Pulmonary tuberculosis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 8 Jun 2025

Last updated: 24 Oct 2024

Pulmonary tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis.

Key risk factors include exposure to infection, birth in an endemic country, and HIV infection.

Symptoms may include cough, fever, and weight loss.

If pulmonary TB is suspected, the patient should be isolated, a chest x-ray obtained, and three sputum samples collected for acid-fast bacilli smear and culture; nucleic acid amplification test should be performed on at least one respiratory specimen.

Directly observed therapy is highly recommended and is particularly indicated in groups where adherence cannot be assumed.

Early recognition and implementation of effective treatment for infectious TB is crucial in interrupting TB transmission.

Definition

In many patients, Mycobacterium tuberculosis becomes dormant before it progresses to active TB. TB most commonly involves the lungs (pulmonary TB) and is communicable in this form, but may affect almost any organ system including the lymph nodes, central nervous system, liver, bones, genitourinary tract, and gastrointestinal tract. See Extrapulmonary tuberculosis.

History and exam

Key diagnostic factors

cough
fever
anorexia
weight loss
malaise

Full details

Other diagnostic factors

night sweats
pleuritic chest pain
hemoptysis
psychological symptoms
abnormal chest auscultation
asymptomatic
dyspnea
clubbing
erythema nodosum and erythema induratum

Full details

Risk factors

exposure to infection
birth in an endemic country
HIV infection
immunosuppressive medications
malignancy
silicosis
end-stage renal disease
apical fibrosis
intravenous drug use
malnutrition
alcoholism
diabetes
high-risk congregate settings
low socioeconomic status or black/Hispanic/Native-American ancestry
age
tobacco smoking

Full details

Diagnostic tests

1st tests to order

chest x-ray
sputum acid-fast bacilli smear
sputum culture
CBC (complete blood count)
nucleic acid amplification tests (NAAT)

Full details

Tests to consider

gastric aspirate
bronchoscopy and bronchoalveolar lavage
stool testing
empiric treatment
drug susceptibility testing
genotyping
HIV test
lateral flow urine lipoarabinomannan (LF-LAM) assay
CT of chest
tuberculin skin testing
interferon-gamma release assays
TB antigen-based skin tests (TBSTs)

Full details

Treatment algorithm

INITIAL

latent TB infection: nonpregnant

latent TB infection: pregnant

ACUTE

active TB HIV-negative nonpregnant: no hepatic dysfunction

active TB HIV-positive nonpregnant: no hepatic dysfunction

active TB pregnant

active TB non-pregnant: pre-existing or drug-induced hepatic dysfunction

ONGOING

recurrent TB

Contributors

Authors

David J. Horne, MD, MPH

Associate Professor

Division of Pulmonary, Critical Care, and Sleep Medicine

Department of Medicine

University of Washington

Seattle

Disclosures

DJH declares that he has no competing interests.

Masahiro Narita, MD

Professor of Medicine

Division of Pulmonary, Critical Care, and Sleep Medicine

Department of Medicine

University of Washington

Seattle

Disclosures

MN declares that he has no competing interests. MN is the author of a reference cited in this topic.

Peer reviewers

Fayez Kheir, MD, MSc

Assistant Professor of Medicine

Harvard Medical School

Division of Pulmonary and Critical Care

Massachusetts General Hospital

Boston

Disclosures

FK declares that he has no competing interests.

William Burman, MD

Professor

Division of Infectious Diseases

University of Colorado at Denver and Health Sciences Center

Denver

Disclosures

WB declares that he has no competing interests.

Ian Campbell, MD (Lond), FRCP (Edin & Lond)

Consultant Chest Physician

Llandough Hospital

Llandough

Penarth

South Wales

Disclosures

IC declares that he has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Nahid P, Dorman SE, Alipanah N, et al. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America clinical practice guidelines: treatment of drug-susceptible tuberculosis. Clin Infect Dis. 2016 Oct;63(7):e147-95.Full text Abstract

Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention clinical practice guidelines: diagnosis of tuberculosis in adults and children. Clin Infect Dis. 2017 Jan 15;64(2):e1-33.Full text Abstract

World Health Organization. WHO consolidated guidelines on tuberculosis: module 5: management of tuberculosis in children and adolescents. Mar 2022 [internet publication].Full text

National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: mycobacterium tuberculosis infection and disease. 2024 [internet publication].Full text

Nahid P, Mase SR, Migliori GB, et al. Treatment of drug-resistant tuberculosis. An official ATS/CDC/ERS/IDSA clinical practice guideline. Am J Respir Crit Care Med. 2019 Nov 15;200(10):e93-142.Full text Abstract

World Health Organization. WHO consolidated guidelines on tuberculosis: module 4: treatment: drug-susceptible tuberculosis treatment. May 2022 [internet publication].Full text

Uthman OA, Okwundu C, Gbenga K, et al. Optimal timing of antiretroviral therapy initiation for HIV-infected adults with newly diagnosed pulmonary tuberculosis: a systematic review and meta-analysis. Ann Intern Med. 2015 Jul 7;163(1):32-9. Abstract

World Health Organization. WHO consolidated guidelines on tuberculosis: module 4: treatment: drug-resistant tuberculosis treatment, 2022 update. Dec 2022 [internet publication].Full text

Tuberculosis Trials Consortium. Rifapentine and isoniazid once a week versus rifampicin and isoniazid twice a week for treatment of drug-susceptible pulmonary tuberculosis in HIV-negative patients: a randomised clinical trial. Lancet. 2002 Aug 17;360(9332):528-34. Abstract

American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America. Controlling tuberculosis in the United States. Am J Respir Crit Care Med. 2005 Nov 1;172(9):1169-227.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available here.

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