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52
Chest Imaging

Pulmonary Tuberculosis: Role
of Radiology in Diagnosis and
Management1
Arun C. Nachiappan, MD
Kasra Rahbar, MD Tuberculosis is a public health problem worldwide, including in
Xiao Shi, MD the United States—particularly among immunocompromised pa-
Elizabeth S. Guy, MD tients and other high-risk groups. Tuberculosis manifests in active
Eduardo J. Mortani Barbosa, Jr, MD and latent forms. Active disease can occur as primary tuberculosis,
Girish S. Shroff, MD developing shortly after infection, or postprimary tuberculosis,
Daniel Ocazionez, MD developing after a long period of latent infection. Primary tubercu-
Alan E. Schlesinger, MD losis occurs most commonly in children and immunocompromised
Sharyn I. Katz, MD patients, who present with lymphadenopathy, pulmonary consolida-
Mark M. Hammer, MD tion, and pleural effusion. Postprimary tuberculosis may manifest
with cavities, consolidations, and centrilobular nodules. Miliary
Abbreviations: AFB = acid-fast bacilli,
HIV = human immunodeficiency virus, PA =
tuberculosis refers to hematogenously disseminated disease that is
posteroanterior more commonly seen in immunocompromised patients, who pres-
RadioGraphics 2017; 37:52–72
ent with miliary lung nodules and multiorgan involvement. The
principal means of testing for active tuberculosis is sputum analysis,
Published online 10.1148/rg.2017160032
including smear, culture, and nucleic acid amplification testing.
Content Codes: Imaging findings, particularly the presence of cavitation, can affect
1
From the Department of Radiology, University treatment decisions, such as the duration of therapy. Latent tuber-
of Pennsylvania, 3400 Spruce St, 1 Silverstein,
Suite 130, Philadelphia, PA 19104 (A.C.N.,
culosis is an asymptomatic infection that can lead to postprimary
E.J.M.B., S.I.K., M.M.H.); Mallinckrodt Insti- tuberculosis in the future. Patients who are suspected of having
tute of Radiology, Washington University School latent tuberculosis may undergo targeted testing with a tuberculin
of Medicine, St Louis, Mo (K.R.); Department
of Radiology (X.S.) and Department of Medi- skin test or interferon-γ release assay. Chest radiographs are used
cine, Section of Pulmonary and Critical Care to stratify for risk and to assess for asymptomatic active disease.
Medicine (E.S.G.), Baylor College of Medi-
cine, Houston, Tex; Department of Diagnostic
Sequelae of previous tuberculosis that is now inactive manifest
Radiology, University of Texas MD Anderson characteristically as fibronodular opacities in the apical and upper
Cancer Center, Houston, Tex (G.S.S.); Depart- lung zones. Stability of radiographic findings for 6 months distin-
ment of Diagnostic and Interventional Imaging,
University of Texas Medical School at Houston, guishes inactive from active disease. Nontuberculous mycobacterial
Houston, Tex (D.O.); and Department of Radi- disease can sometimes mimic the findings of active tuberculosis,
ology, Texas Children’s Hospital, Houston, Tex
(A.E.S.). Presented as an education exhibit at the
and laboratory confirmation is required to make the distinction.
2014 RSNA Annual Meeting. Received February Familiarity with the imaging, clinical, and laboratory features of tu-
28, 2016; revision requested May 17 and received berculosis is important for diagnosis and management.
July 28; accepted August 9. For this journal-based
SA-CME activity, the authors, editor, and re- ©
RSNA, 2017 • radiographics.rsna.org
viewers have disclosed no relevant relationships.
Address correspondence to A.C.N. (e-mail:
arun.nachiappan@uphs.upenn.edu).
©
RSNA, 2017
Introduction
SA-CME Learning Objectives Tuberculosis is caused by mycobacterial species in the Mycobacterium
tuberculosis complex. M tuberculosis is the species responsible for the
After completing this journal-based SA-CME
activity, participants will be able to:
vast majority of cases, but other species can cause similar disease,
■■Describe the clinical and radiologic
including Mycobacterium bovis, Mycobacterium africanum, Mycobacte-
appearances of primary and postprimary rium microti, and Mycobacterium canettii (1). Airborne mycobacteria
tuberculosis. are transmitted by droplets 1–5 µm in diameter, which can remain
■■Explain the differences between active suspended in the air for several hours when a person with active tu-
tuberculosis and latent tuberculosis, par- berculosis coughs, sneezes, or speaks (1). Not all individuals exposed
ticularly the results of the different labo-
ratory tests used to evaluate for each.
to tuberculosis get infected. The probability of transmission to another
individual depends on the infectiousness of the tuberculosis source,
■■Discussthe role of imaging in the man-
agement of patients with tuberculosis. the environment and duration of exposure, and the immune status of
the exposed individual (1). The airborne droplets reach the terminal
See www.rsna.org/education/search/RG.
airspaces by means of inhalation, where the droplets infect alveolar
macrophages. In approximately 5% of infected individuals, the immune

RG  •  Volume 37  Number 1 Nachiappan et al  53

imaging within the clinical context. Laboratory
Teaching Points testing for tuberculosis is also reviewed, to guide
■■ Primary tuberculosis demonstrates radiologic findings that the radiologist in how laboratory findings are
include lymphadenopathy, consolidation, pleural effusion,
and miliary nodules. Postprimary tuberculosis demonstrates
combined with clinical and imaging findings to
consolidations that are predominant in the apical and upper diagnose tuberculosis and manage patients.
lung zones, nodules, and cavitation.
■■ Lymphadenopathy in tuberculosis typically demonstrates a Risk Factors
low-attenuation center with peripheral rim enhancement on Clinical suspicion for tuberculosis may be height-
contrast material–enhanced CT images, findings that are due ened in patients with various risk factors. Thus,
to central caseous necrosis with peripheral granulomatous in-
any individual at increased risk is eligible for
flammatory tissue.
targeted tuberculosis testing to identify and treat
■■ It is important to note that the tuberculin skin test and
interferon-γ release assays are not designed to evaluate sub-
those with latent infection, prevent the develop-
jects for active tuberculosis. ment of active disease, and prevent further spread
■■ Patients with active tuberculosis who have cavitation on the of tuberculosis (1). Risk factors for tuberculosis
initial chest radiograph and who, at the completion of the ini- can be grouped into two categories: those that
tiation phase of treatment, still demonstrate positive 2-month cause increased risk of exposure to tuberculosis,
tuberculosis cultures are at a high risk of relapse and should and those that increase the risk of developing ac-
continue therapy for a total of 9 months.
tive disease, once a person is infected.
■■ Classic (cavitary) nontuberculous mycobacterial infection can Individuals at increased risk of exposure
have an appearance and clinical manifestations indistinguish-
able from those of postprimary tuberculosis; classic nontuber-
include immigrants from endemic regions
culous mycobacterial infection is characterized by upper lobe (Asia, Africa, Russia, Eastern Europe, and Latin
cavitary lesions and centrilobular and tree-in-bud nodules. America), those with a low income and limited
access to health care, intravenous drug users,
people who live or work in high-risk residential
centers (nursing homes, correctional facilities,
system is inadequate at controlling the initial infec- and homeless shelters), and health care workers
tion, and active tuberculosis develops within the (1). In the United States, immigrants from en-
first 1–2 years (2); this category is referred to as demic areas represent an increasing proportion
primary tuberculosis. In another 5% of infected of tuberculosis cases (4).
individuals, the immune system is effective at Risk factors associated with a higher risk of
controlling the initial infection, but viable myco- progression to active tuberculosis include (a) age
bacteria remain dormant and reactivate at a later younger than 4 years, (b) intravenous drug use,
time (2); this category is referred to as postprimary (c) recent tuberculosis infection or test conver-
or reactivation tuberculosis. The remaining 90% of sion within the past 2 years, and (d) immunode-
individuals will never develop symptomatic disease ficiencies, such as those resulting from human
and will harbor the infection only at a subclinical immunodeficiency virus (HIV)/AIDS infection,
level, which is referred to as latent tuberculosis organ transplantation, and treatment with im-
infection. These individuals are asymptomatic munosuppressive drugs. HIV infection is the
and noncontagious. In latent infection, the host strongest known risk factor for developing active
immune response prevents the multiplication and tuberculosis, with a risk of 7%–10% per year (1).
spread of mycobacteria (1). The immune response Patients treated with biological agents, such as
to mycobacteria has important implications for the therapy with tumor necrosis factor α inhibitors
clinical and imaging appearance of tuberculosis, for autoimmune disorders, have a higher risk of
particularly in immunocompromised patients. reactivation (5); the increasing use of these drugs
Tuberculosis infects an estimated one-third of means that radiologists will need to assess for
the world’s population, thereby making the dis- tuberculosis in these patient populations. Other
ease a major public health issue (3). Nine million conditions that can increase the risk of active dis-
people become infected and 1.5 million people ease include diabetes mellitus, silicosis, chronic
die of tuberculosis every year (1). In the United renal failure, low body weight, prior gastrectomy
States, the rate of active tuberculosis cases was or jejunoileal bypass, alcohol or tobacco abuse,
three cases per 100 000 in 2013 (1). Ethnic and certain malignancies (leukemia, head and
minorities are disproportionately affected in the neck carcinoma, and lung carcinoma) (1).
United States, where 65% of active tuberculosis
cases in 2013 were in foreign-born persons (1). Clinical Features
Imaging plays a pivotal role in the diagnosis The classification of pulmonary tuberculosis is
and management of tuberculosis. In this article, based on clinical and radiologic factors (Table
the radiologic appearance of pulmonary tubercu- 1) (6). Active disease may manifest with symp-
losis is discussed, with an emphasis on the role of toms that are only minimal initially but then

Regardless of the indication. berculin skin test or of disease no infection interferon-γ release assay 1 Exposure to History of exposure Negative results of tu. so that pa- can involve multiple organs such as the lungs. No clinical evidence of Positive results of tuberculin No radiographic evidence berculosis disease skin test or interferon-γ of active disease infection.54  January-February 2017 radiographics. then laboratory evaluation for absence of clinical suspicion. positive active disease (current) culture) 4 Previous Medical history of Positive results of tuberculin Abnormal but stable ra- tuberculo. or bones. tients may be placed in respiratory isolation until liver. spleen. evaluation of patients suspected of having active fatigue. No radiographic evidence tuberculosis. gastrointestinal tract. pending laboratory. Radiologists needed. findings of active tuberculosis or if the patient aminations. no release assay. this population. Meets criteria for active Meets current labora. If the chest radiograph is positive for can aid in diagnosis by performing imaging ex. active tuberculosis should be performed. diologic finding that raises the possibility of active togenously disseminated disease characterized by tuberculosis should prompt immediate communi- numerous tiny lesions. Most extrapulmonary disease is not contagious. which cation with the referring provider. fever. active tuberculosis on diagnosis the basis of clinical. berculin skin test or of disease no infection interferon-γ release assay (done at least 10 weeks after exposure) 2 Latent tu. and central nervous system. No radiographic evidence tuberculosis. For Extrapulmonary tuberculosis results from HIV-positive patients. is warranted. then further workup for active tuberculosis and young children are at higher risk of extrapul. skin test or interferon-γ diographic findings. If toms means that physicians caring for these the chest radiograph is negative and the patient patients must maintain a high index of suspicion is HIV negative. despite active disease. Immunocompromised individuals losis. An algorithm for the evaluation of insidious and nonspecific nature of the symp. a chest radiograph should hematogenous spread or direct extension from be obtained. Miliary tuberculosis is a hema. hemoptysis. negative radiographic evidence (inactive) tuberculosis disease results of bacteriologic of active tuberculosis examinations (if done) disease 5 Tuberculosis Ongoing evaluation for … … suspected. no sis disease no evidence of active release assay. negative results of sputum staining are obtained. geni. tuberculosis disease. . Radiographic evidence of losis disease clinical case tory criteria (eg. no further workup may be that is based on the risk factors. sometimes even incidentally in the is HIV positive. malaise. graph do not guide immediate management. but the results of the chest radio- adjacent organs and may involve the larynx.rsna. such a patient is presented in Figure 1 (8). central nervous system. and/or radiographic findings develop during the course of several months (7). any ra- monary disease.org Table 1: Classification of Tuberculosis on the Basis of Clinical and Radiologic Findings Chest Radiographic Class Definition Clinical History Laboratory Test Results Findings 0 No exposure to No history of exposure Negative results of tu. measuring 1–3 mm. and night sweats (7). Active Tuberculosis Typical symptoms of active tuberculosis include Imaging has an important role in the initial a productive cough. pleura. because radiographic findings may be normal in tourinary tract. weight loss. If tuberculosis is not initially suspected clini- with the exception of laryngeal tuberculosis. negative tuberculosis results of bacteriologic disease examinations (if done) 3 Active tubercu. lymph nodes. No cally but radiographic or computed tomographic evidence of tuberculosis may be seen on chest (CT) findings are concerning for active tubercu- radiographs. The tuberculosis.

With regard to postprimary tuberculosis.13). †† = send one of the sputum specimens for a nucleic acid amplifica- tion test. weight loss. although there are several different close contacts are managed appropriately. if either of them is positive. Overall. where available. and postprimary lymphadenopathy is the most common radio- tuberculosis was believed to always represent re. recent exposure and conversion within the past 2 years. forms of active tuberculosis. Note that if the chest radiograph and HIV status are both negative. reactivation causes the majority of cases of postprimary tuberculosis in developed countries. where such a system is in place. consoli. Because ripheral rim enhancement on contrast material– of more-effective therapies and the declining enhanced CT images (Fig 2). however. ** = high-risk factors for tuberculosis exposure or reactivation (eg. it is more important Primary tuberculosis demonstrates radiologic to distinguish between active and latent tuber- findings that include lymphadenopathy.  Lymphadenopathy from primary tuber- culosis in a 6-month-old male infant.  Diagram of an algorithm for the evalua- tion of patients who are suspected of having active tuberculosis (TB) (concern for active tuberculosis).RG  •  Volume 37  Number 1 Nachiappan et al  55 Figure 1. the next step is obtaining sputum. Traditionally. oped countries are actually primary tuberculosis The differential diagnosis of necrotic lymphade- (10. The clinical and imaging manifestations of tuberculosis may be re- Infection prevention personnel should also be no. immigration from endemic area. HIV-positive status. hemopty- sis. and miliary nodules (9). Lymphadenopathy.11). cough. night sweats. granulomatous inflammatory tissue (Fig 3) (16). Postprimary tuberculosis demonstrates consoli- dations that are predominant in the apical and Primary Tuberculosis upper lung zones. † = positive chest radiograph refers to findings that may represent active tuberculosis. In con- trast. logic manifestation of primary tuberculosis (2). AFB = acid-fast bacilli. nodules. activation of latent infection in adults. to ensure suppression. due to central caseous necrosis with peripheral 23%–34% of adult tuberculosis cases in devel. culosis (Table 1) than to distinguish between dation.—Mediastinal and hilar ered a disease of childhood. findings that are prevalence of tuberculosis in developed countries. pleural effusion. and cavitation (2). then stop. nopathy includes nontuberculous mycobacterial . a Lymphadenopathy in tuberculosis typically better understanding of the disease reveals these demonstrates a low-attenuation center with pe- notions to be somewhat inaccurate. primary and postprimary tuberculosis. Axial contrast- enhanced chest CT image shows necrotic medias- tinal lymphadenopathy (arrow) and a small right- sided pleural effusion. Figure 2. particularly immuno- tified. primary tuberculosis was consid. lated more to host factors. and immunosuppression). than to the mechanism of infection that patients with active tuberculosis and their (15). However. * = fever. evidence suggests that patients in endemic areas are more likely to be infected by a second strain of tuberculosis than to experience reactivation of a previously infected strain (12. although a second infection is responsible for a small fraction of cases (14).

  Tuberculous empyema in a 40-year-old woman most frequently manifests as consolidation presenting with weight loss.org Figure 4. consistent with lymphadenopathy (arrow). phages. infection.20). consolidation is generally slow. in contrast to postprimary disease to tuberculous protein.18).) dation (arrowhead) in the right middle and lower lobes. and consoli- sity Hospital. Cavitation occurs in a minority of patients with primary tuberculosis (29% in one series in 6%–11% of pediatric cases. Cytologic adenopathy can be a clue that points toward examination of the pleural fluid typically reveals primary tuberculosis. Parenchymal Disease. and when cavitation occurs. Pleural specimens can be examined for Pleural Effusion. Mineola. and in many cases. rather than frank pleural (2). strong lobar predilection in primary tuberculosis (19). enhancing pleura (arrows) as well as or lobar distribution (Fig 4) (2. Axial contrast- depicted as an area of opacity in a segmental enhanced chest CT image shows a loculated right-sided pleural effusion with thickened. under a CC BY-SA 2. taking as long as such as determining the fluid level of adenosine 2 years. residual opacities are deaminase.—Parenchymal disease Figure 5. If the results of fluid analysis are dation in 15%–18% of patients and is referred to not definitive. Frontal chest radio- shows tuberculous lymphadenitis with central caseous graph shows thickening of the right paratracheal stripe.19).—Pleural effusion is seen in ap. residual parenchy. mediastinal and hilar lymphadenopathy may be the only radiologic finding (9). with increasing [19]). Resolution of pulmonary predominantly lymphocytes. certain fluid studies. There is no infiltration of the extrapleural fat (arrowhead). Winthrop Univer. Tuberculous pleu- thus does not demonstrate an upper lung zone ral effusions usually result from hypersensitivity predominance. also less common in postprimary disease (ap- tion occurs within existing consolidation and proximately 18% of cases) (9). it is known prevalence with age (2. After resolution.56  January-February 2017 radiographics.20). Pleural effusion is and associated with pleural thickening and en- less common in children and may only appear hancement. or Ghon tubercle (9.  Photograph of a gross pathologic specimen (same patient as shown in Fig 2). lymphoma. but the presence of lymph. This cavita. effusions (21). the addition of pleural biopsy can as a Ghon focus. and chills. in adults. findings that represent involvement . Parenchymal disease often appears similar to infection.rsna.0 license. increase the diagnostic yield in these patients (22). NY. At resolution of lymphadenopathy. and metastatic carcinoma (17). MD.  Lymphadenopathy and consolidation in a 6-month-old male infant with primary tuberculosis Figure 3.20). with the vast majority of such effusions Tuberculous empyemas are typically loculated being unilateral (Fig 5) (19). granulomas at histopathologic examination and proximately 25% of primary tuberculosis cases can be cultured for organisms. isolation of M tubercu- bacterial pneumonia. losis from pleural fluid is uncommon. a marker of monocytes and macro- seen (9. necrosis. and therefore. Pleural effusion is as progressive primary disease (2). Lymphadenopathy is seen in 83%–96% of pediatric cases of primary tuberculosis and 10%–43% of adult cases and typically involves the right paratracheal and hilar lymph nodes (Fig 4) (2. are useful in the diagnosis of tuberculous mal scarring can be seen at sites of prior consoli. Within the pediatric population. calcified normal-sized lymph nodes may remain. (Courtesy of Yale Rosen. malaise.

Bronchial stenosis occurs in 10%–40% of patients with active tuberculosis and is due to direct extension from tuberculous lymphadenitis by means of endobronchial or lymphatic dissemi- nation (16). The main radiographic features of proximal airway involvement are indirect.  Airway involvement with tuberculosis in a 41-year-old woman. or failure to thrive. a loculated pleural effusion with marked pleural thickening. Miliary instrumentation is suggestive of a bronchopleural tuberculosis is spread by hematogenous seeding. mucoid impaction. In pri- mary tuberculosis. Miliary tuberculosis may also manifest in- of the pleura.RG  •  Volume 37  Number 1 Nachiappan et al  57 Figure 6. Miliary disease may occur in primary or postprimary tuberculosis. luminal obstruction. residual as demonstrated by the finding of a miliary nod- pleural thickening with calcification can develop. If not treated early. as well as right upper lobe volume loss. On the chest radiograph or CT image.—Bronchial wall involvement Postprimary tuberculosis is typically thought to may be seen in primary and postprimary tubercu. (a) Posteroanterior (PA) chest radio- graph shows right upper lobe collapse (arrow). airway involve- ment can manifest as long segment narrowing with irregular wall thickening. especially in immunocompromised and pediatric patients. and extension into the chest wall (arrows). result from reactivation of dormant M tuberculosis . potentially leading to fibrothorax (9. although it is more common in the former (16. At CT. fistula (20).  Empyema necessitatis in a 35-year-old man with chronic em- pyema related to tuberculosis. tuberculous sidiously. miliary disease often manifests as an acute. (empyema necessitatis) (Fig 6) (16.24). After treatment and healing. such as with a fever of unknown origin empyemas may be complicated with broncho. severe illness with high mortality (25). also with relatively high mor- pleural fistula or extension into the chest wall tality (26). includ- ing segmental or lobar atelectasis (Fig 7a). ule centered on a small blood vessel (Fig 10).16). miliary disease manifests as diffuse 1–3-mm fluid level within an empyema in the absence of nodules in a random distribution (Fig 9). An air. Axial nonenhanced chest CT image shows pleural calcifications (arrowheads).23). and extrinsic compression (Figs 7b. Figure 7. losis. lobar hyperinflation. (b) Coronal contrast-en- hanced reformatted chest CT image at the level of the central bronchi shows irregular thickening of the right upper lobe bronchus (arrow). 8) (9). Postprimary Tuberculosis Airway Disease. Miliary Tuberculosis Hematogenous dissemination results in miliary tuberculosis. and postob- structive pneumonia (16).

  Miliary tuberculosis in a 53-year-old man. Cavitary lesions are often seen within areas feature of postprimary tuberculosis (Fig 11).27).0 license. Isolated predominance may be related to the relatively involvement of the lung bases is rare and is seen in reduced lymphatic drainage and increased oxy.org Figure 8. MD.  Miliary tuberculosis in a different 53-year-old man Figure 9. seen in 20%–45% of patients (28). Con.rsna. culoma (ranging from 5 mm to 40 mm in largest and night sweats. The apical and upper lung zone lobes in postprimary tuberculosis (16). a noncalcified nodule known as a tuber- present with insidious fever. of consolidation and may be multifocal (Fig solidation and cavitation have a strong predilection 11b) (16). reflecting hematogenous seeding. Mineola. especially in endemic areas (12.) Figure 10.0 license.) (Courtesy of Yale Rosen.—Patchy. findings that predispose to bacterial lobes as well as the superior segments of the lower superinfection. mycetoma formation. on chest radiographs. original magnification. original magnification. Residual cavities may persist after for the apical and posterior segments of the upper treatment. Photomicrograph shows granu- chest CT image shows numerous micronodules in a random lomatous inflammation centered around a small blood vessel distribution. In postprimary tuberculosis. under a CC BY-SA 2. poorly velop thick and irregular walls (Figs 12. In 3%–6% of cases of postprimary tuber- bacillary replication (16. Mineola. ×150. NY. A chest radiograph is typically dimension) may be the predominant manifestation. berculosis even if the chest radiograph is negative. these tuberculomas are typically solitary and may Chest CT may be useful in identifying active tu. MD. Photomicrograph shows granuloma- tous destruction of a bronchial wall on the left (arrows). cavitation is a although chest CT is not the standard of practice common finding. Winthrop University Hospital. 13) marginated consolidation is an early and consistent (16).) (Cour- tesy of Yale Rosen. under a CC BY-SA 2. NY.58  January-February 2017 radiographics. weight loss. stain. Patients typically culosis.13). Winthrop Uni- versity Hospital. factors that facilitate cases (2).) infection but may also result from a second infec- tion with a different strain. ×100. Axial (different patient from Fig 9). (Hematoxylin-eosin (arrow) nodules. Note subpleural (arrowhead) and centrilobular (arrow). only approximately 5% of postprimary tuberculosis gen tension in these regions. occur with small satellite nodules (2). obtained to evaluate for findings of active disease. (Hematoxylin-eosin stain. or erosion . The airway epithelium is intact but inflamed on the right (ar- rowheads). Cavities can be several centimeters in largest dimension and can de- Consolidation and Cavitation. cough.  Airway involvement with tuberculosis in a 41-year-old woman.

under a CC BY-SA 2. with a cavitary lesion (arrowheads). (Courtesy of Yale Rosen. Figures 12. which Immunocompromised Patients results in endobronchial spread (2). Mineola. At CT. NY.) of adjacent vasculature resulting in hemoptysis lower lobes. tuberculosis infection are 20–30 times more likely cally as centrilobular nodules and the tree-in-bud to develop active tuberculosis. Consolidation is also noted in the left upper lobe. For example. centrilobular nodules are with HIV-negative patients (30). when compared sign (Fig 16). The presence of an air-fluid level Involvement of the airways and pleura is less com- within a cavity may be related to the tuberculo.RG  •  Volume 37  Number 1 Nachiappan et al  59 Figure 11. mon in postprimary than in primary tuberculosis sis itself or to bacterial superinfection (16. (a) PA chest radiograph shows patchy airspace opacities (arrows) in the right upper lobe.  (12) Postprimary tuberculosis in a 63-year-old man. distant from the cavitary lesions (16). but shows similar imaging features.29).  Postprimary tuberculosis in a 50-year-old man. (Fig 14) (16). viduals are related to reactivation of latent tuber- dation. Photograph of a gross lung specimen shows necrotizing consolidation in the right upper lobe. Although most seen in approximately 95% of cases of active tu.0 license. which has developed several cavities. 13. tuberculosis cases in immunocompromised indi- berculosis (2). (b) Axial chest CT image shows right upper lobe consolidation (arrows) with associated cavitation (arrowheads). Unlike cavitary lesions and consoli. Immunocompromised patients are at a higher risk caseous necrosis and granulomatous inflammation of developing primary and postprimary tuberculo- fill respiratory bronchioles and alveolar ducts (Fig sis. HIV-positive patients with latent 15). This histologic finding manifests radiologi. the radiologic and clinical manifestations . Histologically. Centrilobular Nodules. (13) Postprimary tuberculosis in a different patient from the one shown in Figure 12. centrilobular nodules may be seen in the culosis.—Active tuberculosis often Tuberculosis in communicates with the bronchial tree. Coronal chest CT image shows a thick-walled cavitary lesion (arrow) in the right upper lobe. MD. Winthrop University Hospital.

NY. with an air-fluid level in the larger lesion (arrowhead). within 60 days after the initiation of highly active Treatment of patients with HIV infection antiretroviral therapy (32). and scattered reticulonodular opacities. Winthrop lobular (arrow) and tree-in-bud (arrowhead) nodules. with consolidation and lymphadenopathy) an entity known as the immune reconstitution (Fig 17a). The patient subsequently underwent bronchial artery embolization. Tuberculosis-associated by using highly active antiretroviral therapy in immune reconstitution inflammatory syndrome is patients infected with tuberculosis may result in more common with CD4 cell counts of less than . (c) Phrenic artery angiographic image shows recruitment of addi- tional vasculature (arrow). ×40. (b) Bronchial artery angio- graphic image shows blush of contrast material around the cavitary lesions (arrow). Mineola. In severely immunosuppressed patients inflammatory syndrome (31). Figure 15.0 license.) well as more confluent areas of consolidation. Photomi. a paradoxical worsening of pulmonary disease. (Hematoxylin-eosin stain. Miliary response to a previously subclinical infection and tuberculosis also occurs at a higher rate in patients affects 10%–25% of patients with AIDS. This phenomenon with pulmonary tuberculosis. typically with severe immunosuppression. original tient from Fig 15). (a) PA chest radiograph shows two left-sided cavitary lesions (arrows). chest radiographs reflects a delayed and often vigorous immune may be normal 10%–40% of the time. MD.60  January-February 2017 radiographics.org Figure 14. Axial chest CT image shows centri- magnification. as University Hospital.rsna. sis (ie. Embolization of the superior branch of the phrenic artery was also performed.  Tuberculous cavity in a 32-year-old man with hemoptysis. under a CC BY-SA 2. Figure 16.  Airway dissemination of tuberculosis.  Airway dissemination of tuberculosis in an crograph shows multiple granulomas (arrowheads) localized 86-year-old man with active tuberculosis (different pa- around airways (arrows). more closely resemble those of primary tuberculo.) (Courtesy of Yale Rosen.

A pneumothorax (arrows) is also depicted. the decreased number of bacteria (39). with postprimary tuberculosis being more of patients with tuberculosis-associated immune common than primary tuberculosis (38). The likelihood of develop- Tuberculosis-associated immune reconstitution ing active tuberculosis decreases with age. In ad. corticosteroid therapy may be used.0 license. children and adolescents with active tuberculosis ening lymphadenopathy and pulmonary consoli.34). (Fig 17b–17e reprinted from reference 35 under a CC BY 3. a finding that represents esophageal perforation with a fistula or sinus tract (arrow) to a necrotic lymph node. (e) One month later. (a) Coronal reformatted image (soft-tissue window) at the level of the clavicular heads shows necrotic lymphadenopathy (arrow). the consolidation has resolved.  Primary tuberculosis in a 39-year-old man with AIDS. are more likely to show an adult pattern of dis- dations and/or nodules (Fig 17) (35). (b) Axial chest CT image (soft-tissue window) at a level just below the carina shows an air collection in the subcarinal region. (c) Three weeks after the onset of administration of highly active antiretroviral therapy. Older inflammatory syndrome often demonstrates wors. (c–e) Sequential magnified axial chest CT images (lung window) at a level just below the carina. (a. after antituberculous treatment. b) Magnified contrast-enhanced chest CT images from the same CT examination. In challenges in children. other infectious tients differs from that in adult disease. Without . primary disease (37). the CT image shows multiple centrilobular nodules (arrows). The most agents such as atypical mycobacteria may result in common form of active tuberculosis in children is immune reconstitution inflammatory syndrome.) 50/μL but can occur even in patients with CD4 Pediatric Tuberculosis cell counts of more than 200/μL (33. Bacteriologic confirma- severe cases. Treatment ease. (d) One week later. diffuse consolidation has developed. The manifestation of tuberculosis in pediatric pa- dition to M tuberculosis complex. tion is less frequent in children than in adults or highly active antiretroviral therapy may be dis. representing tuberculosis- associated immune reconstitution inflammatory syndrome. because of the lower frequency of cavitation and continued (36).RG  •  Volume 37  Number 1 Nachiappan et al  61 Figure 17. and the nodules have markedly improved. reconstitution inflammatory syndrome involves Diagnosis of tuberculosis presents several continuing therapy with antituberculous drugs.

acid-fast referring providers and provide the best patient staining occurs in both M tuberculosis complex care. suspected of having tuberculosis should include expectoration of sputum may be induced with obtaining a history and performing a physical administration of nebulized hypertonic saline. as compared with only 9% of may be helpful for diagnosis (45). bronchoscopy is the next step results of cultures from the adult exposure source. Respiratory isolation can be concluded morning (42). contamination Nucleic acid amplification test   When smear is positive 95 98 Rarely   When smear is negative 48–53 95 Rarely AFB smear ×3 68–72 77–98* Nontuberculous mycobacteria. In examination. .org Table 2: Sensitivity and Specificity of Sputum Tests for Active Tuberculosis Disease Test Sensitivity (%) Specificity (%) False Positives Culture 80–85 98 Rarely. lymphadenopathy. Extrinsic compression of adjacent bronchi may Staining cause symptoms related to airway compression or Once a sputum sample is obtained.41). preferably in the early firmation. including be considered in offering a differential diagnosis. these mycobacteria are derstanding of laboratory testing in patients who termed AFB (Fig 18).62  January-February 2017 radiographics. such as the older grate the relevant laboratory findings and clinical Ziehl-Neelsen stain and newer fluorescent stains context. it is pro- postobstructive pneumonia. Several acid-fast stain- are suspected of having tuberculosis and to inte. nasogastric aspiration have a diagnostic yield of tiated with a presumed diagnosis that is based on approximately 40% in those with radiographic the clinical and imaging findings without labora. generally available within 1 day.rsna. The number of even while the culture results are pending (51). In instances the diagnosis. as compared with awaiting culture con- at 8–24-hour intervals. gastric interferon-γ release assay. culture-positive tuberculosis (48–50) and 62% losis should be placed in respiratory isolation. The results of a sputum smear are after three successive negative smears for AFB. Nocardia organisms (47). if there is mediastinal (Fig 2). tuberculin skin testing. cessed by using an acid-fast staining method. Therefore. prevalence of nontuberculous mycobacteria). smear for AFB with three successive expectorated tory tests are summarized in Table 2 (40. and imaging washings obtained in the early morning with (37). empirical therapy must be ini. a recent history of exposure to bacilli identified on the smear correlates with the an infected adult is often critical in establishing patient’s degree of infectiousness (1). The diagnostic approach to a child in which the patient cannot produce sputum. HIV testing. of Active Tuberculosis and the staining is resistant to removal with acid It is important for radiologists to have a basic un. In cases of sputum smear–negative Hilar and mediastinal lymphadenopathy is the pulmonary tuberculosis. a positive culture. as well as a form of false positives and false negatives should number of other bacterial organisms. Of note. in HIV-positive patients (48). the clinical Laboratory evaluation begins with obtaining context and imaging findings are important to sputum for smear and culture (Fig 1). Thus. Earlier in childhood (ages 0–3 years). to optimize communication with the with improved sensitivity (46). cases later in childhood (ages 5–14 years) (20). who commonly swallow sputum. in evaluation. Three determine the need for empirical antituberculous successive sputum samples should be obtained therapy. The sensitivity of the The sensitivity and specificity of relevant labora. In many cases. If sputum can- tory confirmation. ing techniques are available. The limitations of laboratory testing in the and nontuberculous mycobacteria. signs of pulmonary disease (43). bronchial washing has a radiologic hallmark of pediatric tuberculosis and sensitivity of 73% and a negative predictive value may be transiently seen in asymptomatic patients of 93% (44). Mycobacteria have a lipid-rich cell wall (rich Laboratory Evaluation in mycolic acids) that binds basic fuchsin dyes. rarely. and alcohol. children. treatment may be guided by the not be obtained. endobronchial ultrasound nearly 50% of cases can manifest as isolated (US)–guided transbronchial needle aspiration lymphadenopathy. other bacteria *Specificity varies on the basis of population (ie. sputum specimens is 68%–72% in patients with Patients suspected of having active tubercu. culture. In addition.

magnification. The rate of Inactive tuberculosis is characterized by stable culture confirmation is even lower in children. NY. Table 1. because the test can also detect nonvi- Culture can detect as few as 10 mycobacteria able tuberculous mycobacteria (6). In developing countries. Fibronodular monthly until two consecutive negative results are change is associated with a considerably higher obtained. 21) monitoring the treatment response and affects and calcified lymph nodes are associated with an the length and type of treatment. ×400.  Acid-fast staining for active tuberculosis. of mycobacteria to be detected. If both the nucleic acid amplification micrograph of lung tissue shows numerous AFB (arrows) in the cytoplasm of a giant cell.) (Courtesy of Yale Rosen. extremely low risk of reactivation and are com- Culture studies are also important in de. strains—which are resistant to therapy with iso. per milliliter of sample. Cultures should be obtained cal and upper lung zones (Fig 19). evidence of active disease. the myco. Mineola. at least one group patient with positive results on a tuberculosis of investigators has suggested that extensively screening test should undergo chest radiography . termining the drug susceptibility of the organ. at fibronodular changes. previous Mycobacterial culture remains the reference (inactive) disease demonstrates radiographic or standard for diagnosing active tuberculosis. with clinical evidence of previous tuberculosis but no a sensitivity of 80%–85% and a specificity of evidence of currently active tuberculosis (Table 98%. MD. An algorithm for the evaluation of latent niazid. Thus. at least one respiratory specimen from a patient suspected of having active tuberculosis should be tested with the nucleic acid amplifica- tion test. including scarring (peri- approximately 28% (6). for a patient suspected of emerging (1). concurrently with an AFB smear (Fig Figure 18. Although imaging findings cannot having latent tuberculosis. Culture conversion is an important event in In contrast. More narrowly defined. established with culture findings (6). As the one of the injectable antituberculous drugs—are algorithm indicates. Once growth is detected. whereas at least 5000 mycobacteria per milliliter are required for a Latent Tuberculosis positive smear (52). an interferon-γ release assay. original test and sputum smear yield positive findings. clinical judgment bronchial fibrosis. monly seen in other granulomatous diseases. under a CC BY-SA 2. Winthrop this combination is sufficient for confirmation University Hospital. and tuberculosis is presented in Figure 22.RG  •  Volume 37  Number 1 Nachiappan et al  63 drug-resistant tuberculosis has more-extensive parenchymal findings than multidrug-resistant tuberculosis (53). solid culture Latent tuberculosis is a somewhat broad term that. ing tests in the absence of radiographic or clinical berculous mycobacteria. tural distortion) and nodular opacities in the api- negative patients. as defined in 2 weeks (1). 1) (54). (Ziehl-Neelsen AFB stain.0 license.) of tuberculosis. In 10% of adult cases. whereas the use may encompass latent tuberculosis infection and of liquid culture media can shorten this time to previous (inactive) tuberculosis. bronchiectasis. ate initial test is either a tuberculin skin test or extensively drug-resistant strains. Note that the nucleic acid amplification test cannot be used to follow the clinical response to Culture treatment. such as endemic fungal infections and sarcoidosis ism. rifampin. Nucleic Acid Amplification Test The nucleic acid amplification test is a molecular test that can rapidly detect genetic material of tuberculous mycobacteria from sputum samples within 48 hours (41). and architec- must be used in empirically treating culture. the most appropri- be used to distinguish multidrug-resistant strains. multidrug-resistant (55). Photo. (1). latent infection bacterial species can be identified. Traditionally. which is known as culture conversion risk of developing tuberculosis reactivation (55). bacterial infection. calcified granulomas (Figs 20. or mycetoma. media can take as long as 6 weeks for the growth when used in the discussion of patient treatment. confirmation is never 1) (6). By definition. An asymptomatic tible strains of tuberculosis. and suscep. and treatment should be started (6). Healed tuberculous cavities may persist af- strains—which are resistant to isoniazid and ter active disease resolves and can be complicated rifampin therapy—and extensively drug-resistant by hemoptysis. allowing the refers to positive findings on laboratory screen- distinction of M tuberculosis from other nontu. any fluoroquinolone drug. According to current guidelines.

If the test for infection is posi- findings. treatment of patients with sis. If the chest radio- graph shows normal findings or demonstrates calcified granulomas. of radiographic findings. with a residual cavity (arrow). particularly when no if the last exposure to tuberculosis is recent prior imaging results are available. (arrowhead) and volume loss with a residual cavity (ar- ings have been stable for at least 6 months or if row). If the results of the workup reports should describe whether the radiograph are positive. Treatment of patients with latent tuberculosis is typically single-drug therapy with isoniazid or ri- fampin (1). then further clinical and laboratory evaluation for active tuberculosis is patient does not have a history of antitubercu- required.  Fibronodular scarring at the lung apices in a 46-year-old man with previous (inactive) tuberculo- fibronodular changes. Chest patients with normal test results may be started CT may be helpful for better characterization on therapy for latent tuberculosis. If the chest radiograph demonstrates Figure 19. having latent or inactive tuberculosis. the duration of stability).  Calcified nodules from an old granulo- matous infection in a 52-year-old woman with a posi- tive tuberculin skin test before initiation of biological therapy for inflammatory arthritis. It is important to remember that any . for which 6-month stability ing to the algorithm for evaluation for latent cannot be established. for example. owing to a lack of prior examinations. raise concern for active tuberculosis. PA chest radiograph shows scattered calcified nodules (arrows). template for the radiology report is shown in mas) should warrant a test for infection. Occasionally. tive. Radiology ratory evaluation. shows fibronodular scarring (noting therapy for latent tuberculosis (56).rsna. these patients should be managed accord- tionable cavitation. if the Table 4. depending on the presence of risk factors for reactivation. patients tion and risk stratification of patients suspected of will need to undergo further clinical and labo. to evaluate for the presence of active or inactive tuberculosis (Table 3) (6). high-risk further evaluation for active tuberculosis. are negative (16). Chest radiographs are important in the evalua- tion suggestive of active tuberculosis. Patients with equivocal radiographic lous treatment. If the chest (within the past 8–10 weeks) (1). such as ill-defined nodules or ques. If 6-month stability cannot be established. or shows findings that Incidental radiographic findings of fibronodu. (b) Axial CT image shows peribronchial fibrosis the results of a workup for active tuberculosis (arrowhead) and architectural distortion in the lung api- ces.64  January-February 2017 radiographics. instead of single-drug granulomas.org Figure 20. for example. the patient may or may not be treated for latent tuberculosis. A sample lar change (and not merely calcified granulo. (a) PA chest radiograph shows upper lobe fibrosis latent tuberculosis is appropriate if these find. shows calcified tuberculosis is required. radiograph demonstrates cavities or consolida. should similarly undergo tuberculosis (Fig 22). initial four-drug therapy for active shows entirely normal findings.

RG  •  Volume 37  Number 1 Nachiappan et al  65 Figure 21. ×150. original magnification. then expand the investigation and differential diagnosis. such as prolonged corticosteroid therapy or . if workup for active tuberculosis yields negative findings. Tuberculin Skin Test culosis should prompt communication with the The most commonly used test for latent tubercu- referring provider and placement of the patient in losis is the tuberculin skin test. (Hematoxylin-eosin stain. NY. † = for ra- diographic finding of a cavity or consoli- dation.1% with radiographic findings of previous tubercu- per year for healthy patients with normal chest ra.0 license.) (Courtesy of Yale Rosen. TST = tuberculin skin test. Testing is important because patients with old of more than 5 mm of induration is used for latent tuberculosis are at risk for developing active extremely high-risk patients. * = targeted testing implies that there is an indication to treat if the test results are positive. Mineola. resulting induration is measured at 48–72 hours. such as (a) patients tuberculosis later: a risk of approximately 0.  Calcified nodules from an old granulomatous infection in a different patient from the one shown in Figure 20. different size of inactive tuberculosis. and (c) immuno- HIV infection (57). or therapy with immunosuppressive tests are summarized in Table 5 (58). ** = may treat for latent tuberculosis. The size of any high risk of exposure or reactivation. drugs. and a delayed cell-mediated Testing for latent tuberculosis is advised for hypersensitivity immune response is mounted (a) individuals without symptoms. recent exposure within past 2 years). MD. particularly if patient is at high risk for reactivation (eg. finding that raises the possibility of active tuber. A number of different tests are compromised patients with HIV infection. also known as the respiratory isolation. organ available. The center (C) represents the calcific remnant of the granuloma with surrounding fi- brosis (arrows).  Diagram of an algorithm for the evaluation and treatment of patients who are suspected of having latent tuber- culosis (TB) (concern for latent tuberculo- sis infection). Win- throp University Hospital. HIV positive and immunosuppression. as detailed earlier. and (b) indi. viduals with incidental imaging findings suggestive Depending on patient risk factors. A thresh- tested. with a trade-off without any risk factors should generally not be between sensitivity and specificity (6). Photomicro- graph shows an old healed fibro- calcific granuloma. A dose of protein extracted from M tuberculosis is Tests for Infection injected intradermally. the sensitivities and specificities of these transplants. (b) those with recent contacts with persons diographs. Asymptomatic individuals thresholds of induration are used. under a CC BY-SA 2.) Figure 22. losis. IGRA = interferon-γ release assay. and up to 10% per year in patients with with infectious tuberculosis. but who are at against the bacterial proteins. purified protein derivative (PPD) or Mantoux test.

A patient’s tuberculin skin demic regions. communicated to [ ]. False-negative reactions latent tuberculosis is the interferon-γ release may occur in patients with recent tuberculosis assay. a substantial proportion of the elderly a threshold of more than 10 mm of induration is population will have a negative reaction despite used. in those with recent States (QuantiFERON-TB Gold In-Tube. Carnegie.   Centrilobular and tree-in-bud nodules [Mention if depicted: calcified granulomas. Australia) mycobacteria  T-SPOT. two versions of the interferon-γ release infection within the past 8–10 weeks. the only finding. Table 5: Sensitivity and Specificity of Tests for Latent Tuberculosis Infection Test Sensitivity (%) Specificity (%) False Positives Tuberculin skin test 77–80 Up to 97* Nontuberculous myco- bacteria. Radiograph in the Setting of Suspected La- berculosis tent or Active Tuberculosis Active tuberculosis FINDINGS:  Cavitation There is [no] cavitation. Previous (inactive) tuberculosis − Calcified granulomas. Recommend clinical evalu- ation for possible active tuberculosis. BCG vaccine Interferon-γ release assays   QuantiFERON-TB Gold In-Tube 70–80 96–99 Rarely. As a result. phenomenon.” culous mycobacteria (59). Findings communicated to [ ]. In these old of more than 15 mm of induration is used. cal-   Miliary nodules cified lymph nodes. in infants assay are currently approved in the United younger than 6 months. this finding would represent Recommend respiratory isolation and sputum latent tuberculosis infection.TB (Oxford Immunotec. In addition. nontuberculous   Marlborough. and certain pediatric patients. vaccina- tion with BCG vaccine in childhood can cause Interferon-γ Release Assays lasting tuberculin skin test positivity in some An alternative to the tuberculin skin test for individuals.    Traction bronchiectasis − Fibronodular changes suggestive of tuberculosis    Apical and upper lung zone volume loss of uncertain activity. medical conditions.rsna. Recommend comparison   Calcified granulomas or lymph nodes† with prior images. 90 93 Rarely.   Peribronchial fibrosis − Stable fibronodular opacities for 6 months. therapy with tumor necrosis factor α inhibitor.66  January-February 2017 radiographics. consolidation or nodular  Consolidation pattern. particularly if they were vaccinated the evaluation of patients suspected of having after 1 year of age (59). mediastinal or hilar lymph- adenopathy. † If calcified granulomas or lymph nodes are − Findings likely represent active tuberculosis. those with exposure test positivity can revert to negative with time. a repeat test performed 1–3 weeks later False-positive reactions to the tuberculin skin will generally be positive owing to the “booster test may occur because of exposure to nontuber. and in immunocompro- patients at high risk. and . In live-virus vaccination. a thresh. nontuberculous   (Cellestis. drug abusers. con-    Well-defined nodular opacities sistent with inactive tuberculosis. patients. mised patients (1). Mass) mycobacteria *The specificity of the tuberculin skin test is 35%–60% in populations with high rates of BCG vac- cination.org Table 3: Imaging Findings of Active Table 4: Sample Report Template for Chest Tuberculosis and Previous (Inactive) Tu. There are [no] fibronodular changes. Findings *Findings must be stable for at least 6 months. In the absence of any risk factors. those with certain a rate of about 5% per year after initial exposure. at in high-risk congregate settings. consistent with old granu-   Fibronodular scarring* lomatous infection. pleural effusion. previous exposure to tuberculosis (60). sampling. such as immigrants from en.]  Lymphadenopathy IMPRESSION [Pick one:]:   Pleural effusion − No evidence of active or previous tuberculosis.

at the completion uals (eg. as discussed. and threefold that of tuberculosis (72). Diagnosis and Management The results of new studies have shown that Imaging plays a critical role in the diagnosis and weekly therapy with isoniazid and rifapentine for treatment of active tuberculosis.61. particularly because of the time that chest radiograph and patients with a negative it takes for the cell-mediated immune response 2-month culture may need therapy for a total to develop after the initial infection (65). a negative reaction cannot absolutely highlighting the role of imaging in management. does berculosis. depending on sured. Imaging group of mycobacterial species other than M findings suggestive of active tuberculosis. The prevalence of pulmonary sis has two phases: (a) an initiation phase. A patient’s blood is of a four-drug regimen of isoniazid. avium-intracellulare complex—and Mycobacte- Treatment of patients with active tuberculo. sis. The length of sulting interferon-γ immune response is mea. a single PA view is adequate. Interferon-γ are at a high risk of relapse and should continue release assays do not cross-react with BCG vac. cannot tolerate isoniazid therapy or have been exposed to isoniazid-resistant M tuberculosis. Nontubercu- (b) a continuation phase. also known as the steril. the continuation phase. skin test. 4 Role of Imaging in months of rifampin therapy is recommended. be made for cavitary disease (Figs 11a. A chest radiograph should be though a positive result of these tests supports obtained in all patients at the completion of treat- the diagnosis of active tuberculosis. Al.74). able within 24 hours.to known as the bactericidal or intensive phase. of only 6 months. lous mycobacterial disease manifests in two major izing phase (56).TB) (58. most commonly seen with Mycobacterium avium tory isolation until negative sputum samples are complex—also referred to as Mycobacterium obtained. on the chest radiograph. . result should not be used alone for diagnosis. Limited data are is shown in Figure 23 (68). careful cination or with most strains of nontuberculous examination of the initial chest radiograph should mycobacteria (64). A chest radio. Adjunc- tive views. typically. Patients with active available with regard to the use of interferon-γ tuberculosis who have cavitation on the initial release assays in immunocompromised individ. In comparison with the tuberculin skin the risk of relapse of the patient.62). the continuation phase can vary. therapy for a total of 9 months. the principal treatment regimen is 9 not exclude tuberculosis. exposed to M tuberculosis antigen. should prompt environment.66). chest radiograph and who. Thus. It is important to note that the tuberculin skin the decision about the length of treatment in the test and interferon-γ release assays are not de. Although CT is twice as sensitive as chest radiog- Screening Tests in Patients raphy in the detection of cavities (69) and may be with Active Tuberculosis useful in raising suspicion for active tuberculosis. rium kansasii (71). For patients who as providing a definitive answer (8. ethambutol. rather than on the CT The sensitivity of both tests is limited for active images. As with the tuberculin A treatment algorithm for active tuberculosis. the positive ment to establish a new baseline (Fig 24). If the patient is experts may consider the use of screening tests HIV negative and if the chest radiograph shows in cases of suspected active tuberculosis as a normal findings. exclude tuberculosis infection. and pyrazinamide. rifampin. interferon-γ release assays require only one rifampin are typically administered together in visit to conduct the test. then 6 months of therapy with diagnostic aid. such as a lordotic view or dual-energy Nontuberculous Mycobacteria radiography with bone subtraction. Thus. 3 months is an acceptable alternative in selected graph is generally obtained at the time of diagno.RG  •  Volume 37  Number 1 Nachiappan et al  67 T-SPOT. can improve Nontuberculous mycobacteria are a diverse the depiction of the lung apices (67). those with HIV infection) to suggest of the initiation phase of treatment. such tests should not be regarded isoniazid may be sufficient. which are ubiquitous in the it is clinically suspected or not. algorithm is based on the presence of cavities signed to evaluate subjects for active tuberculosis. Patients without cavitation on the initial tuberculosis. A When treatment is indicated for latent tu- negative result of these tests. although many months of therapy with isoniazid. patients (70). Non- immediate communication with the referring tuberculous mycobacterial disease in the lungs is provider and placement of the patient in respira. Isoniazid and test. The bactericidal phase typically forms: classic (cavitary) and nonclassic (bronchi- lasts for 2 months and requires administration ectatic) (73. 14a). still dem- that there may be an increase in false-negative onstrate positive 2-month tuberculosis cultures or indeterminate results (63). also nontuberculous mycobacterial disease is two. and the re. whether tuberculosis complex. with the results avail. including the soil and water.

68  January-February 2017 radiographics. When compared predisposing factors. classic nontuberculous culture is necessary for definitive diagnosis. chronic bronchiectasis and bronchiolitis with a chitectural distortion is often also depicted. the manifestations of tuberculous and nontuber- rial infection can have an appearance and clinical culous mycobacterial infections. for tuberculosis. Upper lobe ar. tuberculous mycobacterial infection manifests as in-bud nodules (Fig 25) (73. It is generally not mistaken with tuberculosis.  Pre.  Diagram of a treatment algorithm for active tuberculosis. emphysema). (b) Posttreatment PA chest radiograph shows residual fibrosis (arrowheads) and nodular opacities (arrow). Classic (cavitary) nontuberculous mycobacte. CXR = chest x-ray. tion and bronchiectasis. and thus a sputum postprimary tuberculosis. predominantly in the bilateral apical and upper lung zones. This sic nontuberculous mycobacterial infection most form of nontuberculous mycobacterial infection commonly affects elderly men with chronic lung is most commonly seen in elderly women without disease (typically. mycobacterial infection is characterized by upper In contrast. The . PZA = pyrazinamide. classic nontuberculous myco.org Figure 23. (a) Pretreatment PA chest radiograph shows nodules and consolidations (arrows). findings that represent this patient’s new baseline. However.74). INH = isoniazid. this infection (74). Figure 24. Clas. However. nonclassic (bronchiectatic) non- lobe cavitary lesions and centrilobular and tree.rsna. mid to lower lung zone predominance (74). Both types of in- manifestations indistinguishable from those of fections yield AFB on smears. if there is more and cavities tend to be smaller with thinner walls bronchiolitis than bronchiectasis.and posttreatment images in a 53-year-old man with tuberculosis. given the midlung zone distribu- bacterial infection tends to progress more slowly. substantial overlap exists between could mimic active postprimary tuberculosis. RIF = rifampin. EMB = etham- butol.

imaging plays an important role in caused by the presence of colonizing mycobacteria risk stratification by helping to distinguish latent may be misleading. In immunocompromised patients. Nontuberculous mycobacterial infection can . and Tuberculosis is an important public health issue in cavitation (75). For M kansasii infection. liver.  Classic nontuberculous mycobacterial infection with M kansasii in a 64-year-old man with emphysema. with possible cavitation. and comorbidi- in HIV-positive patients. particularly the necrotic type. that can influence the likelihood and appear- infection with both types of mycobacteria. For infection with M disseminated infections (74). with disease. is mycobacterial infection are nonspecific and necessary to eradicate nontuberculous myco- may overlap with those of tuberculosis or other bacterial infection (76). rifabutin). Thus. such as tive culture from bronchoalveolar lavage fluid or the length of a course of therapy for active dis- lung biopsy to establish the diagnosis (76). affect treatment decisions. risk factors. is lower. Radiolo- sputum and lymph node sampling (Fig 27). fatigue. previous inactive disease. who are predisposed to ties. and cough. ease. with CD4 cell counts of less than 70/μL. lack of upper lung zone predominance should tients without cavitary disease. Awareness of certain and imaging manifestations between nontuber. false-positive cultures release assay.RG  •  Volume 37  Number 1 Nachiappan et al  69 Figure 25. with surrounding centrilobular nodules (arrow). spleen. Typical symptoms avium complex. A left-sided basilar pneumothorax (arrow) is incidentally depicted. Patients with an incom- the bone marrow. and Disseminated nontuberculous mycobacterial ethambutol is used. plete response to medical therapy may benefit Lymphadenopathy. affecting and ethambutol is used. In patients with positive bacteria can colonize human airways. Pulmonary findings may include centrilobular Conclusion nodules (Fig 26). miliary micronodules. such as vulnerability to exposure. guidelines recommend infection. such as the presence two positive sputum cultures or (b) a single posi. isoniazid. and active (a) obtaining at least three sputum samples. gists need to be familiar with the imaging findings Given the substantial degree of overlap in clinical of pulmonary tuberculosis. testing. alongside imaging and clinical evaluation. usually until at cal and radiologic findings of nontuberculous least 1 year after a negative sputum culture. and lymph nodes. culous mycobacterial infection and tuberculosis altered immunity. AFB can be demonstrated from both developing and developed countries. culture ance of disease is essential. is the most frequent finding at imaging (Fig 26). triple therapy with rifampin (or include fever. (a) PA chest radiograph shows patchy consolidation in the right lower lobe and the apices (arrowheads). weight loss. Prolonged antibiotic therapy. Imaging findings. Unlike M tuberculosis. (b) Axial chest CT image shows a cavitary lesion (arrowhead). nontuberculous myco. so false negatives may delay diagnosis. pediatric age. azithromycin (or clarithromycin). of cavitation. from surgical resection (76). infection occurs particularly in AIDS patients combination therapy with rifampin. In pa. In patients findings on a tuberculin skin test or interferon-γ with chronic lung disease. in the left lung. in establishing a diagnosis. the clini. the diagnostic yield help distinguish these two entities. It is also important to studies are necessary for a definitive diagnosis be aware of the role and limitations of laboratory and to guide therapy.

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