CTICasesPost-Primary Tuberculosis with Upstairs-Downstairs Pattern
Imaging findings
Chest radiograph demonstrates large thick-walled cavities in both upper lobes with surrounding nodules and an air-fluid level with debris. CT confirms bilateral upper lobe cavitary disease with surrounding consolidation, tree-in-bud nodules in the lower lobes from endobronchial spread, and the characteristic upstairs-downstairs distribution of cavitary disease above and airway-spread nodules below. Follow-up radiograph three months later shows improvement with antimicrobial treatment. The patient immigrated from West Africa and presented with cough and fever.
Key takeaways
Post-primary tuberculosis has a characteristic upper lobe cavitary pattern with concomitant lower lobe tree-in-bud nodules from endobronchial spread, sometimes described as an upstairs-downstairs lesion. Bilateral upper lobe cavities with debris and an associated lower lobe nodular pattern in an immigrant patient from an endemic region should prompt high clinical suspicion for active MTB infection. Follow-up CT demonstrating interval improvement with antimicrobial therapy confirms the infectious and treatable nature of the disease.
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