): 417–23. doi:10.1148/radiology.178.2.1987602. PMID 1987602.

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