Lower Lung Field Tuberculosis

¹ Chief, Pulmonary Disease Service, Mount Sinai Hospital Services-City Hospital Center at Elmhurst; Associate Professor of Clinical Medicine, Mount Sinai School of Medicine
² Clinical Assistant in Medicine, Mount Sinai Hospital Services-City Hospital Center at Elmhurst; Associate in Medicine, Mount Sinai School of Medicine

Lower lung field tuberculosis without concomitant upperlobe disease occurs in 7 percent or less of patients with active pulmonary tuberculosis. It most likely results from transbronchial perforation of a hilar lymph node, with spread into the adjacent lung. In our study of 27 patients with lower lung field tuberculosis, the majority were under 40 years of age, there were more men than women, and no racial preference was noted. Diabetes mellitus and pregnancy seem to predispose to lower lung field tuberculosis. The onset of disease is more acute than in upper lobe tuberculosis, but less acute than in bacterial or viral pneumonia with which it is often confused. Radiographic changes are found equally in the right and left lungs and in the basal and superior segments of the lower lobes; involvement of the middle lobe and lingula is less common. Extensive confluent (homogeneous) consolidation is found more often than in upper lobe disease and acinar shadows less frequently. Cavities may be isolated or within consolidated areas, are usually single, often over 3 cm in diameter and more frequently contain fluid than those in the upper lobes. Pleural effusion and hilar lymphadenopathy are also more common than in upperlobe disease. Tubercle bacilli may be difficult to demonstrate on smear and culture and multiple examinations should be performed. Bronchoscopic washings and post bronchoscopy sputa may reveal tubercle bacilli when routine expectorated specimens do not. Tuberculosis should be considered a diagnostic possibility in patients with "lower lung field pneumonia" who do not appear acutely ill or who have had symptoms for more than several days and particularly for several weeks. Important clues to the diagnosis of tuberculosis are hemoptysis, normal white blood cell count, cavitation, hilar lymphadenopathy, pleural effusion, evidence of old tuberculosis, and especially failure to improve radiologically with treatment for pneumonia. The results of treatment with antituberculosis drugs are similar to those in upper lobe tuberculosis.

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