DIAGNOSTIC EXAMINATION OF PULMONARY TUBERCULOSIS

CXR
First-line test.

Is almost always abnormal in non-immunocompromised individuals. Primary disease

commonly presents as middle and lower lung zone infiltrates. Ipsilateral adenopathy,
atelectasis from airway compression, and pleural effusion can be seen.

Re-activation-type (post-primary) pulmonary TB usually involves apical and/or posterior

segment of right upper lobe, apicoposterior segment of left upper lobe, or superior
segment of either lower lobe, with or without cavitation. As disease progresses it
spreads to other segments/lobes.

sputum smear
Sputum may be spontaneously expectorated or induced, and at least 3 specimens
should be collected (minimum 8 hours apart, including an early morning specimen,
which is the best to detect M. tuberculosis).
The examiner looks for AFB (the stained dye remains even after exposure to acidic
media) consistent with M. tuberculosis. Other organisms, especially non-tuberculous
mycobacteria (e.g., M. kansasiiand M. avium), may be positive for AFB stain. Thus, a
positive AFB smear is not highly specific in populations with low TB prevalence.
If sputum is positive for AFB, the results will be graded from 1+ to 4+ depending on
number of organisms seen. Smear positivity and its grading may help estimate the
degree of infectiousness and burden of TB disease. In the US, sensitivity is 50% to 60%.

sputum culture
The most sensitive and specific test. Should always be performed as it is required for
precise identification and for drug susceptibility testing.

Growth on solid media may take 4 to 8 weeks; growth in liquid media may be detected in
1 to 3 weeks. Growth on solid media if positive is reported on quantitation scale (1+ to
4+).

While on treatment, the patient should have sputum cultures performed at least monthly
until 2 consecutive cultures are negative.

FBC
Leukocytosis (without left shift) and anaemia each seen in 10%. Other abnormalities
include elevated monocyte and eosinophil counts. Pancytopenia may be seen in
disseminated disease.
tuberculin skin testing (TST)
A negative TST does not rule out active TB. The sensitivity of TST in diagnosing active
TB is around 75% to 80% and its inability to distinguish between latent infection and
active disease limits its usefulness.

The TST uses purified protein derivative (PPD) to evaluate for delayed hypersensitivity
response in order to diagnose prior exposure to TB. Different cut-offs in size of
induration are used to define a positive test depending on the patient's risk factors.

There is diminished immune response in patients with active TB, especially with
increased age, poor nutrition, and advanced disease.[26]

interferon-gamma release assays (IGRA)

Measure the response of T cells to TB antigens in order to diagnose prior exposure.

IGRAs, similar to TST, have low sensitivity in diagnosing active TB and do not
distinguish between latent infection and active disease, which limits their usefulness.
Sensitivity of QuantiFERON-TB Gold (QFT-G) for active TB is 75%. [26] [32]
Structure of the Respiratory System

The respiratory system is represented by the following structures, shown in Figure  1  : 
 The nose consists of the visible external nose and the internal nasal cavity. The nasal septum
divides the nasal cavity into right and left sides. Air enters two openings, the external nares
(nostrils; singular, naris), and passes into the vestibule and through passages called meatuses.
The bony walls of the meatuses, called concha, are formed by facial bones (the inferior nasal
concha and the ethmoid bone). From the meatuses, air then funnels into two (left and right)
internal nares. Hair, mucus, blood capillaries, and cilia that line the nasal cavity filter, moisten,
warm, and eliminate debris from the passing air.
 The pharynx (throat) consists of the following three regions, listed in order through which
incoming air passes:
o The nasopharynx receives the incoming air from the two internal nares. The two
auditory (Eustachian) tubes that equalize air pressure in the middle ear also enter here.
The pharyngeal tonsil (adenoid) lies at the back of the nasopharynx.
o The oropharyrnx receives air from the nasopharynx and food from the oral cavity. The
palatine and lingual tonsils are located here.
o The laryngopharynx passes food to the esophagus and air to the larynx.

 The larynx receives air from the laryngopharynx. It consists of the following nine
pieces of cartilage that are joined by membranes and ligaments, shown in Figure 2 . 

Figure Anterior and sagittal section of the larynx and the trachea.
2
o The epiglottis, the first piece of cartilage of the larynx, is a flexible flap that covers the
glottis, the upper region of the larynx, during swallowing to prevent the entrance of food.
o The thyroid cartilage protects the front of the larynx. A forward projection of this
cartilage appears as the Adam's apple.
o The paired arytenoids cartilages in the rear are horizontally attached to the thyroid
cartilage in the front by folds of mucous membranes. The upper vestibular folds (false
vocal cords) contain muscle fibers that bring the folds together and allow the breath to
be held during periods of muscular pressure on the thoracic cavity (straining while
defecating or lifting a heavy object, for example). The lower vocal folds (true vocal cords)
contain elastic ligaments that vibrate when skeletal muscles move them into the path of
outgoing air. Various sounds, including speech, are produced in this manner.
 o The cricoid cartilage, the paired cuneiform cartilages, and the paired corniculate
cartilages are the remaining cartilages supporting the larynx.
 The trachea (windpipe) is a flexible tube, 10 to 12 cm (4 inches) long and 2.5 cm (1
inch) in diameter, whose wall consists of four layers, as shown in Figure 2 :
o The mucosa is the inner layer of the trachea. It contains mucusproducing goblet cells
and pseudostratified ciliated epithelium. The movement of the cilia sweep debris away
from the lungs toward the pharynx.
o The submucosa is a layer of areolar connective tissue that surrounds the mucosa.

o Hyaline cartilage forms 16 to 20 C-shaped rings that wrap around the submucosa. The
rigid rings prevent the trachea from collapsing during inspiration.
o The adventitia is the outermost layer of the trachea. It consists of areolar connective
tissue.
 The primary bronchi are two tubes that branch from the trachea to the left and right
lungs.
 Inside the lungs, each primary bronchus divides repeatedly into branches of smaller
diameters, forming secondary (lobar) bronchi, tertiary (segmental) bronchi, and numerous
orders of bronchioles (1 mm or less in diameter), including terminal bronchioles (0.5 mm in
diameter) and microscopic respiratory bronchioles. The wall of the primary bronchi are
constructed like the trachea, but as the branches of the tree get smaller, the cartilaginous rings
and the mucosa are replaced by smooth muscle.
 Alveolar ducts are the final branches of the bronchial tree. Each alveolar duct has
enlarged, bubblelike swellings along its length. Each swelling is called an alveolus, and a cluster
of adjoining alveolar is called an alveolar sac. Some adjacent alveoli are connected by alveolar
pores.
 The respiratory membrane consists of the alveolar and capillary walls. Gas exchange
occurs across this membrane. Characteristics of this membrane follow:
o Type I cells are thin, squamous epithelial cells that constitute the primary cell type of
the alveolar wall. Oxygen diffusion occurs across these cells.
o Type II cells are cuboidal epithelial cells that are interspersed among the type I cells.
Type II cells secrete pulmonary surfactant (a phospholipid bound to a protein) that
reduces the surface tension of the moisture that covers the alveolar walls. A reduction in
surface tension permits oxygen to diffuse more easily into the moisture. A lower surface
tension also prevents the moisture on opposite walls of an alveolus or alveolar duct from
cohering and causing the minute airway to collapse.
o Alveolar macrophage (dust cells) wander among the other cells of the alveolar wall
removing debris and microorganisms.
o A thin epithelial basement membrane forms the outer layer of the alveolar wall.

o A dense network of capillaries surrounds each alveolus. The capillary walls consist of
endothelial cells surrounded by a thin basement membrane. The basement membranes
of the alveolus and the capillary are often so close that they fuse.