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Letters

Primary and Postprimary or Reacti- Annual rate of infection (ARI) studies con- Ben J. Marais
vation Tuberculosis: Time to Revise firm the high infection pressure that exists Stellenbosch University
Confusing Terminology?
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in TB-endemic areas and likely underesti- Tygerberg Hospital


The recent article in the AJR by Jeong and mate the ARI experienced by adults in these Tygerberg, South Africa
Lee [1], “Pulmonary Tuberculosis: Up-to- settings, since only school-going children Sarah K. Parker
Date Imaging and Management,” provides are included in the evaluation. Reactivation University of Colorado
a comprehensive overview of the radiologic disease remains an important entity among Health Sciences Center
features associated with pulmonary tuber- older or immunocompromised individuals, The Children’s Hospital
culosis (TB) in adults. Although the authors but it probably represents a small fraction of Aurora, CO
acknowledged the limitations of current ter- the global TB disease burden. S. Verver
minology, they still elected to follow conven- The second misconception is that cavita- KNCV Tuberculosis Foundation
tion, using the classifications of primary and tion indicates reactivation disease. This per- The Hague, The Netherlands
reactivation TB (also referred to as postpri- ception persists despite the fact that natural Academic Medical Center
mary TB), which have been shown to be in- history studies conducted in the time before Amsterdam, The Netherlands
accurate and confusing. chemotherapy (1920–1950) have shown A. van Rie
The concept of postprimary TB was origi- clearly that adolescents and young adults are University of North Carolina
nally based on the premise that primary My- at risk of developing cavities in the lung api- Chapel Hill, NC
cobacterium tuberculosis infection occurs ces within 6 months to 2 years of documented R. M. Warren
in childhood and the characteristic cavitary primary infection [6]. Primary infection was Stellenbosch University
lung lesions seen in adults with active TB in- defined as close contact with a sputum-smear Tygerberg, South Africa
dicate reactivation of this distant infection. positive index case with skin test conversion
DOI:10.2214/AJR.08.1726
However, the historic distinction between [6]. Although these accurate disease descrip-
WEB—This is a Web exclusive article.
primary and postprimary TB creates numer- tions included primary cavitary disease, the
ous misconceptions that have been exposed terms “reactivation” and “postprimary” TB
by recent scientific evidence. still became entrenched in the TB lexicon. References
The first misconception perpetuated by Continued use of this terminology fails 1. Jeong YJ, Lee KS. Pulmonary tuberculosis: up-
this terminology is that TB infection is a to acknowledge that cavitary TB may be a to-date imaging and management. AJR 2008;
single event. In settings in which TB is en- manifestation of recent primary infection or, 191:834–844
demic, the first infection is likely to occur more commonly in endemic settings, of re- 2. Warren RM, Victor TC, Streicher EM, et al. Pa-
in childhood but is unlikely to be a single infection. Such usage also detracts emphasis tients with active tuberculosis often have different
lifetime event. In all likelihood, ongoing TB from the fact that the challenges facing the strains in the same sputum specimen. Am J Respir
transmission within endemic communities development of an effective TB vaccine in- Crit Care Med 2004; 169:610–614
causes repeated episodes of infection [2]. clude the prevention of primary, reactivation, 3. van Rie A, Warren R, Richardson M, et al. Exog-
The absence of a test to distinguish reinfec- and reinfection disease. Thus, it is important enous reinfection as a cause of recurrent tubercu-
tion from previous primary infection makes not to perpetuate these misconceptions. losis after curative treatment. N Engl J Med 1999;
it a difficult topic to study. However, results From a management point of view, the im- 341:1174–1179
from recent molecular epidemiologic studies portant distinction is between cavitary and 4. Verver S, Warren RM, Munch Z, et al. Proportion
challenge the unitary concept of TB patho- noncavitary disease because the presence of tuberculosis transmission that takes place in
genesis by providing definitive evidence of cavities correlates with organism load, households in a high-incidence area. Lancet 2004;
that reinfection contributes substantially to treatment outcome, risk of acquiring drug 363:212–214
the global TB disease burden. Studies using resistance, and infection risk posed to the 5. Verver S, Warren RM, Beyers N, et al. Rate of
IS6110 fingerprinting have established that community. However, the pathologic mecha- reinfection tuberculosis after successful treatment
most infections causing active TB in adults nisms underlying cavitary TB are variable is higher than rate of new tuberculosis. Am J Re-
from TB-endemic areas represent currently and not restricted to reactivation disease as spir Crit Care Med 2005; 171:1430–1435
circulating strains that were recently trans- implied by the terms postprimary and reac- 6. Marais BJ, Gie RP, Schaaf HS, et al. The natural
mitted [3], most often outside of the house- tivation TB. Developing accurate descriptive history of disease of childhood intra-thoracic tu-
hold [4]. Studies also have shown that more terminology that reduces confusion is an im- berculosis: a critical review of the pre-chemo-
than 50% of recurrent disease occurring in portant priority that requires urgent discus- therapy literature. Int J Tuberc Lung Dis 2004;
endemic settings results from reinfection [5]. sion and debate. 8:392–402

AJR 2009; 192:W198 0361–803X/09/1924–W198 © American Roentgen Ray Society

W198 AJR:192, April 2009