Initial

Roentgenographic

Pulmonry

M ycobacterium

Edward

E. Christensen,
Ho

Ahn,

Geral

M.D.;

M.D.,

F.C.C.P.;

Robert

C. Murry,

Ph.D.;

George

A. Hurst,

M.D.,

W.

John

James

of

Tuberculosis,

Dietz,

M.D.;

S. Chapman,

Anderson,

lnfections*

and M Intracellularis

Kansasii,
Chal

Manifestations

M.D.;

M.D.;

and

F.C.C.P.

The Initial
radiographic
features
of 188 patients
with
pulmonary
infections
due to Mycobacterium
tuberculosis were compared
to 184 patients
with
M
kansasii
and 100 patients with M intraceilularis
infections
The
patients
were all from the University
of Texas
Health
Center at Tyler, all had at least two positive
sputum
cultures and no other potential
pathogen,
and none had a
past medical
history
of any type of tuberculosis.
The
comparison
showed
that
all three
organisms
have
a
strong
tendency
to produce
cavitary
infiltrates
in the
posterior
portions
of the upper lobes. No distinctive
or

pathognomonic
feature
could
be found.
The atypical
organisms
were more likely to produce
thin-wailed
cavities and far advanced
unilateral
disease,
but both
of these
patterns
also occurred
with M
tuberculosis.
Endobronchial
spread and volume
loss
were common
in all
three diseases.
The only definite
difference
seems
to be
the absence
of a primary
or juvenile
form of atypical
tuberculosis
and
a much greater
incidence
of empyema
and postprimary
pleural effusions
with M tuberculosis.
In an individual
case, the roentgenographic
manifestations of the three
diseases
are
indistinguishable.

included

he

incidence

of

pulmonary

infection

from

in the study.
Patients
with a past medical
history
of
of tuberculosis,
a second
potential
pathogen
within
six months,
normal
or equivocal
chest
x-ray films,
or more
than 30 days of antituberculosis
therapy
were
excluded.
A
group of 184 cases of M kansa.sii
and
100 cases of M intracellularis
met these
criteria,
and
they
were
compared
to a
randomly
selected
group
of 188 cases of M tuberculosis
seen
over approximately
the same
time,
and fulfilling
the same
criteria.

the

any

atypical
mycobacteria
has been
gradually
increasing
since
the
1950s.12
The
organisms
most
responsible
for
the
increase
are
Mycobacterium
and

kansasii

years,
losis
much

more
been

described

in

atypical

great

Several

detail

is a retrospective

study

The

tuberculosis

M
in

have
but
the

RESULTS

numerous

reported
the
M kansasii3

of

authors

same
tubercuis still

varieties.

of

three
forms
of tuberculosis,8-7
number
of patients
from
SUBJECrS

This

the

texts.
We recently
manifestations

intracellularis.4

these
large

than

these

from
M
tuberculosis

manifestations

articles
and
genographic
M

Over

of infection
but
typical

common

roentgenographic
have

intracellularis.

the incidence
has declined,

roentand

Age,
Lung
a

of Radiology

at the
University
of Texas
Health
University
of Texas
Health
Science
Reprint
requests:
Dr.
Christensen,
ology,
University
of Texas
Health
75235

132

and

roentof pul-

initial

Internal
Tyler,
Dallas.

Department
Science

age,

and

race,

of disease

of patients
with
almost
identical,
the

Center,
Center,

The
types

genographic
features
of the three
most common
forms
monary
tuberculosis:
M tuberculosis,
M kansasii,
and M introcellularis.
The
cases are all from
the University
of Texas
Health
Center
at Tyler
(formerly
the East Texas
Chest Hospital).
Patients
with
two
positive
sputum
cultures
for
M kansasii
or M intracellularis
between
1957 and 1977 are
#{176}Fromthe Departments

Race,
Sex
Disease

Associated

Obstructive

compared

never
with
same
hospital.

METHODS
comparing

form

Medicine
and

of

Center,

CHRISTENSEN ET Al.

Downloaded From: http://journal.publications.chestnet.org/ on 04/27/2016

the

RadiDallas

patients

at

least

and
are

sex

shown

distribution

of

in Table

1. The

M tuberculosis
and
but
M intracetlularis
a decade

M kansasii
occurred

older.

Female

acquired
M kansasii
infections
at
than
male
subjects
by approximately
three
diseases
were
more
common
especially

women
subjects
mycobacterioses
10 percent
were
black

where

kansasii,

by
were

the
mean

men

three
age
was
in

subjects

a younger
ten years.
in men,

age
All

but

outnumbered

ratio
of 4:1.
The
atypical
less common
in blacks.
Only

of the patients
with
M intracellularis
as opposed
to 40 percent
with
M tuber-

culosis.
Roentgenographically-evident

chronic

obstruc-

CHEST, 80: 2, AUGUST, 1981

Table

1-Age,

Race,

Sex

and

Table

COPD

2-Distribution

of Disease

(Percentage

a/Patients)
M

M
kansasii

tuberculosis
No.

of patients

188

M
intracetlulare

184

48

50

63

Males

50

52

63

Bilateral

Females

45

41

61

Unilateral

Age

(mean),

yr

disease
disease

Right
Race

(percent)
60

Black

39

Latin

Sex

lung

Left

White

80
1

lung

18

Lobar

the

distribution
initial

Right

Male

71

81

65

29

19

35

Left
Right

COPD

(percent)

Bullous

disease

(percent)

pulmonary

emphysema
1)

than

years

with

Fxcunz
bullous

either

Left

18

39

24

Right

and!

intracellularis

The

64

41

36

59

35

22

40

24

14

19

11

78
63

73

72

49

48

65

of

site(s)

of

and

the

fact

more

significant
were

by
an

*Far

or M tuthe inci-

kansasii

intra-

average

lower
lower

lobe
lobe

middle

lobe

0.5

15

unilateral

disease*

kansasii

in

upper lobe
upper
lobe

Extensive

bullous

difference
M

kansasii

or

with

between

is made
with

advanced

in these
similar

three
with

diseas

e in

at

least

two

forms
of tuberculosis
only
one important

lobes.

was remarkably
exception
(Table

that
of

ten

younger.

Characteristics
The

52

common

1).

of COPD

cellularis

61

(COPD)

more

(Table

patients

44

disease
was

berculosis
dence

intracellukiris,
Percent

infection

Female

(Fig

kansa8ii,
Percent

92

(percent)

tive

tuberculosis,
Percent

100

of the

distribution

Pulmonary

and

1. Severe

chronic

emphysema

in

extent

obstructive

Disease
of pulmonary

pulmonary

disease

disease

and

a 44-year-old
white
woman
with
from M kansasii.
Disease
is primari-

small left apical

infiltrate
ly infiltrative
but with several
holes
medially
which
could
represent
either
cavities
or blebs.
Apical
disease
was not
present
one year earlier.

CHEST, 80: 2, AUGUST, 1981

Ficuax
2. Extensive
unilateral
M kansasil
in a 52-year-old
white
man. There
are multiple
cavities
in right
upper
lobe
with extensive
surrounding
lung disease
and endobronchial
spread to right middle and lower lobes. Left lung was normal.

INITIAL ROENTGENOGRAPHICMANIFESTATIONS OF PULMONARY INFECTIONS

Downloaded From: http://journal.publications.chestnet.org/ on 04/27/2016

133

2).The

is that

exception

prone

to

(Fig

produce

2).

All

dilection

far

three

for

the

unilateral.
This
was somewhat
terioses

per

organisms

had
when

Atypical

always
had

Cavitary

disease
M

with

and

96

is one

berculosis,

and

identical

with

of

patients

of

the

significant

and

the

sizes

of

with

little

ease

(Fig

with

4),

three

organisms.

Cicatricial

Hilar
mon

and

sasii,

0.5

percent.

athy

had

ipsilateral,

ease

which

losis.

as

younger

than

kansasii,

pyema.

in

all

all
three

70 percent

cavities
disease

No
had

with

in

patient
either
of

Thickening

with

common

modest

amount

72-year-old

of

white

man

surwith

to

cavities
common

Some

degree

losis,

in

37

the

occurred

more

present

with
M kansasii
a large
pleural

with

all

of contiguous
24

percent

percent

with

three

atypical

the

pleural

of patients
M

intracelor em-

immediately

pleura
with

or M
effusion

kansasii,

adjacent

diseases
but
mycobacterioses.
thickening
with

and

was
was

tubercu-

56

percent

of patients

were

of the
posterior,

these

incidence

tubercuksis,
and

patients

with

upper

lobe

cavitary
and
of re-activation
patients

other

uncom-

The

4 percent;

usually

general,

unusual

Multiple
lung

intracellularis.

pyema.
lularis

tuberculosis.

follows:

characteristic

In

patients

of

of tuberculosis.

All

was

rounding

dis-

and

were

intracellularis,

considered

percent

3.

FIGURE

the numbers
thin-walled

adenopathy

types

was

Most
there

and

Disease

mediastinal

adenopathy

of

10

and

Pleural

in all three

percent;

disease.

atelectasis
occurred
in 55 perM tuberculosis,
68 percent
of

patients
with M kansasii,
with M intracellularis.
and

tu-

parenchymal

were

lobar
with

Lung

3),

between
Solitary,

but

reactions

diseases.
Partial
cent of patients

Adenopathy

of

Mycobacterium

occurred

pa-

is virtually

(Fig

in

with

levels

pulmonary

intracellularis

percent

Fluid

kansasii.

of

cavities.

occurred

of

intracellularis,

surrounding

mycobacterioses

and

percent

with

difference

or

region).

varieties

alMost

apices

the

87

cavities

the

disease

cavitation

three

no

cavities,

in

and

trachea.

and
hallmarks

multiple

was

the

either

resulting

the

had

patients

in

occurred

the

in

infraclavicular

tuberculosis

percent

necrosis

location
lobe

to

disease

upThe

in 2 percent,

Upper

immediate

all three

unusual.

atypical

posterior

some

(the

tients

percent.

was

of the

were

M tuberculosis

pre-

right
lung
mycobac-

portions

an

in

2:1

disease

Typically,

posterior

began

subapices

the

infect
the
the atypical

for

began

more

disease

an almost

distributions

M intracellularis

patients

to

in the

percent
of patients,
M kansasii
in 0.5
most

side

is much

unilateral

M tuberculosis.

began

lobes.

kansasil

right
tendency
stronger

for

than

diseases

advanced,

in

kan-

adenoplung

of

were

patients

5
M

dis-

the type
tubercu-

considerably

their

respective

groups.

Pleural

effusions

percent

of

tracellularis,
were

man
in the
134

small

with
right

patients

and

were

lobe

and

in
M

6
in-

with
M kansasii.
All
for one, a 67-year-old

except

M tuberculosis,

occurring

tuberculosis

4 percent

effusions,

upper

unusual,
M

with

who
and

had
a large

cavitary

disease

ipsilateral

CHRISTENSEN El AL

Downloaded From: http://journal.publications.chestnet.org/ on 04/27/2016

em-

Ficuax
pleural

4. Solitary,
disease
from

thin-walled
M

kansa.csi

cavity
with
in a 63-year-old

contiguous
white

man.

CHEST, 80: 2, AUGUST, 1981

with

ing,

intracellularis.

is, over

cellularis

(16

percent)

Extensive

2 cm,

was

more

percent)

pleural

common

than

with

with

or M tuberculosis

thicken-

were

all

first.

Post

intra-

kansasii

(3

Spread

Intrapulmonary

one
with

all

of

the

lung

forms

three

dissemination

with

least
common
M tuberculosis
general,
diminished
the

immediately

and
per

the
lobe

with

all

the

was

(42

was

types

and

percent).

The

(58

lung

percent).

was

In

disease
of origin;
is,

at greatest

at lowest
spread

risk

risk. Left
upto the lingula

of tuberculosis.

roentgenographic

monary

disease

so

protean

of

that

an

the

For

are

more

example,

rounding

lung

often

in both

cellularis

(10

percent).

frequent

than

than

the

a factor
larger
incidences
of thin-walled

than

by

in

little

than
and

incidence

of the

that

sur-

twice
as
M intra-

tuberculosis

(4

of M tuberculosis

atypical

mycobacterioses

the
cavities.

difference
Therefore,

in the
a thin-

cavity
is more
likely
to be from
M tubercuksis
than
from
either
M kansasti
or M intracellularis.
The
same
sort of an analogy
can be made
extensive

tern.

The

curate

unilateral

disease

differences
that

the

was

by

early

any

other

pat-

too

small

to

allow

ac-

at

this

time.

It

must

be

differentiation

remembered

or

are
name

atypical

mycobacterium

cavitary

rior

diseases

portions
There

a few

mycobacterioses
nisms
do
frequently
M
that

bacilli,

tuberculosis
First,

not form
a primary
encountered
in
did

This
not

is

demonstrate

CHEST, 80: 2, AUGUST, 1981

the

complex
younger
an

site,

not
type

with

difference
our

patients

to another.8
the
atypical

the

lungs

or

in

the

material

rior

and

lobes.
however,

the

case

the

distribution

of

the

intracellularis
they

fact

be

is

no

complex

in the

caused

ab-

be

resembles

that

of the

usual

disease.
with

The

typical

hi-

case,

pattern

from
the

the

site

anywhere

of

in the

evidence

produce

M kansasii

by

same

deposited

fashion

mycolung

sedimentation
from
circupoorly
identified
factors.
the

almost

may
of liquid
For
ex-

would

is,

granulomas

lesions

the

alterna-

mycobacterioses,

pulmonary

existing

intraceltularis

An

lobes
or supeof the lower

that

follow
also

are
is in

tubercuof these

of deposition

atypical

to be
other

the

apical-

of the atypical
an anaerobic

of lesions

of apical

berculosis
is held
lating
blood,
plus

that

of the

progressive

that

the

mycobacteria

tuberculosis,

pathogenesis

fact

to

of the upper
basilar
segments

portions

of re-activation
variety

of
site

posterior

In

halves

from

the aspiration
the pharynx.

from

frequent

axillaiy

lower

foci.10

is through

most

the

disseminates

atypical

fre-

of typical

of the lungs.
Secondary
subsequent
re-activation

ample,
if the pathogenesis
bacterioses
was like that
the

case

bloodstream,

which

semisolid

The distribusilica
dust or

in approximate-

in

disseminated
by

impli-

characteristically
lungs
more

disease
then

of

is not

important

begins

the

atypiroute

disease

In the

primary

via

route

reach

orga-

of the
patients

important
because

are

atypical

the

human
of

halves.

disease

posterior
portions
losis occurs
with
tive

with

of the

bacilli,
of the

patients

The

conceivably

atypical

that
the

upper

of

lungs.

there
the

common

The

but

have

tubercle

If

M tuberculosis,
in the
apical-poste-

between

study.

may

the

that

bacillus.

like

lobes.

differences

in our

tuberculosis.8
we

occur

upper

and

out

brought

that

of the

are

just

with
major
extrapulmo-

understood.

from one
distribution

than

of the

my-

M intra-

and

less

is unknown,

quently

are

body

of tubercle
lower
halves

The

mycobacteria,

pathogenesis

nuclei
the

emphasize

atypical

and

droplet
involves

differences

investigators

kansasii
in patients
Localized

much

the
with

Disseminated

cations
with
respect
to pathogenesis.
tion of inhaled
particles,
for example,

to

The

the

mycobacterioses

bacteriologic
and not roentgenographic
between
these
organisms
and the tubercle

chosen

rare.

also

considered
contagious
The
apical-posterior

scess,

walled

with

into

is not

hematogeneously

disease.

with

occur
more
(10 percent)

percent)

are

epidemiology

entry

follows
common
the atypical

organisms.

mycobacterioses

primary

from
Some

atypical

cavities

disease
M kansasii

However,

is greater

with

thin-walled

pul-

individual

case of M tuberculosis
cannot
be distinguished
#{149}one
of either
M kansas#{252} or M intracellularis.
patterns

atypical

both

usually
occurs
deficiencies.9

ly two-thirds

manifestations

are

infections

these

is also

with

and

nary

cal

DIscussioN
The

Empyema

is rare

The
most

percent)

of endobronchial
from
the site

more
distant
lung
disease
frequently

common

origin
(68

kansasii

adjacent

three

of

intermediate

incidence
centrifugally

from

was

Endobronchial

lobe

intracellularis

with

the

another

of tuberculosis.

beyond

common

disease

of

to

difference

pleural
effusions,
do not occur
with

M tuberculosis,

cellularis
immunologic

dissemination

portion

second

primary

cobacterioses.

(0 percent).

disease
Endobronchial

adults.

a
of other

that
primary

and

suggests
circulation.
origin

could

body,

since

M kansa.s

i or

pulmonary

granulomatous

dis-

eases.
ACKNOWLEDGMENTS:

Glenda

Parkison

The

for manuscript

authors

preparation,

for photography,
John
Moore
and Curtis
assistance
in Dallas,
and Mary Bailey and

technical

assistance

would

like

to

thank

Nancy
Schreiber
Chaney
for technical

Reba

Hackney

for

in Tyler.

INITIAL ROENTGENOGRAPHICMANIFESTATIONS OF PULMONARY INFECTIONS 135

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bacterium

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disease;
individuals
holding
the degree
of M.D.,
D.O.,
Ph.D.,
or Sc.D.
or others
with
comparable
qualifications
for further
training
as scientific
investigators
in this
field.
Priority
will
be given
to applicants
interested
in academic
careers.
Limited
to U.S. citizens
to train
in the U.S.
or Canada
and
to Canadian
citizens
or holders
of bona
fide
U.S.
permanent
visas
for
training
in
U.S.
institutions.
Awards
are up to $14,000.
Renewal
is possible
for a total
of three
years
of support.
Edward
Livingston
Trudeau
Fellowships
are awarded
to holders
of an M.D.
or
equivalent
degree
who
have
completed
graduate
training
in the field
of lung
disease
and
who
have
appointments
in schools
of medicine
or osteopathy.
The
Fellowships
are intended
to give
promising
instructors
an opportunity
to stay in academic
medicine
and

to

the
Trudeau
by

lowship

prove

themselves

school.

as

Awards

Fellowship
support

are

support.
allowable

teachers
up

and
to

$15,000.

If preceded
is four
years.

investigators.
Renewals

The

award

requires

are

possible

for

by a Training
Fellowship,
Limited
to U.S.
citizens

supplement
three

years

of

the maximum
Felin U.S.
or Canadian

citizens
in U.S. schools.
Completed
applications
must be received
by October
1, 1981. Payments
are
made
directly
to the Fellow
on a quarterly
basis. Fellowships
are granted
for one year and
may begin
on any date approved
by the Review
Committees.
The usual
beginning
date
is July 1. Fellowship
grants
will be given
only
to individuals
in institutions
identified
as Equal
Opportunity
Employers.
Further
information
and application
forms
may be
obtained
from:
American
Lung
Association,
Director
of Medical
Affairs,
1740
Broadway, New York, N.Y. 10019.

schools

136

and

to Canadian

CHRISTENSENEl AL

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CHEST, 80: 2, AUGUST, 1981