Cavitary pulmonary tuberculosis in children and adolescents: CT features that may mimic necrotizing pneumonia

Tuberculosis remains a major infectious cause of morbidity and mortality in children worldwide. Cavitary pulmonary tuberculosis is uncommon in children but may be associated with a high bacillary burden and transmissibility. We retrospectively reviewed patients younger than 18 years diagnosed with pulmonary tuberculosis between January 2007 and January 2025 at a tertiary referral center. Cavitary disease was identified on chest computed tomography (CT). Clinical and microbiological data were extracted from medical records. CT examinations were reviewed by a pediatric radiologist blinded to microbiological results. IGRA testing was performed selectively due to limited availability during earlier years of the study period. Cavitary disease was identified in 8 of 250 children with pulmonary tuberculosis (3.2%). Median age was 14 years (range 11.5–15.5), and five patients were female. History of household or close contact was present in five patients (62.5%). Mean symptom duration was 1.8 months. Sputum smear microscopy was positive in four patients (50%) and culture in six (75%). Cavities were not confined to the upper lobes and were frequently accompanied by consolidation, a pattern that can overlap with complicated bacterial pneumonia, particularly when lower-lobe involvement is present. Associated CT findings included consolidation (7/8, 87.5%), lymphadenopathy (6/8, 75%), bronchiectasis (5/8, 62.5%) and tree-in-bud opacities (4/8, 50%). All patients completed treatment with clinical and radiological recovery and no relapse during follow-up (median 42 months). Cavitary pulmonary tuberculosis in children and adolescents may not be confined to the upper lobes and may present with cavitation accompanied by consolidation and other TB-associated CT findings. This pattern can overlap with complicated bacterial pneumonia, particularly in lower-lobe disease. Awareness of this CT pattern may raise suspicion for tuberculosis in cases initially labelled as complicated bacterial pneumonia and prompt timely microbiological testing and appropriate infection control measures.