Pulmonary tuberculosis

Case contribution: Dr Radhiana Hassan


  • A 65 years old man
  • Presented with chronic cough
  • Associated with loss of appetite and loss of weight

Radiographic findings:

  • There are extensive consolidation and cavitating lesions seen at upper and midzone of the left lung (yellow arrow).
  • Similar but less severe changes are also seen at right apical region (red arrow).
  • Small reticulo-nodular opacities are also in the rest of the lungs.
  • No mediastinal widening. No hilar mass.
  • No cardiomegaly. No pleural effusion. No bone lesion.
CT scan thorax in axial planes; lung window (upper row) and soft tissue window (lower row).
CT thorax reformatted image in coronal plane lung window

CT scan findings:

  • There are multifocal collapsed-consolidations with cavitations seen predominantly involving both upper lobes, more severe on the left side.
  • Multiple small lung nodules and tree in bud density are seen scattered in both lungs.
  • Underlying chronic lung changes with fibrosis and emphysematous change are seen.
  • The trachea and main bronchi appears ectatic. However no intraluminal lesion is seen.
  • Subcentimeter paratracheal hilar and axillary nodes are seen.
  • The heart is not enlarged. No pleural effusion is seen.

Diagnosis: Pulmonary tuberculosis (smear positive)


  • Pulmonary tuberculosis (PTB) remains one of the major issue in our clinical practice.
  • Due to population based vaccination, in many cases post primary tuberculosis is more common than primary tuberculosis.
  • The most common radiographic finding of post-primary PTB is focal or patchy heterogeneous, poorly defined consolidation involving the apical and posterior segments of the upper lobes and the superior segments of the lower lobe.
  • In the majority of cases, more than one pulmonary segment is involved.
  • Cavitation is radiographically evident in 20–45% of patients, while air-fluid levels in the cavity occur in 10% of cases.
  • Cavitation may progress to endobronchial spread and results in a typical ‘tree-in-bud’ distribution of nodules in addition to cavitation; this is considered a reliable marker of active TB.
  • High-resolution CT is the method of choice to reveal tree-in-bud sign.
  • Hilar or mediastinal lymphadenopathy is uncommon in post-primary PTB, seen in only 5–10% of patients.
  • A pleural effusion is seen in approximately 18% of post-primary PTB.

Progress of patient:

  • Patient was treated with anti-TB treatment.
  • Good response is seen clinically and radiologically.
  • A repeat radiograph and CT scan shows resolving consolidation and cavitations with bronchiectatic change and fibrosis.



Author: radhianahassan