Daily Radiology Case

Explanation

This presentation is most consistent with active pulmonary tuberculosis complicated by bronchopleural fistula causing hydropneumothorax and right lung collapse. The key diagnostic features emerge progressively: Clue #2 reveals the critical months-long course with constitutional symptoms (fever, night sweats, weight loss) that characterize chronic TB rather than acute pneumonia. Clue #3 demonstrates the brown sputum representing necrotic tissue from cavitary disease. Clue #4 shows the classic bilateral upper lobe cavitation—TB has a predilection for the apex due to higher oxygen tension, making "upper lobe cavities = TB until proven otherwise" a fundamental radiographic principle. Clue #5 explains the acute decompensation: a cavitary lesion has eroded through the visceral pleura, creating a bronchopleural fistula that allows air and fluid into the pleural space, causing the pneumothorax and lung collapse that brought the patient to the ED acutely despite months of prior symptoms. Clue #6 provides definitive microbiological confirmation with AFB-positive sputum on three samples, confirming active Mycobacterium tuberculosis and indicating high infectivity. The complete picture integrates seamlessly: chronic progressive cavitary TB with a serious acute complication.

Source: Nwangwu K, Pulmonary tuberculosis. Case study, Radiopaedia.org (Accessed on 01 Mar 2026) https://doi.org/10.53347/rID-230120

Hints

• A 35-year-old male presents with cough and right-sided chest pain; vitals show
• fever 37.8°C, RR 22, and oxygen saturation 92% on room air.
• Symptoms have persisted for several months with drenching night sweats and
• 10 kg unintentional weight loss over 3 months.
• Cough is productive with copious brownish sputum.
• Chest imaging reveals thick-walled cavitary lesions in both upper lung zones
• with diffuse reticulonodular opacities and mediastinal shift to the left.
• Right hemithorax demonstrates a large area of increased transradiancy with
• air-fluid level consistent with hydropneumothorax and right lung collapse.
• Sputum smear microscopy is positive for acid-fast bacilli on three consecutive
• samples.