1. Pulmonary Tuberculosis
นพ. ชัชชัย หอมเกตุ

2. Pulmonary Tuberculosis
Primary Tuberculosis
Secondary Tuberculosis

3. Primary tuberculosis Clinical feature Asymtomatic 65%
Non specific symptom when present
Progressive primary complex
Fever, cough,hemoptysis,weightloss

4. Primary tuberculosis 1. Parenchymal consolidation 2. Lymphadenopathy
3. Pleural effusion
4. Atelectasis

5. Primary tuberculosis Consolidation
• Pneumonic type common
• Unilobar > multilobar
• Lobar pneumonia almost always associated with lymphadenopathy
- Infiltrate + ipsilateral adenopathy–think TB
• Cavitation is rare

6. Consolidation in primary tuberculosis
Consolidation in primary tuberculosis. Frontal chest radiograph demonstrates
consolidation in the right middle lobe (straight arrow) with right hilar
adenopathy (curved arrow).

7. Primary pulmonary tuberculosis Lymphadenopathy
• Mostly ipsilateral hilar and/or paratracheal. Bilat. up to 31 %
• Usually right-sided
• Much more common in children (95%), adult (43%)
• CT: peripheral enhancement , central low-attenuation

8. Primary tuberculosis Atelectasis and pleural effusion
• Pleural effusion very common in young children

9. Primary tuberculosis Atelectasis
• Classically affects anterior segments of upper lobes, or medial segment of the RML

10. Secondary tuberculosis
Synonyms
Reactivation TB
Reinfection TB
Postprimary TB
Site of involvement
Lung parenchyma - classically the apical and posterior segments of the upper lobes, superior segments of the lower lobes
Trachea and major bronchi - endobronchial TB
Pleura - tuberculous pleuritis

11. Secondary tuberculosis
1. Consolidation %
2. Cavitation %
3. Nodule
4. Airway involvement

12. Primary tuberculosis Consolidation
• Heterogenous, nodular, linear
• calcified primary complex may be identified
• Apico, posterior of upper lobe
85%
Superior segment of lower lobe 14%

14. Primary tuberculosis Cavity
Tuberculous cavitation most commonly occurs within areas of consolidation and indicates a high likelihood of activity. Cavities are often multiple and demonstrate thick, irregular walls.
Air-fluid levels are rare, but when present they suggest the possibility of superinfection

15. Cavitary postprimary tuberculosis. Frontal radiograph demonstrates a
thick-walled cavity with smooth inner margins in the left upper lobe
(arrow).
Pulmonary tuberculosis with cavity

16. Primary tuberculosis Nodule
-Tuberculoma
-SPN:variable borders, satellite lesions
Upper lobe
-Endobronchial
-Centrilobular nodule, tree in bud (CT)
-Hematogenous spread
-Miliary , 1-3 mm, random

17. Endobronchial spread of tuberculosis
Endobronchial spread of tuberculosis. Axial CT scan shows severe changes of bronchiolar dilatation and impaction. Bronchiolar wall thickening (straight arrows) and mucoid impaction of contiguous branching bronchioles produce a tree-in-bud appearance (curved arrows).

18. Primary tuberculosis Airway involvement
-Bronchiectasis
-Bronchitis
-Air way narrowing

19. HIV and TB CD4 count < 200/mm3 , primary TB pattern
CD4 count > 200/mm3 , secondary TB pattern

20. Primary tuberculosis
Delayed hypersensitivity 6-10 wks after initial exposure, then +PPD
Clinical infection following first exposure
Ghon focus : local infection
Ranke complex : local infection with lymph node spread
Often asymptomatic in children
Adults : wt. loss, fever, cough, hemoptysis
Radiography may be normal
Air space consolidation maybe lobar : often slow to clear
Atelectasis in child
Cavitation and miliary spread uncommon
Lymphadenopathy common in children, uncommon in adults
Pleural effusion maybe seen without lung dz

21. Postprimary tuberculosis
Immediate hypersensitivity
Reactivation of latent infection
Most often involve apical and posterior segment of upper lobe and superior segment of lower lobe
Often asso. with progressive disase
Cavitation is common, endobrochial spread may occur.
Fatigue, night sweat, wt loss,low grade fever
Radiographic finding
Poorly defined area of consolidation
Cavitation visible 20-45%
Tree in bud on HRCT
Lymphadenopathy and effusion uncommon
Miliary spreading
Airway stenosis
Tuberculoma

22. The end