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]

Overview

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.

Primary Tuberculosis

• The 3 major findings on chest X-ray are parenchymal infiltrates, hilar adenopathy, and pleural effusion.
• Primary tuberculosis may affect any part in the lung.
• Children often present with hilar lymphadenopathy on chest X-ray, which can be present in up to 95% of children with active tuberculosis.
• Less than 50% of adults with primary tuberculosis present with hilar lymphadenopathy.
• Tuberculomas (opacities similar to a lung mass) can be seen in 5% of patients and can reach 4 cm in size.
• Unilateral pleural effusion can be seen as a complication of primary tuberculosis.

Secondary Tuberculosis

• Secondary tuberculosis usually targets the upper lobes, particularly the apical and posterior segments. However, lesions can be present anywhere in the lungs.
• The X-ray findings in secondary or reactivated tuberculosis include:

• Patchy consolidation is poorly defined.
• Cavitation, that is the most commonly observed finding in secondary tuberculosis

• It has thick walls and irregular margins.
• It may be observed in almost 50% of patients.
• Usually located in the upper lung.
• Cavities in the lower lung can be found in diabetes and HIV infection.
• Despite being rare, superinfection of the cavities may occur and an air-fluid level is seen inside the cavity.

• Pneumothorax is rare but may be seen in 5% of patients.
• Lymphadenopathy is also uncommon in secondary tuberculosis.
• Small pleural effusion may occur in 18% of patients.

• In the majority of cases the consolidation involves more than one lobe.

Chest X-Ray Images in Pulmonary Tuberculosis

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  Pulmonary Tuberculosis

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  Pulmonary Tuberculosis

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  Pulmonary Tuberculosis

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  Bilateral Pulmonary Tuberculosis

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  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.

Further information: [[:Miliary tuberculosis]]

Chest X-Ray Images in Miliary Tuberculosis

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  Miliary Tuberculosis

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  Miliary Tuberculosis

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  Miliary Tuberculosis

CDC Guidelines for Evaluating Chest X-Ray

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

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:

• The signs or symptoms of TB (Class B1).
• Sputum smears positive for AFB (Class A).

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

Other Chest X-Ray Findings

Follow-up

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

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

X-Ray Findings in Complications of Tuberculosis

Complication	X-Ray Findings
Cicatrization	Upper lobe atelectasis Compensatory hyperinflation of the lower lobe Hilar retraction Mediastinal shift Parenchymal bands Fibrotic cavities Fibrotic nodules Traction bronchiectasis
Thin-walled cavity	Present in both active and inactive tuberculosis May regress with treatment Air-filled cysts may persist Maybe misidentified as an emphysematous bulla or pneumatocele.
Aspergilloma	Mobile mass ringed by an air shadow. Calcifications
Broncholithiasis	Calcified material within the lumen of the tracheobronchial tree, originated on a calcified lymph node Airway obstruction Atelectasis Air trapping on the expiration Frequent change in position of the calcified material Mucoid impaction
Fibrosing mediastinitis	Mediastinal widening Localized mass Hilar or mediastinal mass Calcification Pulmonary infiltrates Atelectasis
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.
Malignancy	Bone destruction around the region of the empyema Increased thoracic cavity opacity Medial deviation of the affected pleura Swelling of the soft-tissue