Pathophysiology

A susceptible person inhales mycobacterium bacilli and becomes infected. The bacteria
are transmitted through the airways to the alveoli, where they are deposited and begin to
multiply. The bacilli also are transported via the lymph system and bloodstream to other parts
of the body (kidneys, bones, cerebral cortex) and other areas of the lungs (upper lobes). The
body’s immune system responds by initiating an inflammatory reaction. Phagocytes
(neutrophils and macrophages) engulf many of the bacteria, and TB-specific lymphocytes lyse
(destroy) the bacilli and normal tissue. This tissue reaction results in the accumulation of
exudate in the alveoli, causing bronchopneumonia. The initial infection usually occurs 2 to 10
weeks after exposure.
Granulomas, new tissue masses of live and dead bacilli, are surrounded by
macrophages, which form a protective wall around the granulomas. Granulomas are then
transformed to a fibrous tissue mass, the central portion of which is called a Ghon tubercle. The
material (bacteria and macrophages) becomes necrotic, forming a cheesy mass. This mass may
become calcified and form a collagenous scar. At this point, the bacteria become dormant, and
there is no further progression of active disease.
After initial exposure and infection, the person may develop active disease because of a
compromised or inadequate immune system response. Active disease also may occur with
reinfection and activation of dormant bacteria. In this case, the Ghon tubercle ulcerates,
releasing the cheesy material into the bronchi. The bacteria then become airborne, resulting in
further spread of the disease. Then the ulcerated tubercle heals and forms scar tissue.
This causes the infected lung to become more inflamed, resulting in further development of
bronchopneumonia and tubercle formation.
Unless the process is arrested, it spreads slowly downward to the hilum of the lungs and
later extends to adjacent lobes. The process may be prolonged and characterized by long
remissions when the disease is arrested, only to be followed by periods of renewed activity.
Approximately 10% of people who are initially infected develop active disease. Some people
develop reactivation TB (also called adult-type TB). This type of TB results from a breakdown of
the host defenses. It most commonly occurs within the lungs, usually in the apical or posterior segments
of the upper lobes, or the superior segments of the lower lobes.