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Uncommon Manifestations of Tuberculosis on Chest X-Rays

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Tuberculosis could bring out certain uncommon manifestations on chest X-rays. Read to know more about it.

Medically reviewed by

Dr. Kaushal Bhavsar

Published At March 21, 2024
Reviewed AtMarch 21, 2024


Diseases or comorbidities are often pinned down with the assistance of imaging modalities. Imaging modalities may reveal distinctive and unique manifestations or findings that expedite the recognition of the illness that one is living through. Accurate diagnosis is the first step in ensuring and guaranteeing the treatment outcome. Imaging modalities picture the structures that are otherwise not accessible for visual evaluation. The hallmark findings aid in shutting out suspicions and piloting the doctors to establish the right interpretation of the illness or medical condition.

What Is Tuberculosis?

Tuberculosis, a frequently confronted global threat, is an infectious illness that typically undermines lung functions. Mycobacterium tuberculosis is the culprit bacteria that brings forth tuberculosis following invasion and breach into humans. The infectious nature of tuberculosis inflates and underscores its potency to stretch out to wider groups. Though it is curable, if not critically managed, it could prompt grave dangers. Nonresolving cough, fever, coughing up blood, chest discomfort, night sweats, weight loss, and exhaustion are confronted with tuberculosis infection.

The bacterial transmission is channeled through the air, where one with the bacteria, upon coughing, lets out tiny saliva drops into the immediate surroundings. Numerous mycobacterium are lodged in each of these salivary droplets. Through these droplets, the infectious agent, mycobacterium, gains access to others, thus invading new individuals. However, all the beings who acquire Mycobacterium tuberculosis need not reflect tuberculosis. Despite the presence of tuberculous bacteria, some do not bring forth any related manifestations. Such cases are quoted as latent tuberculosis. In advanced stages, the Mycobacterium seeps into the bloodstream and propagates all through the body, instigating miliary tuberculosis. Miliary tuberculosis can bring forth liver, brain, and spinal involvement, posing grave threats.

Likewise, considering the stage at which the manifestations are inflicted, tuberculosis could be graded as:

  • Primary Tuberculosis: In primary tuberculosis, one may bring forth symptoms within two years past the initial mycobacterial invasion. Primary tuberculosis is customarily confronted in younger age groups.

  • Post-primary Tuberculosis: In post-primary tuberculosis, one may encounter invigoration of the tuberculosis infection that lingered and held out in stagnant and inert form over many years.

Imaging modalities, particularly chest X-rays, are advocated to exemplify the harm that tuberculosis has invoked. In addition, computed tomography scanning has also been advocated for assisting tuberculosis treatment. Imaging also reveals the stage and degree of harm, which masters the treatment choice and guides the intervention choice that ought to be instituted for that particular case. Certain risk quotients are pinned down to expedite and buttress active tuberculosis infection. Mitigated immunity and diabetes (overstated blood sugar level) are deemed to encourage the prospect of tuberculosis infection.

What Are the Uncommon Manifestations of Tuberculosis That Are Reflected on Chest X-Rays?

Chest X-ray is the mainstay imaging tool advocated for one with tuberculosis suspicion. The chest X-ray attributes projected in tuberculosis bring forth variances with the tuberculosis stage. The following specifies the uncommon attributes brought out on the chest X-ray of one with tuberculosis:

  • Lung Tuberculomas: These are expressed as opaqueness in chest X-rays. Single or multiple tuberculoma opacities might be put on view through the radiographic picture. The degree of opaqueness is often revealed to be the same all through each tuberculoma. However, tuberculoma opacities’ incidence is reported to be under five percent of tuberculosis cases and hence quoted as an uncommon presentation. Radiographic opaqueness corresponding to lung tuberculoma set forth its dimension under 1.57 inches.

  • Cannon Ball Shadows: Cannon ball shadows are not routinely evidenced in pulmonary tuberculosis. Nevertheless, there are rare reports documenting canon ball shadows in radiographic imagery of one with tuberculosis. Multiple-rounded opaqueness that shows up to be scattered towards the lung periphery is quoted as cannon ball shadow. Cannon ball shadows are attributes of lung metastatic cancer (cancer that has outspread from initial locations to the lungs).

  • Cystic Lesions: Cystic lesions, though uncommon, may also be reflected and expressed on chest X-rays. In radiographic imageries, these are projected as lucencies. Lucencies exhibited with cystic lesions render those areas a darker tone than the normal lung portions. Collective cystic lesions brought out in chest X-ray stump up speculation of cystic pulmonary tuberculosis, which is an atypical tuberculosis version.

  • Brocholiths: These are pictured as opacities, particularly reflected in the air channeling passages like bronchi and trachea, which pilot the air stream. These opacities downsize the air passage patency, which gets precisely mapped in chest X-rays. Only within two to four percent of tuberculosis cases outlined broncholith presentations. Tuberculosis, which has stretched out into the trachea and bronchi, brings forth bronchiolitis X-ray presentation.

  • Pleural Effusion: Pleural effusions are atypical radiographic tuberculosis attributes in pediatric cases, which are unfolded through chest X-rays. When fluid stockpiles over the a chamber bordered by lung lining and chest cavity lining, it brings forth pleural effusion presentation. Pleural effusion reflects the heightened degree of opaqueness perception on the effused side in chest X-ray. The lung on the effused side also exhibits an apparent downturn in size and volume, which the chest X-ray specifically underscores.

  • Pulmonary Cavitation: These are the radiographic picturizations of lung cavities (pulmonary cavities) brought out by tuberculous infection. Fluid or gaseous accretions that are spotted within the lung space are quoted as pulmonary cavities. These crop up once the dead cellular components get evacuated, prompting a depressed area within the lung space, which eventually gets projected in an X-ray picture. Merely 10 to 30 percent of cases mapped with primary tuberculosis showcased pulmonary cavitation.

The radiographic attributes concerning tuberculosis are not definitive and conclusive. At times, it may showcase atypical and strange presentations. Unusual and off-centric imagery findings might cause trouble in recognizing and interpreting the illness. In addition to chest X-rays, computed tomography imaging is also advocated to augment the diagnosis process owing to its capability to negate other disease possibilities.


Tuberculosis, a global health concern, exhibits varying and diverse presentations in chest X-rays. Tuberculomas, cystic lesions, abnormal cavitations, cannonball shadows, and bronchiolitis are rare presentations confronted with tuberculosis. Nevertheless, the list is not definitive. Atypical presentations may bring on inaccurate and erroneous diagnoses. Therefore, the output derived from the chest X-ray imaging ought to be correlated with other diagnostic tools, like computed tomography, in advance of the final diagnosis proceedings. Clinical signs are another critical integrant that could drive and expedite disease identification practice. This underscores the necessity for an integrative approach in corroborating diagnosis and devising apt treatment plans. All these collectively upscale the treatment outcomes.

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Dr. Kaushal Bhavsar
Dr. Kaushal Bhavsar

Pulmonology (Asthma Doctors)


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