Correlation of microbiological yield with radiographic activity on chest computed tomography in cases of suspected pulmonary tuberculosis
Identifieur interne : 000688 ( Pmc/Corpus ); précédent : 000687; suivant : 000689Correlation of microbiological yield with radiographic activity on chest computed tomography in cases of suspected pulmonary tuberculosis
Auteurs : Yousang Ko ; Ho Young Lee ; Yong Bum Park ; Su Jin Hong ; Jeong Hwan Shin ; Seok Jin Choi ; Changhwan Kim ; So Young Park ; Jin Young JeongSource :
- PLoS ONE [ 1932-6203 ] ; 2018.
Abstract
Little is known about the correlation between microbiological yield and radiographic activity, on chest computed tomography (CT), in suspected pulmonary tuberculosis (PTB) cases, despite CT being widely used, clinically.
We used multicenter retrospective data, obtained from medical records, focusing on the diagnostic performance for definite PTB. We categorized patients into four groups, by radiographic activity: definitely active, probably active, indeterminate activity, and probably inactive.
Of the 650 patients included, 316 had culture-confirmed PTB; 190 (29.2%), 323 (49.7%), 70 (10.8%), and 67 (10.3%) were classified into the definitely active, probably active, indeterminate activity, and probably inactive groups, respectively. The corresponding observed culture rates for CT radiographic activity were 61.6%, 60.7%, 4.3% and 0%, respectively. When not only culture rates but TB-PCR and histological results were taken into consideration as definite PTB, it showed 66.6%, 67.2%, 14.3%, and 0% of each CT radiographic activity, respectively. Regarding the diagnostic performance for definite PTB, radiographic activity displayed high sensitivity (97.1%, 95% confidence interval (CI), 94.6–98.5) and negative predictive values (92.7%, 95% CI, 86.6–96.2), considered definitely and probably active PTB. Apart from PTB, other etiologies, according to radiographic activity, were predominantly respiratory infections such as bacterial pneumonia and non-tuberculous mycobacterial infection.
Radiographic activity showed good diagnostic performance, and can be used easily in clinical practice. However, clinicians should consider other possibilities, because radiologic images do not confirm microbiological PTB.
Url:
DOI: 10.1371/journal.pone.0201748
PubMed: 30091997
PubMed Central: 6084932
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Correlation of microbiological yield with radiographic activity on chest computed tomography in cases of suspected pulmonary tuberculosis</title><author><name sortKey="Ko, Yousang" sort="Ko, Yousang" uniqKey="Ko Y" first="Yousang" last="Ko">Yousang Ko</name><affiliation><nlm:aff id="aff001"><addr-line>Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea</addr-line></nlm:aff></affiliation><affiliation><nlm:aff id="aff002"><addr-line>Lung Research Institute of Hallym University College of Medicine, Chuncheon, Republic of Korea</addr-line></nlm:aff></affiliation></author><author><name sortKey="Lee, Ho Young" sort="Lee, Ho Young" uniqKey="Lee H" first="Ho Young" last="Lee">Ho Young Lee</name><affiliation><nlm:aff id="aff003"><addr-line>Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea</addr-line></nlm:aff></affiliation></author><author><name sortKey="Park, Yong Bum" sort="Park, Yong Bum" uniqKey="Park Y" first="Yong Bum" last="Park">Yong Bum Park</name><affiliation><nlm:aff id="aff001"><addr-line>Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea</addr-line></nlm:aff></affiliation><affiliation><nlm:aff id="aff002"><addr-line>Lung Research Institute of Hallym University College of Medicine, Chuncheon, Republic of Korea</addr-line></nlm:aff></affiliation></author><author><name sortKey="Hong, Su Jin" sort="Hong, Su Jin" uniqKey="Hong S" first="Su Jin" last="Hong">Su Jin Hong</name><affiliation><nlm:aff id="aff004"><addr-line>Department of Radiology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Republic of Korea</addr-line></nlm:aff></affiliation></author><author><name sortKey="Shin, Jeong Hwan" sort="Shin, Jeong Hwan" uniqKey="Shin J" first="Jeong Hwan" last="Shin">Jeong Hwan Shin</name><affiliation><nlm:aff id="aff005"><addr-line>Department Laboratory Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea</addr-line></nlm:aff></affiliation></author><author><name sortKey="Choi, Seok Jin" sort="Choi, Seok Jin" uniqKey="Choi S" first="Seok Jin" last="Choi">Seok Jin Choi</name><affiliation><nlm:aff id="aff006"><addr-line>Department of Radiology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea</addr-line></nlm:aff></affiliation></author><author><name sortKey="Kim, Changhwan" sort="Kim, Changhwan" uniqKey="Kim C" first="Changhwan" last="Kim">Changhwan Kim</name><affiliation><nlm:aff id="aff007"><addr-line>Department of Internal Medicine, Jeju National University Hospital, Jeju, Republic of Korea</addr-line></nlm:aff></affiliation></author><author><name sortKey="Park, So Young" sort="Park, So Young" uniqKey="Park S" first="So Young" last="Park">So Young Park</name><affiliation><nlm:aff id="aff008"><addr-line>Department of Pulmonary and Critical Care Medicine, Chung Nam National University Medical Center, Daejeon, Republic of Korea</addr-line></nlm:aff></affiliation></author><author><name sortKey="Jeong, Jin Young" sort="Jeong, Jin Young" uniqKey="Jeong J" first="Jin Young" last="Jeong">Jin Young Jeong</name><affiliation><nlm:aff id="aff009"><addr-line>Hallym Research Institute of Clinical Epidemiology, Chuncheon, Republic of Korea</addr-line></nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">30091997</idno><idno type="pmc">6084932</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6084932</idno><idno type="RBID">PMC:6084932</idno><idno type="doi">10.1371/journal.pone.0201748</idno><date when="2018">2018</date><idno type="wicri:Area/Pmc/Corpus">000688</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000688</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Correlation of microbiological yield with radiographic activity on chest computed tomography in cases of suspected pulmonary tuberculosis</title><author><name sortKey="Ko, Yousang" sort="Ko, Yousang" uniqKey="Ko Y" first="Yousang" last="Ko">Yousang Ko</name><affiliation><nlm:aff id="aff001"><addr-line>Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea</addr-line></nlm:aff></affiliation><affiliation><nlm:aff id="aff002"><addr-line>Lung Research Institute of Hallym University College of Medicine, Chuncheon, Republic of Korea</addr-line></nlm:aff></affiliation></author><author><name sortKey="Lee, Ho Young" sort="Lee, Ho Young" uniqKey="Lee H" first="Ho Young" last="Lee">Ho Young Lee</name><affiliation><nlm:aff id="aff003"><addr-line>Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea</addr-line></nlm:aff></affiliation></author><author><name sortKey="Park, Yong Bum" sort="Park, Yong Bum" uniqKey="Park Y" first="Yong Bum" last="Park">Yong Bum Park</name><affiliation><nlm:aff id="aff001"><addr-line>Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea</addr-line></nlm:aff></affiliation><affiliation><nlm:aff id="aff002"><addr-line>Lung Research Institute of Hallym University College of Medicine, Chuncheon, Republic of Korea</addr-line></nlm:aff></affiliation></author><author><name sortKey="Hong, Su Jin" sort="Hong, Su Jin" uniqKey="Hong S" first="Su Jin" last="Hong">Su Jin Hong</name><affiliation><nlm:aff id="aff004"><addr-line>Department of Radiology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Republic of Korea</addr-line></nlm:aff></affiliation></author><author><name sortKey="Shin, Jeong Hwan" sort="Shin, Jeong Hwan" uniqKey="Shin J" first="Jeong Hwan" last="Shin">Jeong Hwan Shin</name><affiliation><nlm:aff id="aff005"><addr-line>Department Laboratory Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea</addr-line></nlm:aff></affiliation></author><author><name sortKey="Choi, Seok Jin" sort="Choi, Seok Jin" uniqKey="Choi S" first="Seok Jin" last="Choi">Seok Jin Choi</name><affiliation><nlm:aff id="aff006"><addr-line>Department of Radiology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea</addr-line></nlm:aff></affiliation></author><author><name sortKey="Kim, Changhwan" sort="Kim, Changhwan" uniqKey="Kim C" first="Changhwan" last="Kim">Changhwan Kim</name><affiliation><nlm:aff id="aff007"><addr-line>Department of Internal Medicine, Jeju National University Hospital, Jeju, Republic of Korea</addr-line></nlm:aff></affiliation></author><author><name sortKey="Park, So Young" sort="Park, So Young" uniqKey="Park S" first="So Young" last="Park">So Young Park</name><affiliation><nlm:aff id="aff008"><addr-line>Department of Pulmonary and Critical Care Medicine, Chung Nam National University Medical Center, Daejeon, Republic of Korea</addr-line></nlm:aff></affiliation></author><author><name sortKey="Jeong, Jin Young" sort="Jeong, Jin Young" uniqKey="Jeong J" first="Jin Young" last="Jeong">Jin Young Jeong</name><affiliation><nlm:aff id="aff009"><addr-line>Hallym Research Institute of Clinical Epidemiology, Chuncheon, Republic of Korea</addr-line></nlm:aff></affiliation></author></analytic><series><title level="j">PLoS ONE</title><idno type="eISSN">1932-6203</idno><imprint><date when="2018">2018</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec id="sec001"><title>Background</title><p>Little is known about the correlation between microbiological yield and radiographic activity, on chest computed tomography (CT), in suspected pulmonary tuberculosis (PTB) cases, despite CT being widely used, clinically.</p></sec><sec id="sec002"><title>Methods</title><p>We used multicenter retrospective data, obtained from medical records, focusing on the diagnostic performance for definite PTB. We categorized patients into four groups, by radiographic activity: definitely active, probably active, indeterminate activity, and probably inactive.</p></sec><sec id="sec003"><title>Results</title><p>Of the 650 patients included, 316 had culture-confirmed PTB; 190 (29.2%), 323 (49.7%), 70 (10.8%), and 67 (10.3%) were classified into the definitely active, probably active, indeterminate activity, and probably inactive groups, respectively. The corresponding observed culture rates for CT radiographic activity were 61.6%, 60.7%, 4.3% and 0%, respectively. When not only culture rates but TB-PCR and histological results were taken into consideration as definite PTB, it showed 66.6%, 67.2%, 14.3%, and 0% of each CT radiographic activity, respectively. Regarding the diagnostic performance for definite PTB, radiographic activity displayed high sensitivity (97.1%, 95% confidence interval (CI), 94.6–98.5) and negative predictive values (92.7%, 95% CI, 86.6–96.2), considered definitely and probably active PTB. Apart from PTB, other etiologies, according to radiographic activity, were predominantly respiratory infections such as bacterial pneumonia and non-tuberculous mycobacterial infection.</p></sec><sec id="sec004"><title>Conclusions</title><p>Radiographic activity showed good diagnostic performance, and can be used easily in clinical practice. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">PLoS One</journal-id><journal-id journal-id-type="iso-abbrev">PLoS ONE</journal-id><journal-id journal-id-type="publisher-id">plos</journal-id><journal-id journal-id-type="pmc">plosone</journal-id><journal-title-group><journal-title>PLoS ONE</journal-title></journal-title-group><issn pub-type="epub">1932-6203</issn><publisher><publisher-name>Public Library of Science</publisher-name><publisher-loc>San Francisco, CA USA</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">30091997</article-id><article-id pub-id-type="pmc">6084932</article-id><article-id pub-id-type="doi">10.1371/journal.pone.0201748</article-id><article-id pub-id-type="publisher-id">PONE-D-18-03185</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Research and Analysis Methods</subject><subj-group><subject>Imaging Techniques</subject><subj-group><subject>Neuroimaging</subject><subj-group><subject>Computed Axial Tomography</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Neuroscience</subject><subj-group><subject>Neuroimaging</subject><subj-group><subject>Computed Axial Tomography</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Diagnostic Medicine</subject><subj-group><subject>Diagnostic Radiology</subject><subj-group><subject>Tomography</subject><subj-group><subject>Computed Axial Tomography</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Research and Analysis Methods</subject><subj-group><subject>Imaging Techniques</subject><subj-group><subject>Diagnostic Radiology</subject><subj-group><subject>Tomography</subject><subj-group><subject>Computed Axial Tomography</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Radiology and Imaging</subject><subj-group><subject>Diagnostic Radiology</subject><subj-group><subject>Tomography</subject><subj-group><subject>Computed Axial Tomography</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Organisms</subject><subj-group><subject>Bacteria</subject><subj-group><subject>Actinobacteria</subject><subj-group><subject>Mycobacterium Tuberculosis</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Pathology and Laboratory Medicine</subject><subj-group><subject>Etiology</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Infectious Diseases</subject><subj-group><subject>Bacterial Diseases</subject><subj-group><subject>Tuberculosis</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Tropical Diseases</subject><subj-group><subject>Tuberculosis</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Diagnostic Medicine</subject></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Anatomy</subject><subj-group><subject>Histology</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Anatomy</subject><subj-group><subject>Histology</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Diagnostic Medicine</subject><subj-group><subject>Tuberculosis Diagnosis and Management</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Diagnostic Medicine</subject><subj-group><subject>Signs and Symptoms</subject><subj-group><subject>Lesions</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Pathology and Laboratory Medicine</subject><subj-group><subject>Signs and Symptoms</subject><subj-group><subject>Lesions</subject></subj-group></subj-group></subj-group></subj-group></article-categories><title-group><article-title>Correlation of microbiological yield with radiographic activity on chest computed tomography in cases of suspected pulmonary tuberculosis</article-title><alt-title alt-title-type="running-head">Clinical evidence of radiographic grades</alt-title></title-group><contrib-group><contrib contrib-type="author" equal-contrib="yes"><contrib-id authenticated="true" contrib-id-type="orcid">http://orcid.org/0000-0002-1703-6590</contrib-id><name><surname>Ko</surname><given-names>Yousang</given-names></name><role content-type="http://credit.casrai.org/">Conceptualization</role><role content-type="http://credit.casrai.org/">Data curation</role><role content-type="http://credit.casrai.org/">Formal analysis</role><role content-type="http://credit.casrai.org/">Methodology</role><role content-type="http://credit.casrai.org/">Resources</role><role content-type="http://credit.casrai.org/">Writing – original draft</role><role content-type="http://credit.casrai.org/">Writing – review & editing</role><xref ref-type="aff" rid="aff001"><sup>1</sup></xref><xref ref-type="aff" rid="aff002"><sup>2</sup></xref><xref ref-type="corresp" rid="cor001">*</xref></contrib><contrib contrib-type="author" equal-contrib="yes"><name><surname>Lee</surname><given-names>Ho Young</given-names></name><role content-type="http://credit.casrai.org/">Resources</role><role content-type="http://credit.casrai.org/">Writing – original draft</role><role content-type="http://credit.casrai.org/">Writing – review & editing</role><xref ref-type="aff" rid="aff003"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>Park</surname><given-names>Yong Bum</given-names></name><role content-type="http://credit.casrai.org/">Data curation</role><role content-type="http://credit.casrai.org/">Resources</role><role content-type="http://credit.casrai.org/">Writing – review & editing</role><xref ref-type="aff" rid="aff001"><sup>1</sup></xref><xref ref-type="aff" rid="aff002"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Hong</surname><given-names>Su Jin</given-names></name><role content-type="http://credit.casrai.org/">Data curation</role><role content-type="http://credit.casrai.org/">Resources</role><role content-type="http://credit.casrai.org/">Writing – review & editing</role><xref ref-type="aff" rid="aff004"><sup>4</sup></xref></contrib><contrib contrib-type="author"><name><surname>Shin</surname><given-names>Jeong Hwan</given-names></name><role content-type="http://credit.casrai.org/">Data curation</role><role content-type="http://credit.casrai.org/">Methodology</role><role content-type="http://credit.casrai.org/">Resources</role><role content-type="http://credit.casrai.org/">Writing – review & editing</role><xref ref-type="aff" rid="aff005"><sup>5</sup></xref></contrib><contrib contrib-type="author"><name><surname>Choi</surname><given-names>Seok Jin</given-names></name><role content-type="http://credit.casrai.org/">Conceptualization</role><role content-type="http://credit.casrai.org/">Data curation</role><role content-type="http://credit.casrai.org/">Methodology</role><role content-type="http://credit.casrai.org/">Resources</role><role content-type="http://credit.casrai.org/">Writing – review & editing</role><xref ref-type="aff" rid="aff006"><sup>6</sup></xref></contrib><contrib contrib-type="author"><contrib-id authenticated="true" contrib-id-type="orcid">http://orcid.org/0000-0003-3318-2528</contrib-id><name><surname>Kim</surname><given-names>Changhwan</given-names></name><role content-type="http://credit.casrai.org/">Conceptualization</role><role content-type="http://credit.casrai.org/">Data curation</role><role content-type="http://credit.casrai.org/">Methodology</role><role content-type="http://credit.casrai.org/">Resources</role><role content-type="http://credit.casrai.org/">Writing – review & editing</role><xref ref-type="aff" rid="aff007"><sup>7</sup></xref></contrib><contrib contrib-type="author"><name><surname>Park</surname><given-names>So Young</given-names></name><role content-type="http://credit.casrai.org/">Conceptualization</role><role content-type="http://credit.casrai.org/">Data curation</role><role content-type="http://credit.casrai.org/">Methodology</role><role content-type="http://credit.casrai.org/">Resources</role><role content-type="http://credit.casrai.org/">Writing – review & editing</role><xref ref-type="aff" rid="aff008"><sup>8</sup></xref></contrib><contrib contrib-type="author"><name><surname>Jeong</surname><given-names>Jin Young</given-names></name><role content-type="http://credit.casrai.org/">Data curation</role><role content-type="http://credit.casrai.org/">Formal analysis</role><role content-type="http://credit.casrai.org/">Methodology</role><role content-type="http://credit.casrai.org/">Supervision</role><role content-type="http://credit.casrai.org/">Writing – review & editing</role><xref ref-type="aff" rid="aff009"><sup>9</sup></xref></contrib></contrib-group><aff id="aff001"><label>1</label><addr-line>Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea</addr-line></aff><aff id="aff002"><label>2</label><addr-line>Lung Research Institute of Hallym University College of Medicine, Chuncheon, Republic of Korea</addr-line></aff><aff id="aff003"><label>3</label><addr-line>Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea</addr-line></aff><aff id="aff004"><label>4</label><addr-line>Department of Radiology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Republic of Korea</addr-line></aff><aff id="aff005"><label>5</label><addr-line>Department Laboratory Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea</addr-line></aff><aff id="aff006"><label>6</label><addr-line>Department of Radiology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea</addr-line></aff><aff id="aff007"><label>7</label><addr-line>Department of Internal Medicine, Jeju National University Hospital, Jeju, Republic of Korea</addr-line></aff><aff id="aff008"><label>8</label><addr-line>Department of Pulmonary and Critical Care Medicine, Chung Nam National University Medical Center, Daejeon, Republic of Korea</addr-line></aff><aff id="aff009"><label>9</label><addr-line>Hallym Research Institute of Clinical Epidemiology, Chuncheon, Republic of Korea</addr-line></aff><contrib-group><contrib contrib-type="editor"><name><surname>Cardona</surname><given-names>Pere-Joan</given-names></name><role>Editor</role><xref ref-type="aff" rid="edit1"></xref></contrib></contrib-group><aff id="edit1"><addr-line>Fundació Institut d’Investigació en Ciències de la Salut Germans Trias i Pujol, Universitat Autònoma de Barcelona, SPAIN</addr-line></aff><author-notes><fn fn-type="COI-statement" id="coi001"><p><bold>Competing Interests: </bold>The authors have declared that no competing interests exist.</p></fn><corresp id="cor001">* E-mail: <email>koyus@naver.com</email></corresp></author-notes><pub-date pub-type="epub"><day>9</day><month>8</month><year>2018</year></pub-date><pub-date pub-type="collection"><year>2018</year></pub-date><volume>13</volume><issue>8</issue><elocation-id>e0201748</elocation-id><history><date date-type="received"><day>30</day><month>1</month><year>2018</year></date><date date-type="accepted"><day>20</day><month>7</month><year>2018</year></date></history><permissions><copyright-statement>© 2018 Ko et al</copyright-statement><copyright-year>2018</copyright-year><copyright-holder>Ko et al</copyright-holder><license xlink:href="http://creativecommons.org/licenses/by/4.0/"><license-p>This is an open access article distributed under the terms of the <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">Creative Commons Attribution License</ext-link>, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</license-p></license></permissions><self-uri content-type="pdf" xlink:href="pone.0201748.pdf"></self-uri><abstract><sec id="sec001"><title>Background</title><p>Little is known about the correlation between microbiological yield and radiographic activity, on chest computed tomography (CT), in suspected pulmonary tuberculosis (PTB) cases, despite CT being widely used, clinically.</p></sec><sec id="sec002"><title>Methods</title><p>We used multicenter retrospective data, obtained from medical records, focusing on the diagnostic performance for definite PTB. We categorized patients into four groups, by radiographic activity: definitely active, probably active, indeterminate activity, and probably inactive.</p></sec><sec id="sec003"><title>Results</title><p>Of the 650 patients included, 316 had culture-confirmed PTB; 190 (29.2%), 323 (49.7%), 70 (10.8%), and 67 (10.3%) were classified into the definitely active, probably active, indeterminate activity, and probably inactive groups, respectively. The corresponding observed culture rates for CT radiographic activity were 61.6%, 60.7%, 4.3% and 0%, respectively. When not only culture rates but TB-PCR and histological results were taken into consideration as definite PTB, it showed 66.6%, 67.2%, 14.3%, and 0% of each CT radiographic activity, respectively. Regarding the diagnostic performance for definite PTB, radiographic activity displayed high sensitivity (97.1%, 95% confidence interval (CI), 94.6–98.5) and negative predictive values (92.7%, 95% CI, 86.6–96.2), considered definitely and probably active PTB. Apart from PTB, other etiologies, according to radiographic activity, were predominantly respiratory infections such as bacterial pneumonia and non-tuberculous mycobacterial infection.</p></sec><sec id="sec004"><title>Conclusions</title><p>Radiographic activity showed good diagnostic performance, and can be used easily in clinical practice. However, clinicians should consider other possibilities, because radiologic images do not confirm microbiological PTB.</p></sec></abstract><funding-group><funding-statement>The authors received no specific funding for this work.</funding-statement></funding-group><counts><fig-count count="2"></fig-count><table-count count="6"></table-count><page-count count="13"></page-count></counts><custom-meta-group><custom-meta id="data-availability"><meta-name>Data Availability</meta-name><meta-value>All relevant data are within the paper and its Supporting Information files.</meta-value></custom-meta></custom-meta-group></article-meta><notes><title>Data Availability</title><p>All relevant data are within the paper and its Supporting Information files.</p></notes></front><body><sec sec-type="intro" id="sec005"><title>Introduction</title><p>Chest computed tomography (CT) plays a significant role in the diagnosis of pulmonary tuberculosis (PTB) [<xref rid="pone.0201748.ref001" ref-type="bibr">1</xref>]. Although chest radiography is used as the first diagnostic method, owing to its rapidity [<xref rid="pone.0201748.ref002" ref-type="bibr">2</xref>], it is limited by poor specificity and reader inconsistency [<xref rid="pone.0201748.ref003" ref-type="bibr">3</xref>–<xref rid="pone.0201748.ref005" ref-type="bibr">5</xref>]. It is important to overcome this disadvantage, therefore. Chest CT can detect early lesions of PTB and distinguish them from other etiologies [<xref rid="pone.0201748.ref001" ref-type="bibr">1</xref>, <xref rid="pone.0201748.ref006" ref-type="bibr">6</xref>, <xref rid="pone.0201748.ref007" ref-type="bibr">7</xref>]. Moreover, it can also provide additional information on the mycobacterial activity of TB lesions [<xref rid="pone.0201748.ref008" ref-type="bibr">8</xref>].</p><p>Early studies evaluated the pathologic and radiologic correlation using chest CT, and presented the radiological characteristics of PTB, as ‘cavitation’, ‘tree-in-bud’ and ‘consolidation’ [<xref rid="pone.0201748.ref009" ref-type="bibr">9</xref>, <xref rid="pone.0201748.ref010" ref-type="bibr">10</xref>]. Later, several studies attempted to ascertain the association between each radiographic feature and the smear grade of the sputum or culture yield of <italic>Mycobacterium tuberculosis</italic> (MTB) [<xref rid="pone.0201748.ref011" ref-type="bibr">11</xref>–<xref rid="pone.0201748.ref013" ref-type="bibr">13</xref>]. It is important for clinicians in charge of PTB treatment to anticipate the culture yield of MTB based on CT, to guide proper management. Unfortunately, the results of previously conducted studies, according to each radiographic manifestation, are too complex for diagnostic use in clinical practice, for PTB. Moreover, the culture yield might be underestimated based on the methods used, such as sputum vs. bronchoscopic specimen or culture media. No study so far has addressed these limitations.</p><p>Therefore, we evaluated the correlation between the microbiologic yield of MTB and the categorized radiographic grade, on chest CT, via bronchoscopy, in presumptive PTB patients. The categorized grade can be used easily in clinical practice. Bronchoscopy is the most useful and powerful tool for the diagnosis of PTB, and it has discriminative ability [<xref rid="pone.0201748.ref014" ref-type="bibr">14</xref>, <xref rid="pone.0201748.ref015" ref-type="bibr">15</xref>]. The aim of this study was to (1) determine the relative frequencies of MTB-positive cultures, according to radiographic grades, based on chest CT, in presumptive PTB patients, (2) evaluate the correlation between radiographic activity and PTB (3) identify the other etiology according to radiographic grades.</p></sec><sec sec-type="materials|methods" id="sec006"><title>Methods</title><sec id="sec007"><title>Study population and design</title><p>This retrospective review included patients older than 18 years of age, with suspected PTB, between January 2012 and February 2015. It was performed at the Hallym University Kangdong Sacred Heart Hospital and Inje University Busan Paik Hospital, in the Republic of Korea, a country with an intermediate TB burden and an annual incidence of 86/100,000 persons, in 2014 [<xref rid="pone.0201748.ref016" ref-type="bibr">16</xref>].</p><p>As per the enrollment criteria, patients who underwent both chest CT and bronchoscopy for the diagnosis of PTB were included. The exclusion criteria were: 1) patients who had received any anti-TB treatment before bronchoscopy (as it could have affected the mycobacterial culture); 2) patients who were previously treated for PTB, 3) patients with only endobronchial TB, without parenchymal lesions; 4) patients with known diseases associated with parenchymal disease, confused with PTB, such as interstitial lung disease, bronchiectasis and malignancy involving the lung. If the second and fourth criteria were not adhered to, the interpretation of radiographic activity could have been affected.</p><p>The study protocol was approved by the institutional review board of each hospital (Kangdong Sacred Heart Hospital and Busan Paik Hospital), and permission was obtained to publish information from patients’ records. The need for informed consent was waived due to the retrospective nature of the study.</p></sec><sec id="sec008"><title>Classification of the radiologic activity of PTB based on chest CT</title><p>Chest CT was reviewed by one radiologist from each institution, and they were all blinded to the microbiological results. Patients with presumptive PTB were categorized into four groups, by radiographic activity, from the highest to lowest grade, based on previously published criteria: definitely active, with lesions including a cavity; probably active, showing a “tree-in-bud” appearance or multiple non-calcified poorly circumscribed nodules without a cavity; indeterminate activity, with lesions appearing mainly as non-calcified well-circumscribed nodules; and probably inactive, with lesions appearing mainly as calcified nodules or fibrotic bands [<xref rid="pone.0201748.ref010" ref-type="bibr">10</xref>, <xref rid="pone.0201748.ref017" ref-type="bibr">17</xref>–<xref rid="pone.0201748.ref019" ref-type="bibr">19</xref>]. If the lesion of the suggested PTB was in two or more of the above categories, the radiographic activities were determined as being of a higher grade of those. The classification of the radiographic activities is shown in <xref ref-type="fig" rid="pone.0201748.g001">Fig 1</xref>.</p><fig id="pone.0201748.g001" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0201748.g001</object-id><label>Fig 1</label><caption><title>The representative cases according to chest CT classification.</title><p>(A) definitely-active, with lesions including a cavity (B) probably-active, showing a “tree-in-bud” appearance or multiple non-calcified poorly circumscribed nodules without a cavity (C) indeterminate-activity, with lesions appearing mainly as non-calcified well-circumscribed nodules (D) probably-inactive, with lesions appearing mainly as calcified nodules or fibrotic bands.</p></caption><graphic xlink:href="pone.0201748.g001"></graphic></fig></sec><sec id="sec009"><title>Bronchoscopy procedure and microbiological examination</title><p>Bronchoscopy was conducted by the faculty staff of the pulmonology division in each hospital. The choice between bronchial washing (BW) and bronchoalveolar lavage (BAL) via bronchoscopy was based on the judgment of individual bronchoscopists. When the multiple lesions of suggested PTB were observed on CT, BW or BAL was conducted on the most severe lesion.</p><p>All the bronchoscopic specimens for the Acid-Fast Bacilli (AFB) smears and cultures were processed and pretreated as recommended [<xref rid="pone.0201748.ref020" ref-type="bibr">20</xref>]. The AFB smears were examined after auramine–rhodamine fluorescent staining, and graded on a scale from 0 to 4+.[<xref rid="pone.0201748.ref021" ref-type="bibr">21</xref>] All the specimens were simultaneously cultured on both solid and liquid media using 3% Ogawa medium (Eiken Chemical, Tokyo, Japan) and the mycobacterial growth indicator tube 960 system (Becton Dickinson, Mountain view, CA, USA). TB-PCR was conducted using either the Xpert MTB/RIF assay (Cepheid Inc., Sunnyvale, CA) or AdvanSure TB/NTM RT-PCR kit (LG Life Sciences, Seoul, Korea) [<xref rid="pone.0201748.ref022" ref-type="bibr">22</xref>, <xref rid="pone.0201748.ref023" ref-type="bibr">23</xref>].</p></sec><sec id="sec010"><title>Definition of PTB and other etiologies</title><p>Microbiologically confirmed PTB was defined as the growth of MTB in the culture. Histologically confirmed PTB was defined as the presence of caseating or necrotizing granulomatous inflammation in a tissue sample, with a positive TB-PCR result in that tissue. Genetically confirmed PTB was defined as the detection of positive TB-PCR in the respiratory specimen. Clinically diagnosed PTB was defined as cases in which patients were considered to have PTB, based on symptoms and radiographic findings compatible with PTB, and whose symptoms and radiographic findings improved after anti-TB treatment, even with a negative MTB culture. Of the aforementioned definitions, microbiologically, histologically and genetically confirmed PTB were classified as definite PTB. Cases of clinically diagnosed PTB were classified as probable PTB [<xref rid="pone.0201748.ref024" ref-type="bibr">24</xref>].</p><p>Other etiologies were identified as follows. Pulmonary non-tuberculous mycobacterial (PNTM) infection was identified according to the isolation of NTM species and the American Thoracic Society criteria [<xref rid="pone.0201748.ref025" ref-type="bibr">25</xref>]. Pulmonary bacterial infection was identified according to the isolation of compatible pathogenic bacteria in the bronchoscopic specimen and/or a positive urinary antigen test for <italic>Streptococcus pneumoniae</italic> and <italic>Legionella pneumophila</italic> and/or positive PCR for bacterial pathogens such as <italic>Streptococcus pneumoniae</italic>, <italic>Legionella pneumophila</italic>, <italic>Mycoplasma pneumoniae</italic> and <italic>Chlamydia pneumoniae</italic> of the bronchoscopic specimens. Pulmonary viral infection was identified based on the result of a multiplex reverse-transcription PCR assay using a bronchoscopic specimen. Pulmonary fungal infection was identified by the guidelines for each organism [<xref rid="pone.0201748.ref026" ref-type="bibr">26</xref>].</p></sec><sec id="sec011"><title>Statistical analysis</title><p>The data are presented as median and IQR (interquartile range) for continuous variables, and as number (percentage) for categorical variables. Data were compared using the Mann–Whitney U test for continuous variables and Pearson’s chi-square test or Fisher’s exact test for categorical variables. To determine the accuracy of each radiographic activity to predict PTB, we estimated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR-) for each kind of radiographic activity. The Youden index, defined as (sensitivity + specificity) − 1, was calculated for every type of radiographic activity. The cutoff radiographic activity at which the Youden index was the highest was considered the optimal cut-off. All tests were two-sided, and a <italic>P</italic>-value <0.05 was considered significant. Data were analyzed using IBM SPSS Statistics version 24 (IBM Corp., Armonk, NY).</p></sec></sec><sec sec-type="results" id="sec012"><title>Results</title><sec id="sec013"><title>Patients’ characteristics</title><p>During the study period, 731 patients underwent chest CT and bronchoscopy because of presumed PTB. Of these patients, 81 met the exclusion criteria. Thus, 650 patients were eligible to participate, and they comprised 190 patients (29.2%) classified as the definitely active group, 323 patients (49.7%) as the probably active group, 70 (10.8%) as the indeterminate activity group, and 67 (10.3%) as the probably inactive group. The demographic and descriptive data of the enrolled cases are summarized in <xref rid="pone.0201748.t001" ref-type="table">Table 1</xref>. There were 370 (56.9%) males with a median age of 57.0 (41.0–71.0) years. The enrolled patients had predominantly localized PTB, involving one lobe of the lung parenchyma.</p><table-wrap id="pone.0201748.t001" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0201748.t001</object-id><label>Table 1</label><caption><title>Demographic and clinical characteristics of 650 patients with presumed PTB.</title></caption><alternatives><graphic id="pone.0201748.t001g" xlink:href="pone.0201748.t001"></graphic><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col></colgroup><thead><tr><th align="left" rowspan="1" colspan="1"></th><th align="left" rowspan="1" colspan="1">No. of patients (%) or median (IQR)</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Age, years</td><td align="center" rowspan="1" colspan="1">57.0 (41.0–71.0)</td></tr><tr><td align="left" rowspan="1" colspan="1">Male sex, %</td><td align="center" rowspan="1" colspan="1">370 (56.9)</td></tr><tr><td align="left" rowspan="1" colspan="1">Comorbidity<xref ref-type="table-fn" rid="t001fn002"><sup>a</sup></xref></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> COPD or asthma</td><td align="center" rowspan="1" colspan="1">28 (4.3)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Thyroid disease</td><td align="center" rowspan="1" colspan="1">6 (0.9)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Cardiovascular disease</td><td align="center" rowspan="1" colspan="1">56 (8.6)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Malignancy</td><td align="center" rowspan="1" colspan="1">21 (3.2)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Hematologic disease</td><td align="center" rowspan="1" colspan="1">2 (0.3)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Chronic liver disease</td><td align="center" rowspan="1" colspan="1">25 (3.8)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Rheumatic disease</td><td align="center" rowspan="1" colspan="1">27 (4.1)</td></tr><tr><td align="left" rowspan="1" colspan="1"> CKD</td><td align="center" rowspan="1" colspan="1">18 (2.8)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Diabetes</td><td align="center" rowspan="1" colspan="1">34 (5.2)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Neurologic disease</td><td align="center" rowspan="1" colspan="1">13 (2.0)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Cerebrovascular disease</td><td align="center" rowspan="1" colspan="1">19 (2.9)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Immune-suppressive disease</td><td align="center" rowspan="1" colspan="1">6 (0.9)</td></tr><tr><td align="left" rowspan="1" colspan="1"> HIV infected</td><td align="center" rowspan="1" colspan="1">2 (0.3)</td></tr><tr><td align="left" rowspan="1" colspan="1">Bronchoscopic specimen</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> BW</td><td align="center" rowspan="1" colspan="1">430 (66.2)</td></tr><tr><td align="left" rowspan="1" colspan="1"> BAL</td><td align="center" rowspan="1" colspan="1">220 (33.8)</td></tr><tr><td align="left" rowspan="1" colspan="1">Radiographic activities based on chest CT</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Definitely active</td><td align="center" rowspan="1" colspan="1">190 (29,2)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Probably active</td><td align="center" rowspan="1" colspan="1">323 (49.7)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Indeterminate activity</td><td align="center" rowspan="1" colspan="1">70 (10.8)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Probably inactive</td><td align="center" rowspan="1" colspan="1">67 (10.3)</td></tr><tr><td align="left" rowspan="1" colspan="1">Extent of lung lesion</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Unilobar involvement</td><td align="center" rowspan="1" colspan="1">378 (57.9)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Multilobar involvement</td><td align="center" rowspan="1" colspan="1">275 (42.1)</td></tr></tbody></table></alternatives><table-wrap-foot><fn id="t001fn001"><p>The data are presented as median (interquartile range) or No. (%)</p></fn><fn id="t001fn002"><p><sup>a</sup> Cases are duplicated</p></fn><fn id="t001fn003"><p>PTB = pulmonary tuberculosis; IQR = interquartile range; COPD = chronic obstructive lung disease; CKD = chronic kidney disease; HIV = human immunodeficiency virus; BW = bronchial washing; BAL = broncho-alveolar lavage</p></fn></table-wrap-foot></table-wrap></sec><sec id="sec014"><title>Culture yield of MTB according to the radiographic activity on chest CT</title><p>The culture yields, according to the radiographic activities, were 61.6%, 60.7%, 4.3% and 0%, respectively (<xref rid="pone.0201748.t002" ref-type="table">Table 2</xref> and <xref ref-type="fig" rid="pone.0201748.g002">Fig 2</xref>). Considering the microbiologically, histologically and genetically confirmed cases, the diagnosis rates of definite PTB according to the radiographic activities were 66.8%, 67.2%, 14.3% and 0%, respectively. When probable PTB was included, the overall rates of PTB diagnosed, according to the radiographic activities, were 71.6%, 75.2%, 22.9% and 9.9%, respectively. In the prediction of PTB, based on the radiographic activities on chest CT, good results were observed for definite or overall PTB. The culture yield of MTB was better in the definitely active group than the probably active group. But, in the prediction of definite and overall PTB, the probably active group had conversely slightly better results than the definitely active group. However, statistical significance was not noted in both.</p><fig id="pone.0201748.g002" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0201748.g002</object-id><label>Fig 2</label><caption><title>MTB culture yield according to radiographic activities of chest CT (A) and final diagnosis as definite or probable PTB by each radiographic grades (B).</title><p>MTB = Mycobacterium tuberculosis Definite TB, defined as microbiologically, histologically or genotypically confirmed cases Probable TB, defined as clinically diagnosed case.</p></caption><graphic xlink:href="pone.0201748.g002"></graphic></fig><table-wrap id="pone.0201748.t002" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0201748.t002</object-id><label>Table 2</label><caption><title>Characteristics of study participants according to the radiographic activities on chest CT.</title></caption><alternatives><graphic id="pone.0201748.t002g" xlink:href="pone.0201748.t002"></graphic><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col></colgroup><thead><tr><th align="left" rowspan="1" colspan="1"></th><th align="center" rowspan="1" colspan="1">Definitely active<break></break>(n = 190)</th><th align="center" rowspan="1" colspan="1">Probably active<break></break>(n = 323)</th><th align="center" rowspan="1" colspan="1">Indeterminate activity<break></break>(n = 70)</th><th align="center" rowspan="1" colspan="1">Probably inactive<break></break>(n = 67)</th><th align="center" rowspan="1" colspan="1"><italic>P</italic>-value</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Age, years</td><td align="center" rowspan="1" colspan="1">55.0 (42.0–70.0)</td><td align="center" rowspan="1" colspan="1">55.0 (35.0–69.0)</td><td align="center" rowspan="1" colspan="1">61.0 (43.0–71.0)</td><td align="center" rowspan="1" colspan="1">66.0 (53.0–76.0)</td><td align="char" char="." rowspan="1" colspan="1"><0.001</td></tr><tr><td align="left" rowspan="1" colspan="1">Male sex, %</td><td align="center" rowspan="1" colspan="1">130 (68.4)</td><td align="center" rowspan="1" colspan="1">157 (48.6)</td><td align="center" rowspan="1" colspan="1">43 (61.4)</td><td align="center" rowspan="1" colspan="1">40 (59.7)</td><td align="char" char="." rowspan="1" colspan="1"><0.001</td></tr><tr><td align="left" rowspan="1" colspan="1">Comorbidity<xref ref-type="table-fn" rid="t002fn002"><sup>a</sup></xref></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> COPD and asthma</td><td align="center" rowspan="1" colspan="1">3 (1.6)</td><td align="center" rowspan="1" colspan="1">15 (4.6)</td><td align="center" rowspan="1" colspan="1">3 (4.3)</td><td align="center" rowspan="1" colspan="1">7 (10.4)</td><td align="char" char="." rowspan="1" colspan="1">0.022</td></tr><tr><td align="left" rowspan="1" colspan="1"> Thyroid disease</td><td align="center" rowspan="1" colspan="1">1 (0.5)</td><td align="center" rowspan="1" colspan="1">5 (1.5)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="char" char="." rowspan="1" colspan="1">0.394</td></tr><tr><td align="left" rowspan="1" colspan="1"> Cardiovascular disease</td><td align="center" rowspan="1" colspan="1">15 (7.9)</td><td align="center" rowspan="1" colspan="1">25 (7.7)</td><td align="center" rowspan="1" colspan="1">6 (8.6)</td><td align="center" rowspan="1" colspan="1">10 (14.9)</td><td align="char" char="." rowspan="1" colspan="1">0.281</td></tr><tr><td align="left" rowspan="1" colspan="1"> Malignancy</td><td align="center" rowspan="1" colspan="1">5 (2.6)</td><td align="center" rowspan="1" colspan="1">9 (2.8)</td><td align="center" rowspan="1" colspan="1">3 (4.3)</td><td align="center" rowspan="1" colspan="1">4 (6.0)</td><td align="char" char="." rowspan="1" colspan="1">0.516</td></tr><tr><td align="left" rowspan="1" colspan="1"> Hematologic disease</td><td align="center" rowspan="1" colspan="1">1 (0.5)</td><td align="center" rowspan="1" colspan="1">1 (0.3)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="char" char="." rowspan="1" colspan="1">0.869</td></tr><tr><td align="left" rowspan="1" colspan="1"> Chronic liver disease</td><td align="center" rowspan="1" colspan="1">8 (4.2)</td><td align="center" rowspan="1" colspan="1">10 (3.1)</td><td align="center" rowspan="1" colspan="1">6 (8.6)</td><td align="center" rowspan="1" colspan="1">1 (1.5)</td><td align="char" char="." rowspan="1" colspan="1">0.122</td></tr><tr><td align="left" rowspan="1" colspan="1"> Rheumatic disease</td><td align="center" rowspan="1" colspan="1">13 (6.8)</td><td align="center" rowspan="1" colspan="1">8 (2.7)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">3 (4.5)</td><td align="char" char="." rowspan="1" colspan="1">0.073</td></tr><tr><td align="left" rowspan="1" colspan="1"> CKD</td><td align="center" rowspan="1" colspan="1">5 (2.6)</td><td align="center" rowspan="1" colspan="1">10 (3.1)</td><td align="center" rowspan="1" colspan="1">1 (1.4)</td><td align="center" rowspan="1" colspan="1">2 (3.0)</td><td align="char" char="." rowspan="1" colspan="1">0.892</td></tr><tr><td align="left" rowspan="1" colspan="1"> Diabetes</td><td align="center" rowspan="1" colspan="1">14 (7.4)</td><td align="center" rowspan="1" colspan="1">11 (3.4)</td><td align="center" rowspan="1" colspan="1">4 (5.7)</td><td align="center" rowspan="1" colspan="1">5 (7.5)</td><td align="char" char="." rowspan="1" colspan="1">0.201</td></tr><tr><td align="left" rowspan="1" colspan="1"> Neurologic disease</td><td align="center" rowspan="1" colspan="1">1 (0.5)</td><td align="center" rowspan="1" colspan="1">9 (2.8)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">3 (4.5)</td><td align="char" char="." rowspan="1" colspan="1">0.084</td></tr><tr><td align="left" rowspan="1" colspan="1"> Cerebrovascular disease</td><td align="center" rowspan="1" colspan="1">7 (3.7)</td><td align="center" rowspan="1" colspan="1">9 (2.8)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">3 (4.5)</td><td align="char" char="." rowspan="1" colspan="1">0.378</td></tr><tr><td align="left" rowspan="1" colspan="1"> Immune-suppressive disease</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">4 (1.2)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">2 (3.0)</td><td align="char" char="." rowspan="1" colspan="1">0.117</td></tr><tr><td align="left" rowspan="1" colspan="1"> HIV infected, %</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">1 (0.3)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">1 (1.5)</td><td align="char" char="." rowspan="1" colspan="1">0.276</td></tr><tr><td align="left" rowspan="1" colspan="1">Overall PTB</td><td align="center" rowspan="1" colspan="1">136 (71.6)</td><td align="center" rowspan="1" colspan="1">243 (75.2)</td><td align="center" rowspan="1" colspan="1">16 (22.9)</td><td align="center" rowspan="1" colspan="1">7 (9.9)</td><td align="char" char="." rowspan="1" colspan="1"><0.001</td></tr><tr><td align="left" rowspan="1" colspan="1">Definite PTB</td><td align="center" rowspan="1" colspan="1">127 (66.8)</td><td align="center" rowspan="1" colspan="1">217 (67.2)</td><td align="center" rowspan="1" colspan="1">10 (14.3)</td><td align="center" rowspan="1" colspan="1">0</td><td align="char" char="." rowspan="1" colspan="1"><0.001</td></tr><tr><td align="left" rowspan="1" colspan="1">Microbiologically confirmed PTB</td><td align="center" rowspan="1" colspan="1">117 (61.6)</td><td align="center" rowspan="1" colspan="1">196 (60.7)</td><td align="center" rowspan="1" colspan="1">3 (4.3)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Histologically confirmed PTB</td><td align="center" rowspan="1" colspan="1">1 (0.5)</td><td align="center" rowspan="1" colspan="1">3 (0.9)</td><td align="center" rowspan="1" colspan="1">4 (5.7)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Genetically confirmed PTB</td><td align="center" rowspan="1" colspan="1">10 (5.3)</td><td align="center" rowspan="1" colspan="1">18 (5.6)</td><td align="center" rowspan="1" colspan="1">3 (4.3)</td><td align="center" rowspan="1" colspan="1">0</td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Probable PTB</td><td align="center" rowspan="1" colspan="1">9 (4.7)</td><td align="center" rowspan="1" colspan="1">26 (8.0)</td><td align="center" rowspan="1" colspan="1">6 (8.6)</td><td align="center" rowspan="1" colspan="1">7 (10.4)</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Extent of lung lesion</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="char" char="." rowspan="1" colspan="1">0.189</td></tr><tr><td align="left" rowspan="1" colspan="1"> Unilobar involvement</td><td align="center" rowspan="1" colspan="1">98 (51.6)</td><td align="center" rowspan="1" colspan="1">193 (59.8)</td><td align="center" rowspan="1" colspan="1">42 (60.0)</td><td align="center" rowspan="1" colspan="1">43 (64.2)</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Multilobar involvement</td><td align="center" rowspan="1" colspan="1">92 (48.4)</td><td align="center" rowspan="1" colspan="1">130 (40.2)</td><td align="center" rowspan="1" colspan="1">28 (40.0)</td><td align="center" rowspan="1" colspan="1">24 (35.8)</td><td align="center" rowspan="1" colspan="1"></td></tr></tbody></table></alternatives><table-wrap-foot><fn id="t002fn001"><p>The data are presented as median (interquartile range) or No. (%)</p></fn><fn id="t002fn002"><p><sup>a</sup> Cases are duplicated</p></fn><fn id="t002fn003"><p>CT = computed tomography; PTB = pulmonary tuberculosis; IQR = interquartile range; COPD = chronic obstructive lung disease; CKD = chronic kidney disease; HIV = human immunodeficiency virus; BW = bronchial washing; BAL = broncho-alveolar lavage</p></fn></table-wrap-foot></table-wrap></sec><sec id="sec015"><title>Diagnostic performance of the radiographic classification for PTB</title><p>The sensitivity, specificity, PPV, and NPV for definite and overall PTB, according to the radiographic activities on CT, are presented in <xref rid="pone.0201748.t003" ref-type="table">Table 3</xref>. In the definitely active and probably active groups, low sensitivity but modest specificity in predicting definite and overall PTB, respectively, were noted. However, when combined, the definitely and probably active groups were considered to suggest active PTB, with high sensitivity and NPV, but low specificity and modest PPV. The optimal cut-off radiographic activities for the prediction of definite and overall PTB, assessed by the Youden index, were over the probably active grade in both.</p><table-wrap id="pone.0201748.t003" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0201748.t003</object-id><label>Table 3</label><caption><title>Diagnostic performance of the radiographic activities on chest CT in predicting definite and overall PTB in patients with presumed PTB.</title></caption><alternatives><graphic id="pone.0201748.t003g" xlink:href="pone.0201748.t003"></graphic><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col></colgroup><thead><tr><th align="center" rowspan="1" colspan="1">Radiographic activity</th><th align="center" rowspan="1" colspan="1">Sensitivity<break></break>% (95% CI)</th><th align="center" rowspan="1" colspan="1">Specificity<break></break>% (95% CI)</th><th align="center" rowspan="1" colspan="1">PPV<break></break>% (95% CI)</th><th align="center" rowspan="1" colspan="1">NPV<break></break>% (95% CI)</th><th align="center" rowspan="1" colspan="1">LR+<break></break>% (95% CI)</th><th align="center" rowspan="1" colspan="1">LP-<break></break>% (95% CI)</th><th align="center" rowspan="1" colspan="1">Youden index<xref ref-type="table-fn" rid="t003fn001"><sup>a</sup></xref></th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Definite PTB</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">suggested active PTB</td><td align="center" rowspan="1" colspan="1">97.1 (94.6–98.5)</td><td align="center" rowspan="1" colspan="1">42.9 (37.2–48.7)</td><td align="center" rowspan="1" colspan="1">66.9 (62.7–71.0)</td><td align="center" rowspan="1" colspan="1">92.7 (86.6–96.2)</td><td align="center" rowspan="1" colspan="1">2.03 (1.76–2.32)</td><td align="center" rowspan="1" colspan="1">0.07 (0.04–0.14)</td><td align="char" char="." rowspan="1" colspan="1">0.40</td></tr><tr><td align="left" rowspan="1" colspan="1">(combined with definitely and probably active)</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Definitely active</td><td align="center" rowspan="1" colspan="1">35.8 (30.9–41.1)</td><td align="center" rowspan="1" colspan="1">78.7 (73.5–83.1)</td><td align="center" rowspan="1" colspan="1">66.8 (59.6–73.3)</td><td align="center" rowspan="1" colspan="1">50.6 (59.6–73.3)</td><td align="center" rowspan="1" colspan="1">2.01 (1.60–2.52)</td><td align="center" rowspan="1" colspan="1">0.97 (0.88–1.07)</td><td align="char" char="." rowspan="1" colspan="1">0.15</td></tr><tr><td align="left" rowspan="1" colspan="1">Probably active</td><td align="center" rowspan="1" colspan="1">61.2 (55.9–66.3)</td><td align="center" rowspan="1" colspan="1">64.1 (58.4–69.5)</td><td align="center" rowspan="1" colspan="1">67.1 (61.7–72.2)</td><td align="center" rowspan="1" colspan="1">58.1 (52.5–63.4)</td><td align="center" rowspan="1" colspan="1">2.04 (1.72–2.43)</td><td align="center" rowspan="1" colspan="1">0.72 (0.63–0.82)</td><td align="char" char="." rowspan="1" colspan="1">0.25</td></tr><tr><td align="left" rowspan="1" colspan="1">Indeterminate activity</td><td align="center" rowspan="1" colspan="1">2.8 (1.4–5.3)</td><td align="center" rowspan="1" colspan="1">79.7 (74.6–84.1)</td><td align="center" rowspan="1" colspan="1">14.2 (7.4–25.1)</td><td align="center" rowspan="1" colspan="1">40.7 (36.7–44.8)</td><td align="center" rowspan="1" colspan="1">0.167 (0.09–0.29)</td><td align="center" rowspan="1" colspan="1">1.45 (1.35–1.56)</td><td align="char" char="." rowspan="1" colspan="1">-0.17</td></tr><tr><td align="left" rowspan="1" colspan="1">Probably inactive</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">77.3 (72.0–81.9)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">39.3 (35.3–43.4)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">1.54 (1.44–1.65)</td><td align="char" char="." rowspan="1" colspan="1">-0.23</td></tr><tr><td align="left" rowspan="1" colspan="1">Overall PTB</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Suggested active PTB</td><td align="center" rowspan="1" colspan="1">94.2 (91.3–96.2)</td><td align="center" rowspan="1" colspan="1">45.9 (39.6–52.3)</td><td align="center" rowspan="1" colspan="1">73.8 (69.7–77.5)</td><td align="center" rowspan="1" colspan="1">83.2 (75.6–88.8)</td><td align="center" rowspan="1" colspan="1">2.82 (2.41–3.29)</td><td align="center" rowspan="1" colspan="1">0.20 (0.13–0.29)</td><td align="char" char="." rowspan="1" colspan="1">0.40</td></tr><tr><td align="left" rowspan="1" colspan="1">(combined with definitely and probably active)</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Definitely active</td><td align="center" rowspan="1" colspan="1">33.8 (29.2–38.7)</td><td align="center" rowspan="1" colspan="1">78.2 (72.4–83.0)</td><td align="center" rowspan="1" colspan="1">71.5 (64.5–77.7)</td><td align="center" rowspan="1" colspan="1">42.1 (37.6–46.8)</td><td align="center" rowspan="1" colspan="1">2.51 (1.97–3.21)</td><td align="center" rowspan="1" colspan="1">1.37 (1.26–1.49)</td><td align="char" char="." rowspan="1" colspan="1">0.12</td></tr><tr><td align="left" rowspan="1" colspan="1">Probably active</td><td align="center" rowspan="1" colspan="1">60.4 (55.4–65.2)</td><td align="center" rowspan="1" colspan="1">67.7 (61.4–73.4)</td><td align="center" rowspan="1" colspan="1">75.2 (70.0–79.7)</td><td align="center" rowspan="1" colspan="1">51.3 (45.8–56.8)</td><td align="center" rowspan="1" colspan="1">3.03 (2.48–3.71)</td><td align="center" rowspan="1" colspan="1">0.94 (0.84–1.06)</td><td align="char" char="." rowspan="1" colspan="1">0.28</td></tr><tr><td align="left" rowspan="1" colspan="1">Indeterminate activity</td><td align="center" rowspan="1" colspan="1">3.9 (2.3–6.5)</td><td align="center" rowspan="1" colspan="1">78.2 (72.4–83.0)</td><td align="center" rowspan="1" colspan="1">22.8 (14.0–34.7)</td><td align="center" rowspan="1" colspan="1">33.5 (29.6–37.5)</td><td align="center" rowspan="1" colspan="1">0.29 (0.18–0.46)</td><td align="center" rowspan="1" colspan="1">1.98 (1.86–2.12)</td><td align="char" char="." rowspan="1" colspan="1">-0.18</td></tr><tr><td align="left" rowspan="1" colspan="1">Probably inactive</td><td align="center" rowspan="1" colspan="1">1.7 (0.7–3.7)</td><td align="center" rowspan="1" colspan="1">75.8 (69.8–80.9)</td><td align="center" rowspan="1" colspan="1">10.4 (4.6–20.9)</td><td align="center" rowspan="1" colspan="1">32.3 (28.5–36.2)</td><td align="center" rowspan="1" colspan="1">0.11 (5.7–23.6)</td><td align="center" rowspan="1" colspan="1">2.10 (1.97–2.23)</td><td align="char" char="." rowspan="1" colspan="1">-0.22</td></tr></tbody></table></alternatives><table-wrap-foot><fn id="t003fn001"><p><sup>a</sup>Youden index = ((sensitivity + specificity) − 1).</p></fn><fn id="t003fn002"><p>CT = computed tomography; PTB = pulmonary tuberculosis; CI = confidence interval; PPV = positive predictive value; NPV = negative predictive value; LR+ = positive likelihood ratio; LR− = negative likelihood ratio.</p></fn></table-wrap-foot></table-wrap></sec><sec id="sec016"><title>Other etiologies according to the radiographic activities on chest CT</title><p><xref rid="pone.0201748.t004" ref-type="table">Table 4</xref> shows the isolated or detected microorganisms, other than MTB. When organisms other were classified according to the radiographic activities, no remarkable differences were observed. <xref rid="pone.0201748.t005" ref-type="table">Table 5</xref> shows the final diagnosis of the enrolled cases, according to the radiographic activities. In almost all the cases except PTB, bacterial pneumonia as the cause of parenchymal lung lesion was the most prevalent, followed by PNTM. We further analyzed the distribution of the microbial etiologies in the cases finally diagnosed as bacterial pneumonia (<xref rid="pone.0201748.t006" ref-type="table">Table 6</xref>), but no statistical differences was not noted.</p><table-wrap id="pone.0201748.t004" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0201748.t004</object-id><label>Table 4</label><caption><title>Microbiological etiology other than PTB according to the radiographic activities on chest CT.</title></caption><alternatives><graphic id="pone.0201748.t004g" xlink:href="pone.0201748.t004"></graphic><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col></colgroup><thead><tr><th align="left" rowspan="1" colspan="1"></th><th align="center" rowspan="1" colspan="1">Definitely active<break></break>(n = 190)</th><th align="center" rowspan="1" colspan="1">Probably active<break></break>(n = 323)</th><th align="center" rowspan="1" colspan="1">Indeterminate activity<break></break>(n = 70)</th><th align="center" rowspan="1" colspan="1">Probably inactive<break></break>(n = 67)</th><th align="center" rowspan="1" colspan="1"><italic>P</italic>-value</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">NTM</td><td align="center" rowspan="1" colspan="1">16 (8.4)</td><td align="center" rowspan="1" colspan="1">22 (6.8)</td><td align="center" rowspan="1" colspan="1">9 (12.9)</td><td align="center" rowspan="1" colspan="1">4 (6.0)</td><td align="char" char="." rowspan="1" colspan="1">0.348</td></tr><tr><td align="left" rowspan="1" colspan="1"> <italic>Mycobacterium absscessus</italic></td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> <italic>Mycobacterium masilliense</italic></td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> <italic>Mycobacterium avium</italic></td><td align="center" rowspan="1" colspan="1">4</td><td align="center" rowspan="1" colspan="1">3</td><td align="center" rowspan="1" colspan="1">3</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> <italic>Mycobacterium intracellulare</italic></td><td align="center" rowspan="1" colspan="1">9</td><td align="center" rowspan="1" colspan="1">15</td><td align="center" rowspan="1" colspan="1">4</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> <italic>Mycobacterium kansasii</italic></td><td align="center" rowspan="1" colspan="1">3</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> <italic>Mycobacterium smegmatis</italic></td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1">Bacteria</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> <italic>Streptococcus pneumoniae</italic></td><td align="center" rowspan="1" colspan="1">4 (2.1)</td><td align="center" rowspan="1" colspan="1">3 (0.9)</td><td align="center" rowspan="1" colspan="1">1 (1.4)</td><td align="center" rowspan="1" colspan="1">0</td><td align="char" char="." rowspan="1" colspan="1">0.513</td></tr><tr><td align="left" rowspan="1" colspan="1"> Other streptococcus spp.</td><td align="center" rowspan="1" colspan="1">50 (26.3)</td><td align="center" rowspan="1" colspan="1">98 (30.3)</td><td align="center" rowspan="1" colspan="1">17 (24.3)</td><td align="center" rowspan="1" colspan="1">21 (31.3)</td><td align="char" char="." rowspan="1" colspan="1">0.604</td></tr><tr><td align="left" rowspan="1" colspan="1"> <italic>Staphylococcus aureus</italic></td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">7 (2.2)</td><td align="center" rowspan="1" colspan="1">1 (1.4)</td><td align="center" rowspan="1" colspan="1">0</td><td align="char" char="." rowspan="1" colspan="1">0.135</td></tr><tr><td align="left" rowspan="1" colspan="1"> <italic>Pseudomonas</italic> spp.</td><td align="center" rowspan="1" colspan="1">2 (1.1)</td><td align="center" rowspan="1" colspan="1">3 (0.9)</td><td align="center" rowspan="1" colspan="1">3 (4.3)</td><td align="center" rowspan="1" colspan="1">0</td><td align="char" char="." rowspan="1" colspan="1">0.090</td></tr><tr><td align="left" rowspan="1" colspan="1"> <italic>Stenotrophomonas maltophilia</italic></td><td align="center" rowspan="1" colspan="1">1 (0.5)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">1 (1.5)</td><td align="char" char="." rowspan="1" colspan="1">0.206</td></tr><tr><td align="left" rowspan="1" colspan="1"> <italic>Mycoplasma pneumoniae</italic></td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">1 (0.3)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="char" char="." rowspan="1" colspan="1">0.489</td></tr><tr><td align="left" rowspan="1" colspan="1"> <italic>Klebsiella</italic> spp.</td><td align="center" rowspan="1" colspan="1">10 (5.3)</td><td align="center" rowspan="1" colspan="1">7 (2.2)</td><td align="center" rowspan="1" colspan="1">3 (4.3)</td><td align="center" rowspan="1" colspan="1">3 (4.5)</td><td align="char" char="." rowspan="1" colspan="1">0.293</td></tr><tr><td align="left" rowspan="1" colspan="1"> <italic>Haemophilus influenzae</italic></td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">3 (0.9)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="char" char="." rowspan="1" colspan="1">0.384</td></tr><tr><td align="left" rowspan="1" colspan="1"> <italic>Enterobacter</italic> spp.</td><td align="center" rowspan="1" colspan="1">1 (0.5)</td><td align="center" rowspan="1" colspan="1">1 (0.3)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="char" char="." rowspan="1" colspan="1">0.869</td></tr><tr><td align="left" rowspan="1" colspan="1"> <italic>Acinetobacter</italic> spp.</td><td align="center" rowspan="1" colspan="1">2 (1.1)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="char" char="." rowspan="1" colspan="1">0.183</td></tr><tr><td align="left" rowspan="1" colspan="1"> Others</td><td align="center" rowspan="1" colspan="1">10 (5.3)</td><td align="center" rowspan="1" colspan="1">28 (8.7)</td><td align="center" rowspan="1" colspan="1">5 (7.1)</td><td align="center" rowspan="1" colspan="1">8 (11.9)</td><td align="char" char="." rowspan="1" colspan="1">0.301</td></tr><tr><td align="left" rowspan="1" colspan="1">Fungus</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> <italic>Candida</italic> spp.</td><td align="center" rowspan="1" colspan="1">8 (4.2)</td><td align="center" rowspan="1" colspan="1">6 (1.9)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">1 (1.5)</td><td align="char" char="." rowspan="1" colspan="1">0.153</td></tr><tr><td align="left" rowspan="1" colspan="1">Virus</td><td align="center" rowspan="1" colspan="1">3 (1.6)</td><td align="center" rowspan="1" colspan="1">3 (0.9)</td><td align="center" rowspan="1" colspan="1">1 (1.4)</td><td align="center" rowspan="1" colspan="1">2 (3.0)</td><td align="char" char="." rowspan="1" colspan="1">0.615</td></tr><tr><td align="left" rowspan="1" colspan="1"> Cytomegalovirus</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Corona virus</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> HSV type B</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Parainfluenza</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> RSV-A</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> Rhino virus</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1"></td></tr></tbody></table></alternatives><table-wrap-foot><fn id="t004fn001"><p>CT = computed tomography; NTM = non-tuberculous mycobacteria; spp = species; HSV = herpes simplex virus; RSV = Respiratory syncytial virus</p></fn></table-wrap-foot></table-wrap><table-wrap id="pone.0201748.t005" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0201748.t005</object-id><label>Table 5</label><caption><title>Final diagnosis of 650 patients with presumed PTB.</title></caption><alternatives><graphic id="pone.0201748.t005g" xlink:href="pone.0201748.t005"></graphic><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col></colgroup><thead><tr><th align="left" rowspan="1" colspan="1"></th><th align="center" rowspan="1" colspan="1">Definitely active<break></break>(n = 190)</th><th align="center" rowspan="1" colspan="1">Probably active<break></break>(n = 323)</th><th align="center" rowspan="1" colspan="1">Indeterminate activity<break></break>(n = 70)</th><th align="center" rowspan="1" colspan="1">Probably inactive<break></break>(n = 67)</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">PTB</td><td align="center" rowspan="1" colspan="1">136 (71.6)</td><td align="center" rowspan="1" colspan="1">243 (75.2)</td><td align="center" rowspan="1" colspan="1">16 (22.9)</td><td align="center" rowspan="1" colspan="1">7 (10.4)</td></tr><tr><td align="left" rowspan="1" colspan="1">PNTM</td><td align="center" rowspan="1" colspan="1">15 (7.9)</td><td align="center" rowspan="1" colspan="1">21 (6.5)</td><td align="center" rowspan="1" colspan="1">9 (12.9)</td><td align="center" rowspan="1" colspan="1">3 (4.5)</td></tr><tr><td align="left" rowspan="1" colspan="1">Bacterial pneumonia</td><td align="center" rowspan="1" colspan="1">28 (14.7)</td><td align="center" rowspan="1" colspan="1">43 (13.3)</td><td align="center" rowspan="1" colspan="1">37 (52.9)</td><td align="center" rowspan="1" colspan="1">28 (41.8)</td></tr><tr><td align="left" rowspan="1" colspan="1">LCA</td><td align="center" rowspan="1" colspan="1">6 (3.2)</td><td align="center" rowspan="1" colspan="1">4 (1.2)</td><td align="center" rowspan="1" colspan="1">1 (1.4)</td><td align="center" rowspan="1" colspan="1">0</td></tr><tr><td align="left" rowspan="1" colspan="1">CCPA</td><td align="center" rowspan="1" colspan="1">1 (0.5)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td></tr><tr><td align="left" rowspan="1" colspan="1">PJP</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">1 (0.3)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td></tr><tr><td align="left" rowspan="1" colspan="1">Sarcoidosis</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">1 (0.3)</td><td align="center" rowspan="1" colspan="1">2 (2.9)</td><td align="center" rowspan="1" colspan="1">0</td></tr><tr><td align="left" rowspan="1" colspan="1">Viral pneumonia</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">2 (0.6)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td></tr><tr><td align="left" rowspan="1" colspan="1">Unidentified</td><td align="center" rowspan="1" colspan="1">4 (2.1)</td><td align="center" rowspan="1" colspan="1">8 (2.5)</td><td align="center" rowspan="1" colspan="1">5 (7.1)</td><td align="center" rowspan="1" colspan="1">29 (43.3)</td></tr></tbody></table></alternatives><table-wrap-foot><fn id="t005fn001"><p>PTB = pulmonary tuberculosis; PNTM = pulmonary non-tuberculous mycobacteria; LCA = lung cancer, CCPA = chronic cavitary pulmonary aspergillosis; PJP = pneumocystis jirovecii pneumonia</p></fn></table-wrap-foot></table-wrap><table-wrap id="pone.0201748.t006" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0201748.t006</object-id><label>Table 6</label><caption><title>Microbial etiology of finally diagnosed bacterial pneumonia according to radiographic activity.</title></caption><alternatives><graphic id="pone.0201748.t006g" xlink:href="pone.0201748.t006"></graphic><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col></colgroup><thead><tr><th align="left" rowspan="1" colspan="1"></th><th align="center" rowspan="1" colspan="1">Definitely active<break></break>(n = 31)</th><th align="center" rowspan="1" colspan="1">Probably active<break></break>(n = 44)</th><th align="center" rowspan="1" colspan="1">Indeterminate activity<break></break>(n = 37)</th><th align="center" rowspan="1" colspan="1">Probably inactive<break></break>(n = 29)</th><th align="center" rowspan="1" colspan="1"><italic>P</italic>-value</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Bacterial Pneumonia</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"> <italic>Streptococcus pneumoniae</italic></td><td align="center" rowspan="1" colspan="1">4 (10.5)</td><td align="center" rowspan="1" colspan="1">1 (2.6)</td><td align="center" rowspan="1" colspan="1">1 (2.0)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0.712</td></tr><tr><td align="left" rowspan="1" colspan="1"> Other streptococcus spp.</td><td align="center" rowspan="1" colspan="1">5 (17.2)</td><td align="center" rowspan="1" colspan="1">6 (15.4)</td><td align="center" rowspan="1" colspan="1">10 (20.0)</td><td align="center" rowspan="1" colspan="1">3 (10.3)</td><td align="center" rowspan="1" colspan="1">0.730</td></tr><tr><td align="left" rowspan="1" colspan="1"> <italic>Staphylococcus aureus</italic></td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">1 (2.6)</td><td align="center" rowspan="1" colspan="1">3 (6.0)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0.301</td></tr><tr><td align="left" rowspan="1" colspan="1"> Pseudomonas spp.</td><td align="center" rowspan="1" colspan="1">1 (3.4)</td><td align="center" rowspan="1" colspan="1">3 (7.7)</td><td align="center" rowspan="1" colspan="1">1 (2.0)</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0.320</td></tr><tr><td align="left" rowspan="1" colspan="1"> <italic>Stenotrophomonas maltophilia</italic></td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">1 (3.4)</td><td align="center" rowspan="1" colspan="1">0.251</td></tr><tr><td align="left" rowspan="1" colspan="1"> <italic>Mycoplasma pneumoniae</italic></td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">NA</td></tr><tr><td align="left" rowspan="1" colspan="1"> Klebsiella spp.</td><td align="center" rowspan="1" colspan="1">5 (17.2)</td><td align="center" rowspan="1" colspan="1">2 (5.1)</td><td align="center" rowspan="1" colspan="1">2 (4.0)</td><td align="center" rowspan="1" colspan="1">3 (10.3)</td><td align="center" rowspan="1" colspan="1">0.171</td></tr><tr><td align="left" rowspan="1" colspan="1"> <italic>Haemophilus influenzae</italic></td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">NA</td></tr><tr><td align="left" rowspan="1" colspan="1"> Enterobacter spp.</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">NA</td></tr><tr><td align="left" rowspan="1" colspan="1"> Acinetobacter spp.</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">NA</td></tr><tr><td align="left" rowspan="1" colspan="1"> Others</td><td align="center" rowspan="1" colspan="1">1 (3.4)</td><td align="center" rowspan="1" colspan="1">3 (7.7)</td><td align="center" rowspan="1" colspan="1">6 (12.0)</td><td align="center" rowspan="1" colspan="1">3 (10.3)</td><td align="center" rowspan="1" colspan="1">0.613</td></tr></tbody></table></alternatives><table-wrap-foot><fn id="t006fn001"><p>Cases with no growth of bacteria in the lower respiratory specimen or other urologic, serologic tests are not presented in this table</p></fn></table-wrap-foot></table-wrap></sec></sec><sec sec-type="conclusions" id="sec017"><title>Discussion</title><p>The study evaluated the correlation between microbiological yield and radiographic activity on chest CT, in suspected PTB patients. In this real-world study, the culture rates of each radiographic activity were 61.6%, 60.7%, 4.3% and 0%, respectively. However, with regards to the diagnostic performance of definite and overall PTB, the radiographic activities showed high sensitivity and NPV when the definitely and probably active grades were considered as active PTB. These findings suggest that radiographic activity can be used for the diagnosis of PTB, and in the initial guidance of anti-TB therapy, for presumptive PTB, in clinical practice. This is the first study to evaluate the correlation of microbiologic yield with radiographic activities on chest CT, in suspected PTB cases, in real-world settings.</p><p>PTB has a long history of challenging physicians more than any other infectious lung disease, due to the great morbidity and mortality associated with it. Moreover, in addition to the outcome, the diagnosis of PTB is also challenging because, although microbial identification of MTB is the gold standard in the diagnosis of PTB, it is frequently not properly performed and is relatively time-consuming, despite recent advances in the culture methods [<xref rid="pone.0201748.ref027" ref-type="bibr">27</xref>]. So, chest radiography or CT plays a critical role in the diagnosis of PTB and initial guidance of anti-TB therapy for presumptive PTB patients [<xref rid="pone.0201748.ref003" ref-type="bibr">3</xref>, <xref rid="pone.0201748.ref012" ref-type="bibr">12</xref>]. CT is more advantageous than radiography in several aspects and is widely used even now [<xref rid="pone.0201748.ref019" ref-type="bibr">19</xref>, <xref rid="pone.0201748.ref028" ref-type="bibr">28</xref>–<xref rid="pone.0201748.ref030" ref-type="bibr">30</xref>]. However, little has been reported on the correlation of microbiological yield with radiographic activities on CT, in suspected PTB cases. Moreover, the shadow of the lung lesion in CT does not confirm microbiological PTB [<xref rid="pone.0201748.ref030" ref-type="bibr">30</xref>–<xref rid="pone.0201748.ref034" ref-type="bibr">34</xref>].</p><p>Researchers have, in the past, tried to define the radiographic characteristics and activities of PTB for its early detection and to prevent its transmission, as it has threatening outcomes. In many previously conducted studies, several radiologic features, such as cavity, centrilobular nodules, tree-in-bud, air-space consolidation, etc., and locations such as the upper lobe or superior segment of the lower lobes, were suggestive of active PTB [<xref rid="pone.0201748.ref008" ref-type="bibr">8</xref>, <xref rid="pone.0201748.ref010" ref-type="bibr">10</xref>, <xref rid="pone.0201748.ref012" ref-type="bibr">12</xref>, <xref rid="pone.0201748.ref017" ref-type="bibr">17</xref>, <xref rid="pone.0201748.ref018" ref-type="bibr">18</xref>, <xref rid="pone.0201748.ref029" ref-type="bibr">29</xref>–<xref rid="pone.0201748.ref033" ref-type="bibr">33</xref>, <xref rid="pone.0201748.ref035" ref-type="bibr">35</xref>]. Moreover, some research studies classified and provided the radiographic criteria for PTB activity based on chest CT [<xref rid="pone.0201748.ref010" ref-type="bibr">10</xref>, <xref rid="pone.0201748.ref014" ref-type="bibr">14</xref>, <xref rid="pone.0201748.ref017" ref-type="bibr">17</xref>, <xref rid="pone.0201748.ref018" ref-type="bibr">18</xref>].</p><p>However, radiographic findings alone, despite CT scans proving valuable in clinical practice, cannot provide a definitive diagnosis of PTB, because radiologic similarity has been observed in other disease entities too [<xref rid="pone.0201748.ref030" ref-type="bibr">30</xref>–<xref rid="pone.0201748.ref034" ref-type="bibr">34</xref>]. Therefore, the microbiological confirmation of PTB should be done carefully. Recently, liquid culture systems have been developed and are widely used to hasten and augment the yield of the MTB culture; the World Health Organization also recommends the widespread adoption of liquid culture [<xref rid="pone.0201748.ref035" ref-type="bibr">35</xref>]. However, many previously conducted studies focused on the identification of the radiologic characteristics and activities based on histological correlation, or the microbiological confirmation mostly through sputum [<xref rid="pone.0201748.ref009" ref-type="bibr">9</xref>, <xref rid="pone.0201748.ref010" ref-type="bibr">10</xref>, <xref rid="pone.0201748.ref017" ref-type="bibr">17</xref>, <xref rid="pone.0201748.ref018" ref-type="bibr">18</xref>, <xref rid="pone.0201748.ref030" ref-type="bibr">30</xref>, <xref rid="pone.0201748.ref033" ref-type="bibr">33</xref>, <xref rid="pone.0201748.ref035" ref-type="bibr">35</xref>]. Several studies have focused on each radiologic pattern, such as tree-in-bud or cavity, and its cause [<xref rid="pone.0201748.ref032" ref-type="bibr">32</xref>, <xref rid="pone.0201748.ref034" ref-type="bibr">34</xref>, <xref rid="pone.0201748.ref036" ref-type="bibr">36</xref>, <xref rid="pone.0201748.ref037" ref-type="bibr">37</xref>], but there are no data with regards to the overall causes of presumptive PTB, based on chest CT, according to the grade of the radiographic activities. Although it is important to identify the radiologic characteristics of definite PTB, it is conversely, in clinical practice, more important and useful to identify the relative frequency of definite PTB in presumptive PTB patients, based on a chest CT scan.</p><p>For these reasons, we conducted this study using a concept borrowed from the radiographic criteria for PTB activities based on chest CT [<xref rid="pone.0201748.ref010" ref-type="bibr">10</xref>, <xref rid="pone.0201748.ref014" ref-type="bibr">14</xref>, <xref rid="pone.0201748.ref017" ref-type="bibr">17</xref>, <xref rid="pone.0201748.ref018" ref-type="bibr">18</xref>]. We aimed to estimate the relative incidence of microbiologically confirmed PTB, by bronchoscopy, which is regarded as the most powerful diagnostic method for PTB, according to previously published criteria of radiographic activity based on a chest CT scan. In this study, we identified a significant correlation between radiographic activity, according to the morphological characteristics of chest CT, and the microbiological confirmation of PTB. This information will prove useful to clinicians for the diagnosis of PTB and in the initial guidance of anti-TB therapy for presumptive PTB patients.</p><p>There are several potential limitations to our study that should be acknowledged. First, given its retrospective nature, selection bias may have influenced our findings. In this study, we only enrolled patients who underwent bronchoscopy because, through it, other etiologies can be differentiated from PTB. Moreover, the proportion of definite PTB cases corresponding to each radiographic activity could have been underestimated because the enrolled patients predominantly had localized disease (57.9%), and were determined as requiring bronchoscopy for diagnosis. However, this inclusion could have decreased the proportion of undiagnosed cases, unlike previous other studies [<xref rid="pone.0201748.ref034" ref-type="bibr">34</xref>, <xref rid="pone.0201748.ref037" ref-type="bibr">37</xref>]. Second, the CT image protocol was not the same in all the enrolled patients. This may have affected the morphological characteristics required for some subtle findings. Third, we conducted this study in South Korea, an intermediate TB burden county, so this result should be interpreted with infectious etiology of each lesion. For example, the most prevalent cause of tree-in-bud appearance on chest CT is PNTM infection in US study, while PTB and pneumonia due to <italic>Streptococcus pneumonia and Haemophilus</italic> species in Israel study [<xref rid="pone.0201748.ref034" ref-type="bibr">34</xref>, <xref rid="pone.0201748.ref037" ref-type="bibr">37</xref>]. Moreover, cavitary lesion of lung is also diagnosed other than PTB [<xref rid="pone.0201748.ref032" ref-type="bibr">32</xref>, <xref rid="pone.0201748.ref036" ref-type="bibr">36</xref>]. Thus, this result of study should be applied in other clinical setting with caution.</p><p>In conclusion, the radiographic activities, based on chest CT, showed a modest correlation with the microbiological yield of MTB, and in combination with definitely and probably active lesions showed a good performance for the diagnosis of PTB. The results of this study suggest that the radiographic activity, based on chest CT can be used easily in clinical practice. However, clinicians should consider possibilities other than PTB, because radiologic images do not confirm microbiological PTB.</p></sec><sec sec-type="supplementary-material" id="sec018"><title>Supporting information</title><supplementary-material content-type="local-data" id="pone.0201748.s001"><label>S1 File</label><caption><title>Raw data.</title><p>(XLS)</p></caption><media xlink:href="pone.0201748.s001.xls"><caption><p>Click here for additional data file.</p></caption></media></supplementary-material></sec></body><back><ack><p>The authors thank Ms. Youn Jung Lee, Ms IL Han and Ms. Young-ok Kim for their help in the data collection.</p></ack><ref-list><title>References</title><ref id="pone.0201748.ref001"><label>1</label><mixed-citation publication-type="journal"><name><surname>Ryu</surname><given-names>YJ</given-names></name>. <article-title>Diagnosis of pulmonary tuberculosis: recent advances and diagnostic algorithms</article-title>. <source>Tuberculosis and respiratory diseases</source>. <year>2015</year>;<volume>78</volume>(<issue>2</issue>):<fpage>64</fpage>–<lpage>71</lpage>. 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