Multi-drug-resistant tuberculosis chest x ray

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]

Overview

An X-ray is a very important diagnostic tool in pulmonary tuberculosis. Chest X-ray findings include parenchymal infiltrates, hiliar adenopathy, cavitation, nodules and pleural effusion. The most common location of a pulmonary tuberculosis lesion is the upper lobes.

Chest X-Ray

An antero-posterior chest X-ray is one of the most important tests to be performed in a patient with tuberculosis or suspected tuberculosis.

Primary Tuberculosis

• The 3 main X-ray findings in primary tuberculosis include parenchymal infiltrates, hiliar adenopathy, and pleural effusion.
• Primary tuberculosis may appear at any location in the lung.
• Hiliar lymphadenopathy is commonly seen in children, and may be present in up to 95% of children with active tuberculosis.
• Less than half of adults with primary tuberculosis present with lymphadenopathy.
• Tuberculomas, which are opacities similar to a lung mass, may be observed in 5% of patients and can be almost 4 cm in size.
• Unilateral pleural effusion may be observed and it is commonly related to complicated primary tuberculosis.

Secondary Tuberculosis

• The most common location of secondary tuberculosis is in the upper lobes, specially in the apical and posterior segments. However, lesions may appear anywhere in the lungs.
• The X-ray findings in secondary or reactivated tuberculosis include:

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

• Appears as a lesion with irregular margins and thick walls.
• It may be observed in almost 50% of patients.
• It is most commonly seen in the upper lung..
• Cavities in the lower lung can be found in diabetes and HIV infection.
• Although it is rare, cavities may be superinfected and an air-fluid level is seen inside the cavity.

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

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

Chest X-Ray Images in Pulmonary Tuberculosis

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  Pulmonary Tuberculosis

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  Pulmonary Tuberculosis

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  Pulmonary Tuberculosis

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  Bilateral Pulmonary Tuberculosis

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  Pulmonary Tuberculosis

Common Findings of Miliary Tuberculosis on Chest X-Ray

• Fine, pin point approximately 1-2mm in size, discrete, uniform distribution, soft mottlings.
• Commonly found throughout both lungs.

Further information: [[:Miliary tuberculosis]]

Chest X-Ray Images in Miliary Tuberculosis

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  Miliary Tuberculosis

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  Miliary Tuberculosis

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  Miliary Tuberculosis

CDC Guidelines for Evaluating Chest X-Ray

A medical examination is mandatory for all refugees coming to the U.S. and all applicants outside the U.S. applying for an immigrant visa. The purpose of the medical examination is to identify applicants with inadmissible health-related conditions such as active tuberculosis. Outside the U.S., medical examinations are performed by approximately 400 physicians (panel physicians) selected by United States Department of State consular officials. In the U.S., medical examinations are performed by approximately 3,000 physicians (civil surgeons) designated by district directors of the U.S. Citizenship and Immigration Services. Guidelines were developed by the Centers for Disease Control and Prevention (CDC).

The chest X-ray and classification worksheet is designed to group findings into categories based on their likelihood of being related to TB or non-TB conditions needing medical follow-up (either at the time of the chest X-ray or after resettlement).

Abnormal Findings

Chest X-Ray Findings that Can Suggest Active TB

This category comprises all findings typically associated with active pulmonary TB. An applicant with any of the following findings must submit sputum specimens for examination.

Chest X-ray Findings	Description
Infiltrate or consolidation	Opacification of airspaces within the lung parenchyma. Consolidation or infiltrate can be dense or patchy and might have irregular, ill-defined, or hazy borders.
Any cavitary lesion	Lucency (darkened area) within the lung parenchyma, with or without irregular margins that might be surrounded by an area of airspace consolidation or infiltrates, or by nodular or fibrotic (reticular) densities, or both. The walls surrounding the lucent area can be thick or thin. Calcification can exist around a cavity.
Nodule with poorly defined margins	Round density within the lung parenchyma, also called a tuberculoma. Nodules included in this category are those with margins that are indistinct or poorly defined. The surrounding haziness can be either subtle or readily apparent and suggests coexisting airspace consolidation.
Pleural effusion	Presence of a significant amount of fluid within the pleural space. This finding must be distinguished from blunting of the costophrenic angle, which may or may not represent a small amount of fluid within the pleural space (except in children when even minor blunting must be considered a finding that can suggest active TB).
Hilar or mediastinal lymphadenopathy (bihilar lymphadenopathy)	Enlargement of lymph nodes in one or both hila or within the mediastinum, with or without associated atelectasis or consolidation.
Linear, interstitial disease (in children only)	Prominence of linear, interstitial (septal) markings.
Other	Any other finding suggestive of active TB, such as miliary TB. Miliary findings are nodules of millet size (1 to 2 millimeters) distributed throughout the parenchyma.
Adpated from CDC

Chest X-Ray Findings that Can Suggest Inactive TB

This category includes findings that are suggestive of prior TB, that is inactive. It must be remembered that assessments of the activity of TB cannot be made accurately on the basis of a single radiograph alone. If there is any question of active TB, sputum smears must be obtained. Furthermore, if the applicant has any signs or symptoms of TB, sputum smears must be obtained. Obtaining sputum smears is necessary if there is any question of active TB. Therefore, any applicant might have findings grouped in this category, but still have active TB as suggested by:

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

Chest X-ray Findings	Description
Discrete fibrotic scar or linear opacity	Discrete linear or reticular densities within the lung. The edges of these densities should be distinct and there should be no suggestion of airspace opacification or haziness between or surrounding these densities. Calcification can be present within the lesion and then the lesion is called a fibrocalcific scar.
Discrete nodule(s) without calcification	One or more nodular densities with distinct borders and without any surrounding airspace opacification. Nodules are generally round or have rounded edges. These features allow them to be distinguished from infiltrates or airspace opacities. To be included here, these nodules must be noncalcified.
Discrete fibrotic scar with volume loss or retraction	Discrete linear densities with reduction in the space occupied by the upper lobe. Associated signs include upward deviation of the fissure or hilum on the corresponding side with asymmetry of the volumes of the two thoracic cavities.
Discrete nodule(s) with volume loss or retraction	One or more nodular densities with distinct borders and no surrounding airspace opacification with reduction in the space occupied by the upper lobe. Nodules are generally round or have rounded edges.
Other	Any other finding suggestive of prior TB, such as upper lobe bronchiectasis. Bronchiectasis is bronchial dilation with bronchial wall thickening.
Adpated from CDC

Other Chest X-Ray Findings

Follow-up

This category includes findings that suggest the need for a follow-up evaluation for non-TB conditions either at the time of the chest X-ray or after resettlement of the applicant in the United States.

Chest X-ray Findings	Description
Musculoskeletal abnormalities	New bony fractures or radiographically apparent bony abnormalities that need follow-up.
Cardiac abnormalities	Cardiac enlargement or anomalies, vascular abnormalities, or any other radiographically apparent cardiovascular abnormality of significant nature to require follow-up.
Pulmonary abnormalities	Pulmonary finding of a non-TB nature, such as a mass, that needs follow-up.
Other	Any other finding that the panel physician believes needs follow-up, but is not one of the above.
Adpated from CDC

Follow-up Not Required

This category includes findings that are minor and not suggestive of TB disease. These findings require no follow-up evaluation after resettlement of the applicant.

Chest X-ray Findings	Description
Pleural thickening	Irregularity or abnormal prominence of the pleural margin, including apical capping (thickening of the pleura in the apical region). Pleural thickening can be calcified.
Diaphragmatic tenting	A localized accentuation of the normal convexity of the hemidiaphragm as if 'pulled upwards by a string'.
Blunting of costophrenic angle (in adults)	Loss of sharpness of one or both costophrenic angles. Blunting can be related to a small amount of fluid in the pleural space or to pleural thickening and, by itself, is a non-specific finding (except in children, when even minor blunting may suggest active TB). In contrast a large pleural effusion, or the presence of a significant amount of fluid in the pleural space, may be a sign of active TB at any age.
Solitary calcified nodules or granuloma	Discrete calcified nodule or granuloma, or calcified lymph node. The calcified nodule can be within the lung, hilium, or mediastinum. The borders must be sharp, distinct, and well defined. This was considered a Class B3 TB in the past; however, Class B3 has been omitted from the classification scheme because it has not been found to be associated with active TB.
Adpated from CDC

X-Ray Findings in Complications of Tuberculosis

Complication	X-Ray Findings
Cicatrization	Upper lobe atelectasis Compensatory hyperinflation of the lower lobe Hilar retraction Mediastinal shift Parenchymal bands Fibrotic cavities Fibrotic nodules Traction bronchiectasis
Thin-walled cavity	Present in active and inactive forms of the disease May regress with treatment Air-filled cysts may persist May be misidentified as an emphysematous bulla or pneumatocelle.
Aspergilloma	Mobile mass ringed by an air shadow. Calcifications
Broncholithiasis	Calcified material within the tracheobronchial lumen, originated on a calcified lymph node Airway obstruction Atelectasis Air trapping on expiration Frequent change in position of the calcified material Mucoid impaction
Fibrosing mediastinitis	Mediastinal widening Localized mass Hilar or mediastinal mass Calcification Pulmonary infiltrates Atelectasis
Tuberculous spondylitis (Pott's disease)	Vertebral end plate irregularities Reduction of the intervertebral disk space Adjacent bone sclerosis In later stages of the disease, kyphosis, due to anterior compression of the vertebral bodies, and paravertebral abscesses may occur
Malignancy	Bone destruction around the region of the empyema Increased thoracic cavity opacity Medial deviation of the affected pleura Swelling of the soft-tissue