Indian J Pediatr
DOI 10.1007/s12098-015-1949-2
ORIGINAL ARTICLE
Evaluation of Chest X-ray and Thoracic Computed Tomography
in Patients with Suspected Tuberculosis
Mehmet Sait Durmus 1,2 & Ismail Yildiz 1 & Murat Sutcu 1 & Muhammet Bulut 1 &
Muhammet Ali Varkal 1 & Furkan Ubeydullah Ertem 1 & Ayse Kilic 1 & Fatma Oguz 1 &
Emin Unuvar 1 & Ensar Yekeler 3
Received: 14 January 2015 / Accepted: 4 November 2015
# Dr. K C Chaudhuri Foundation 2015
Abstract
Objective To investigate if there is any correlation between
positive findings detected by posterior-anterior (PA) chest ra-
diograph and thoracic computerized tomography (CT) in
cases with suspected lung tuberculosis (TB) due to positive
tuberculin skin test (TST) results.
Methods This is a retrospective evaluation of the medi-
cal files of patients who visited the Department of
Pediatrics, Istanbul University, Istanbul Faculty of
Medicine from 2006, through 2011 as outpatients and
had positive TST (>15 mm) results.
Results A total of 326 patients were included in the study;
45.7 % (n = 149) were girls, and the mean age was 9.0 ± 4.1
y (range: 1–17 y). In total, 14.4 % (n = 47) had TB findings, all
of which were in the form of hilar lymphadenopathy. Among
the 47 cases with TB findings in PA chest X-ray, 45 (95.7 %)
also had findings in thoracic CT. Only 2 (4.3 %) patients had
normal thoracic CT results although their PA chest X-ray re-
sults were positive.
Conclusions Evaluation for pulmonary TB in children with
positive isolated TSTs should be made primarily with PA
chest X-ray. A routine thoracic CT scan is not necessary for
asymptomatic patients with only hilar lymphadenopathy find-
ings in PA chest radiographs.
* Mehmet Sait Durmus
msaitdurmus@gmail.com
1
Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul
University, Istanbul, Turkey
2
Merkez mah. Silahtaraga cad, No:73 Eyüp, Istanbul, Turkey
3
Department of Radiology, Istanbul Faculty of Medicine, Istanbul
University, Istanbul, Turkey
Keywords Children . Chest X-ray . Tuberculosis . Tuberculin
skin test . Radiology
Introduction
Tuberculosis (TB) is a highly prevalent disease worldwide
that continues to be a significant cause of morbidity and mor-
tality, especially in the developing countries. On clinical sus-
picion of TB, tuberculin skin test (TST) and/or interferon – γ
release assay (IGRA) are among the firstline tests in the diag-
nostic work up of the patient. However their positivity cannot
discriminate active TB infection from latent TB infection
(LTBI) [1]. For adults with suspected TB, postero-anterior
(PA) chest X-ray (CXR) is often the first preferred radiological
evaluation. CXR and thoracic computerized tomography (CT)
are effective radiological methods for identifying
Mycobacterium tuberculosis infection in children. Up-to-
date guidelines recommend CXR screening for excluding
the possibility of pulmonary TB in asymptomatic children
with positive TST/IGRA test. Thoracic CT is recommended
for patients with suspicious CXR findings [2, 3]. However,
recent studies report that CXR may be of limited value in
detecting asymptomatic TB infection in adults [4]. The reli-
ability of CXR is not clear for TB diagnosis among asymp-
tomatic children with thoracic TB, and there are few studies
conducted with children on this issue [5]. With thoracic CT,
more detailed information is obtained regarding the presence
and the extensity of thoracic TB, allowing identification of
micronodules, nodules, masses, lymphadenopathy (LAP),
consolidation, ground-glass opacities, etc. [6].
Differentiating LTBI from active TB disease is significant
in determining the course of treatment. The active infection
may be missed if CXR is used alone. On the other hand,

ordering thoracic CT may lead to unnecessary X-ray exposure
of a patient with LTBI.
The aim of this study was to investigate if there is any
correlation between findings of CXR and thoracic CT in pa-
tients with suspected thoracic TB and positive TST/IGRA
results.
Material and Methods
This is a retrospective evaluation of the medical files of
patients who visited the Department of Pediatrics,
Istanbul University, Istanbul Faculty of Medicine, from
2006 through 2011, as outpatients and had positive TST
(>15 mm) results.
TST was provided to those patients who presented to the
outpatient clinic due to chronic cough and suspected TB. TST
is a screening test for TB; positive criteria for TST is 15 mm
for those who have got BCG vaccination.
The age, sex, and TST result were recorded for all patients.
For TST, the diameter at the widest induration area was mea-
sured and patients with values >15 mm were considered
positive.
TST is not the gold standard for the diagnosis of TB;
the goal in the present study is not to diagnose TB but
to evaluate radiological findings in patients with posi-
tive TST.
The patients included were those with positive TST and
who had PA CXR and/or thoracic CT performed at the depart-
ment of Radiology, Istanbul University, Istanbul Faculty of
Medicine for the differential diagnosis of thoracic TB.
Imaging results were retrospectively evaluated through re-
ports written by radiologists. Patients whose imaging results
had not been interpreted by a radiologist were excluded from
the study.
Patients with PA CXR results in favor of TB were consid-
ered positive, and those with normal results were considered
negative.
PA CXR findings of TB in pediatric patients include hilar
or mediastinal LAP, consolidation, atelectasis, pleural effu-
sions and miliary TB. Hilar/mediastinal LAP are the most
common findings in children. The most common site for
LAP is the hilum of the lung and right paratracheal area.
Less commonly, subcarinal area and aortopulmonary window
can be involved [2, 6].
Increased opacity crossing through the azygos vein and
loss of concave hilar angle in the CXR are considered to be
positive findings for TB.
Pertinent findings on CT of the thorax in children include
consolidation, cavities, nodular pattern, LAP, stenosis of the
airways, pleural lesions. On contrast CT, LAP may demon-
strate central necrosis, calcifications and peripheral uptake of
Indian J Pediatr
contrast [2, 6, 7]. LAP larger than 1 cm and paratrachael lo-
calization is considered to be significant on thorax CT [6–8].
The authors recorded whether or not thoracic TB findings
were present upon thoracic CT in patients considered positive
in their PA CXR.
Results
There were 330 patients with positive TST results who had
undergone radiological evaluation. Four patients were exclud-
ed from the study due to missing interpretation/information.
Of the 326 cases included in the study, 45.7 % (n = 149)
were girls, and the mean age was 9.0 ± 4.1 y (Range: 1–17 y).
The mean TST value of all the patients was 19.1 ± 3.2 mm
(range: 16–30 mm). The radiologists' evaluation of PA CXR
yielded that 85.6 % (n = 279) of the patients had no findings of
pulmonary TB and 14.4 % (n = 47) had TB findings or hilar
LAP (Fig. 1).
Among the 47 patients with TB findings in PA CXR, 45
(95.7 %) also had findings in thoracic CT. Only 2 (4.3 %)
patients had normal thoracic CT results although their PA
CXR results were positive.
Of the 45 patients with thoracic CT findings, 30 (66.7 %)
had LAP smaller than 1 cm, 11 (24.5 %) had LAP larger than
1 cm, 2 (4.4 %) had multiple calcific LAP, and 2 (4.4 %)
had other radiological findings that could be interpreted in
favor of TB.
Also two patients positive on CXR and negative on CT
would have to be taken as false positive.
None of the patients with normal PA CXR findings
had undergone thoracic CT. All of the patients who had tho-
racic CT scans had undergone PA chest X-rays prior to the
Number of patients with positive TST: 330
Number of patients excluded from evaluation: 4
Number of patients with positive TST that underwent PA chest X-ray: 326
Number of patients with hilar LAP findings (increased opacity crossing through the
azygos vein and loss of concave hilar angle) in PA chest X-ray: 47 (47/326; 14.4%)
Number of cases with normal thoracic CT results
despite hilar LAP findings in PA chest X-ray: 2
(2/47; 4.3%)
Number of patients with abnormal thoracic CT scan: 45 (45/47;95.7%)
Patients with:
LAP smaller than 1 cm: 30 (30/45; 66.7%)
LAP greater than 1 cm: 11 (11/45; 24.5%)
Multiple calcific LAPs: 2 (2/45; 4.4%)
Tomographic findings that could be interpreted in favor of tuberculosis: 2 (2/45; 4.4%)
Fig. 1 Patient disposition flowchart
TST Tuberculin skin test; LAP Lymphadenopathy
Indian J Pediatr
thoracic CT. All patients who had positive thoracic CT scan
results also had positive results on their former PA CXR
imaging.
Discussion
TB remains a significant health issue worldwide. Though the
morbidity and mortality rates associated with TB are declin-
ing, they are still high [9, 10].
Diagnosis of thoracic TB in children is often made by his-
tory of contact with an adult having TB, TST, and evaluation
of both clinical and radiological findings [7, 11].
Microbiological diagnostic methods have a lower rate of pos-
itive results in children than in adults. Therefore, it is impor-
tant to include medical history, physical examination, and
TST along with the imaging methods in the diagnosis of tho-
racic TB [7, 12].
TST is a test of delayed hypersensitivity reaction against
M. tuberculosis bacilli using a purified protein derivative ob-
tained from the bacilli. For the sensitivity against
M. tuberculosis to develop, 3–6 wk must have passed since
contact with the TB bacilli [13]. In Turkey, where TB preva-
lence is high and BCG vaccination is included in the routine
care, a TST result over 15 mm is considered a positive finding
for TB. TST positivity indicates that an individual has been
exposed to TB bacilli. Determining whether a child with a
positive TST result has an active or a latent TB infection is
highly important for the diagnosis and treatment of the disease
[11, 14]. A multiple anti-TB therapy should be administered in
the event of active thoracic TB; however, isoniazid prophy-
laxis therapy alone is sufficient in cases of a latent TB infec-
tion. In patients with positive TST results, radiologic diagnos-
tic methods can be used to differentiate between active and
latent TB infections.
The most common PA CXR finding of TB is hilar LAP
[15]. In this study, 14.4 % (n = 47) of the patients with positive
TST results had hilar LAP in their PA chest X-rays. Among
these, 45 (95.7 %) of the patients had TB findings in thoracic
CT, and 2 (4.3 %) patients had normal thoracic CT results.
These results indicate a marked correlation between PA chest
X-rays and thoracic CT scans.
Compared with PA CXR, CT emits much greater
amount of radiation [8, 15]. It is known that the risk of
malignancy in older age increases as the amount of pre-
vious exposure to radiation increases [16]. Additionally,
CT is also more expensive and more time-consuming
method than X-ray, which is a simple and cheap diag-
nostic method. The CXR and thoracic CT findings of
almost all of the patients in this study that were evaluat-
ed for primary thoracic TB were congruent. Considering
the risks associated with excessive radiation exposure,
unnecessary costs and time loss, use of PA CXR may
be a sufficient radiological evaluation when there is sus-
picion of thoracic TB associated with isolated TST
positivity.
Conclusions
Thus, evaluation for thoracic TB in children with posi-
tive isolated TSTs should be made primarily with PA
CXR. A routine thoracic CT scan is not necessary for
asymptomatic cases with only hilar LAP findings in PA
chest X-rays. Each case should be evaluated individual-
ly and decisions on which radiologic imaging to be
used should be made accordingly.
Contributions MSD, AK and EY: Planned the study; EU and FO:
Critically read the study and contributed to the study design; MB, MS,
MAV and FUE: Made significant contribution to case collection and
statistical analysis along with IY and MB. EY: Physician in Department
of Pediatric Radiology. EU will act as guarantor for this paper.
Conflict of Interest None.
Source of Funding None.
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