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Clinical characteristics of active tuberculosis with pulmonary thromboembolism

BMC Pulmonary Medicine volume 25, Article number: 156 (2025) Cite this article

Abstract

Background

In this study, we summarized clinical characteristics in patients with active tuberculosis (ATB) complicated by pulmonary thromboembolism (PTE), to further determine the influencing factors of PTE in ATB patients.

Methods

The study population consisted of ATB patients who were first seen and hospitalized from January 2014 to January 2022 in Haihe Hospital. The diagnosis of PTE was confirmed by computed tomography pulmonary angiography (CTPA), and the ATB patients were divided into a test group with PTE and a control group without PTE in this study. The Padua score is a guideline-recommended validated tool for venous thromboembolism (VTE) risk assessment in medical patients. The two groups were retrospectively compared and analyzed by clinical characteristics, including gender, age, Padua score, clinical symptoms, tuberculosis (TB) classification, routine blood tests, coagulation indexes, inflammatory indexes, imaging manifestations, and rifampicin application, etc.

Results

There are 43 patients diagnosed with ATB complicated by PTE in this study, including 27 males (62.8%) and 16 females (37.2%), with a ratio of 1.69. Compared with the control group, test group showed higher Padua score, more frequent chest tightness and dyspnea, higher D-dimer, but with lower arterial partial pressure of carbon dioxide. Pathologically, more lobes in the test group patients had pulmonary lesions, with higher occurance in the lower and middle lobes, more image manifestations of pulmonary infarction and atelectasis. Lastly, CTPA traits showed that peripheral types are more than central types in the test group.

Conclusions

ATB patients should be alert to the occurrence of PTE and consider initiating anticoagulant therapy, if they have anemia, hypoproteinemia, increased D-dimer, increased inflammatory indicators, serious imaging, more pulmonary lobe involvement and lower lobe involvement.

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Background

Tuberculosis (TB) is a chronic infection caused by Mycobacterium tuberculosis and is contagious, with a predominance of PTB.The Global Tuberculosis Report 2024 shows 10.8 million new cases of TB worldwide in 2023 [1]. At present, infection rate of TB bacilli is as high as 25% worldwide, and 5%−10% of them will progress to active TB (ATB) [2, 3].

Tuberculosis is one of the chronic infections that can cause hypercoagulability in the blood system leading to venous thromboembolism (VTE). Recently, many studies have reported an increased risk of venous thrombosis due to TB infection [2,3,4]. A recent meta-analysis study showed that patients with ATB are at high risk of VTE and pulmonary embolism [5]. According to the clinical manifestations at different sites and stages, VTE can be categorized into pulmonary thromboembolism (PTE) and deep vein thrombosis (DVT) with the same susceptibility factors, while DVT is the main source of PTE. Pulmonary embolism (PE) is a clinical and pathophysiological syndrome of impaired pulmonary circulation due to obstruction of the venous system or the pulmonary trunk or branches of the right heart, including PTE, fat embolism syndrome, amniotic fluid embolism, air embolism, and tumor embolism, among which PTE is the most common type. However, there are few studies on ATB complicating PTE [2, 5,6,7]. Here, we found many related cases in our own clinical work, which accelerated the death of patients with pulmonary tuberculosis.

This study retrospectively analyzed the clinical cases of ATB complicated with PTE in Haihe Hospital of Tianjin University from 2013 to 2020, including clinical characteristics, lab examinations and imaging examinations. The risk factors of PTE occurrence in ATB patients were summarized to provide basis for prediction and prophylactic anticoagulation therapy of PTE in TB diagnosis and treatment.

Methods

Samples collection

In this study, from January 1, 2013 to January 1, 2020, 103 ATB cases hospitalized in Tianjin Haihe Hospital were collected, the only hospital in Tianjin that can accept TB inpatients. These patients received a standardized anti-tuberculosis treatment regimen based on the WHO consolidated guidelines on tuberculosis. Through the PTE diagnosis by CTPA, 103 ATB cases were divided into two group: 43 ATB with PTE cases as test group and 60 ATB without PTE cases as control group.

Diagnosis of ATB and PTE

Inclusion criteria for ATB patients

The newly ATB patients were all diagnosed with four aspects: clinical symptoms, imaging manifestations, etiological evaluation (acid-fast staining, mycobacterial culture or molecular biology of sputum, bronchial lavage fluid, urine, pleural effusion or peritoneal fluid) and pathological assessment (bronchoscopy or lung biopsy). PTE was diagnosed by CTPA [8].

Criteria for PTE

All patients in the test group met the clinical diagnostic criteria for acute pulmonary embolism in the 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism and were dignosed by CTPA [8, 9], patients with complete clinical data and good consciousness can cooperate with the research. Patients receive anticoagulation or thrombolytic therapy according to 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism as soon as the diagnosis of acute pulmonary embolism is confirmed [8].

All the patients enrolled in this study and their families signed informed consent voluntarily.

Clinical data and follow-up

Basic information

Age, gender, complication, TB types, time from the onset of ABT, clinical presentation, secondary infection. Blood indexes: white blood cell count (WBC), neutrophil percentage (NEUT), hemoglobin, platelet count, coagulation indicators, D-dimer. Inflammatory indicators: C-reactive protein (CRP), platelet crit (PCT) and brain natriuretic peptide (BNP). All the inclusive patients were examined by CTPA. According to CTPA findings to determine the type of pulmonary embolism(central type or peripheral type).

Radiological evaluation

The instrument were aquilion Prime 64-slice spiral CT (Canon) and definition AS 64-slice spiral CT (Siemens). Subjects were trained to hold their breath after deep inhalation before the scanning. Those who could not hold their breath were instructed to shallow breath slowly. The scanning range was from thoracic inlet to both sides of posterior costal diaphragm angle plane. Scanning parameters were 120 kV tube voltage, automatic tube current, standard reconstruction, 5 mm layer thickness, 5 mm layer spacing, pitch: 1.375:1, scanning collination 0.625 mm × 64. The specific scanning process is as follows: the enhanced scanning was performed with a double-cylinder high-pressure syringe. The non-ionic contrast agent, ultravist (300 mgI/ml), was injected into the cubital vein for 80–100 ml, and the infusion speed was 3.0–3.5 ml/s. The superior vena cava was selected as the monitoring vessel, and the dynamic CT value monitoring triggered the scan with a threshold of 100 HU. After the contrast agent injection, 30 ml of normal saline was injected at the same flow rate.

The flow path of image processing after scanning and CTPA diagnosis were that all the original data were reconstructed in thin layers of 1 mm thick and 1 mm apart, and then transmitted to AW 4.4 workstation. All data were processed by maximum density projection, volume reconstruction and multi-plane recombination. The determination of embolism was mainly judged through the multi-angle observation combined with the enhanced cross-sectional thin layer imaging. At the same time, we divided pulmonary thromboembolism into peripheral type and central type according to embolism position. Peripheral type refers to the position of embolism mainly involving the pulmonary segment and sub-segment pulmonary artery. The location of the central finger embolization mainly involves the main pulmonary artery and the pulmonary artery. Two physicians above the deputy director of radiology evaluated all the data by independent blind method, and reached a unified conclusion through consultation when the diagnosis was inconsistent.

Statistical analysis

In this study, SPSS22.0 was the main software to conduct the statistical analysis. Enumeration data were presented in percentage (%), and chi-square test was used to analyze them. Data were expressed as medians with interquartile ranges (IQR) for continuous variables, and analyze by Mann–Whitney U test. The results with P < 0.05 were considered to be statistically significant.

Results

Clinical characteristics of patients in two groups

For all patients in test group, there were 27 males (62.8%) and 16 females (37.2%), with a median age of 64 (54–75) years old (Table 1). The onset time of PTE was about 60 (14–75) days after the onset of TB (Table 1). In 43 patients, there were 35 cases (81.4%) of secondary TB, 6 TB pleurisy (14%), 1 blood type disseminated TB (2.3%), 1 abdominal TB (2.3%), 1 urinary TB (2.3%), 1 TB meningitis (2.3%), and 1 bone TB (2.3%) (Table 2). In control group, the median age of all cases was 60 years old, of which 41 were (68.3%) males and 19 were (31.7%) females (Table 1). All the 60 cases were secondary pulmonary TB, among whom, 15 cases were TB pleurisy (25%), 12 were bronchial TB (20.0%), and 1 were abdominal TB (1.7%) (Table 2). Compared between the two groups, the internal medicine Padua score of test group was significantly higher than that of control group (median score: 2.0 vs. 1.0, P < 0.001). There were no statistically significant differences in the BMI index, smoking, drinking, complications (hypertension, coronary heart disease, diabetes, chronic bronchitis, tumors, etc.), fever, cough, expectoration, hemoptysis, syncope, chest pain, secondary bacterial and fungal infections between the two groups of patients (P > 0.05). Test group were significantly higher than control group in the case number of chest tightness (31 vs. 15, P < 0.001) and dyspnea (30 vs. 13, P < 0.001) (Table 1).

Table 1 Baseline and clinical characteristics of the patients
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Table 2 Type of tuberculosis and drug resistance
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Blood laboratory comparison

Compared with control group, the hemoglobin, albumin, and arterial carbon dioxide partial pressure were significantly lower in test group (P < 0.05), meanwhile the inflammatory indexes of NEUT, CRP, PCT, and D-dimer of test group was significantly higher than that of control group (P < 0.05) (Table 3). Besides, there was no significant differences in sputum X-Pert positive rate, drug resistance, rifampicin treatment, WBC count, platelet count, BNP and oxygen partial pressure in the two groups (P > 0.05) (Tables 2 and 3).

Table 3 Results of patient laboratory tests
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CT scan findings of test group compared with control group

The CT scan manifestations of the cases enrolled in this study were mainly lobular central nodule, tree in bud, marginal fuzzy nodule and pulmonary consolidation in various areas, cavity with or without drainage bronchus, lymphadenopathy and pleural effusion. These signatures have high value in active PTE [10]. The number of patients with pulmonary lesions in test group was significantly higher than that in control group (6 vs. 4, P = 0.001) (Table 4), and the lesions in lower lobe (right 40 vs. 41, P = 0.003; left 39 vs. 44, P = 0.028) and middle lobe (35 vs. 36, P = 0.021) were higher than those in control group (Table 4).

Table 4 CTPA results of the patients
Full size table

This study separately analyzed the CTPA characteristics of patients with ATB and PTE, and its direct signs of central, eccentric, mixed, and complete obstructive filling defects in the pulmonary artery; indirect signs include sparse blood vessels in the lung field, wedge-shaped pulmonary infarction with the tip pointing to the hilar and atelectasis, pulmonary hypertension, pleural effusion, etc. In this group, The CTPA characteristics of patients in test group were analyzed separately, and the peripheral type was higher than the central type (39 vs. 20, P = 0.024). The imaging characteristics of pulmonary infarction (8 vs. 0, P = 0.001) and atelectasis (34 vs. 31, P = 0.004) in test group were significantly more than those in control group, however, there was no difference in pleural effusion and cavity between the two groups (P > 0.05) (Table 4). From the images, we can see the chest CT findings of the two patients with pulmonary tuberculosis. Both patients have extensive lesions. According to the vascular embolization site, one is a pure peripheral type, and the other has both central and peripheral types (Fig. 1).

Fig. 1
figure 1

Chest CT scan findings of the two pulmonary tuberculosis patients. Both pulmonary tuberculosis have extensive lesions, according to the vascular embolization site, one is a pure peripheral type, and the other has both central and peripheral types. A1-D1: Pulmonary tuberculosis with peripheral pulmonary embolism: chest CT plain scan and coronal reconstruction showed multiple patchy ground glass opacity, consolidation in different areas, irregular cavities in the left upper lobe, and irregular filling defects in the basilar artery and its branches in the right lower lobe (arrow). A2-D2: Tuberculosis with central and peripheral pulmonary embolism: chest CT plain scan and coronal reconstruction showed multiple central lobular nodules and tree buds in both upper lobes, ground glass density shadow and consolidation shadow in the right lower lobe, and irregular filling defects in the trunk of main pulmonary artery, pulmonary artery and its branches in both lower lobes (arrow)

Full size image

Discussion

Tuberculosis (TB) is a serious threat to health, which is one of the top 10 causes of death globally. The Global Tuberculosis Report 2024 shows 1.25 million deaths due to tuberculosis globally in 2023, with tuberculosis returning as the leading cause of death from a single infectious disease globally [1]. In 6 major countries of the European Union, the number of symptomatic VTE cases exceeds 1 million per year. 36% of patients present sudden fatal PTE, with 53% of patients remaining undiagnosed until death, and only 7% of patients diagnosed before death [11]. The mortality rate of patients with ATB complicated with VTE was higher than that of patients with ATB (P < 0.001). Secondary pulmonary tuberculosis was significantly associated with the occurrence of PTE in this study. Dentan et al. [2]. concluded from the premier hospitality database in the United States that the incidence of thromboembolism in patients with TB is 1.55 times higher than that in patients without TB, and the incidence of VTE in ATB is 2.07% (95% CI, 1.62%—2.59%). Chung et al. [7] indicated in the study that the incidence of PE in TB patients is 2.9 times that of non-TB patients,active TB increases risk of VTE,coagulation changes in TB patients due to TB [12,13,14].

Padua score [15] should be given to patients in internal medicine after admission. In this study, Padua score was higher in test group than that in control group. A meta-analysis showed that Padua not only predicted the risk of thrombosis in medical patients, but also predicted the adverse events of acute pulmonary embolism (APE) patients during hospitalization [16]. This study demonstrated that Padua score in patients with ATB risk assessment is meaningful. Patients in test group were significantly higher than of TB group in clinical symptoms, chest tightness, dyspnea symptoms, other indexes such as fever, cough, expectoration, hemoptysis, chest pain and so on have no statistical difference. Patients with heart failure or pulmonary disease in the past, dyspnea may be the only symptom of acute PE. Dyspnea is acute and serious in patients with central acute PE, but it is usually transient and mild in patients with small peripheral acute PE. When TB patients have obvious dyspnea, we should be alert to the possibility of PE. In this study, PTE mostly occurred about 60 days after the onset of ATB, which was not related to whether taking rifampicin, this is not consistent with previous studies that rifampicin can make blood hypercoagulable [12].

In this study, the hemoglobin and albumin of test group were lower than that of control group, which indicated poor nutritional status and the chronic consumption state of patients. Anemia can be used as a chronic consumptive index of ATB [17]. A nationwide cohort study indicated that aplastic anemia, a rare factor of PE [18], was associated with increased incidence and risk of VTE [19]. However, research by Harringa et al. [20] revealed that anemia was not related with PE. The pathogenesis of platelet hyperpolymerization is associated with hypoproteinemia [21]. In a study by Vittorio et al. [22], it was proved that low serum albumin level is an independent predictor of long-term mortality in patients with acute PE. Some studies have pointed out that albumin level is related to the severity of pulmonary embolism [23]. Our results suggested that if anemia and hypoproteinemia appeared in ATB, we should be alert to PTE, actively correct hypoproteinemia in treatment, and pay attention to preventive anticoagulant therapy.

Besides, our study illustrated that the NEUT, CRP, PCT and D-dimer of patients with ATB combined with PTE were higher than those with ATB. There were some studies about the principle of PTE in ATB. In fact, some experimental studies have shown that in the acute phase of Mycobacterium TB infection, lymph nodes produce proinflammatory cytokines (IL-1, IL-6, TNF-α), and splenic macrophages interact with Mycobacterium products [24, 25]. These cytokines induce hepatocytes to produce various acute inflammatory phase proteins and coagulation factors, resulting in hypercoagulability [26, 27]. It has also been shown that in vitro, Mycobacterium TB induces the expression of tissue factors in monocyte macrophages, the main activator of coagulation cascade reaction [28, 29]. The neutrophil lymphocyte ratio (NLR) reflects the balance between neutrophils and lymphocytes, and is an indicator of systemic inflammatory response. Kurtipek et al. [30] confirmed that NLR of PE patients was significantly higher than that of healthy control group (P < 0.05) [31]. The increase of CRP often indicates the persistence of inflammatory reaction [32], meanwhile severe TB can also lead to transient hypercoagulable state [13, 33].

In this study, in patients with ATB combined with PTE, chest CT scan imaging showed that the number of lung lobes involved was more than that in control group, indicating that the lesions were more extensive. This finding was consistent with the results of Goncalves et al. [33] that critical pulmonary TB was a risk factor for thromboembolic diseases. CTPA showed that the location of embolism in test group was mainly peripheral type, and the proportion of central type was less than that of peripheral type (Table 4). This result was consistent with Hyeyoung’s study that the central type of embolism in TB combined with PE group was lower than that of PE patients without TB [34]. In test group, the distribution characteristics of TB were double lower lobes and middle lobes. There was difference between the two groups, and there was no difference in the number of cavities between the two groups.

Mycobacterium TB infections result in chronic granulomatous inflammation, which may be associated with haemostatic changes and a hypercoagulable status [34]. Chronic infection and inflammation may modulate thrombotic responses by upregulating the activation procoagulants, downregulating the anticoagulants, and suppressing fibrinolysis [35]. Hemon et al. [36] described the acquired factors of PTE, that is, acquired multiple pathophysiological abnormalities that are prone to VTE, and infection is among the causes of internal medicine. TB is a high-risk factor of VTE, the decrease of antithrombin III and protein C, the increase of fibrinogen level and platelet aggregation, and the damage of fibrinolysis all lead to hypercoagulable state [12, 13, 37].This study has several limitations. First, our study was performed retrospectively and involved patients who were assessed in a single situation so that the selection bias could not be avoided. Therefore, a multicenter, randomized prospective study should be carried out. Second, the sample size of patients in our study was too small to draw conclusions. A prospective study involving a large population is needed to confirm the current findings. However, the prevalence of PTE combined with ATB is low, which means that enormous amount of effort and time will be needed to enroll an adequate number of patients for such a study. Third, we only conducted bivariate analyses and did not conduct multifactor logistic regression analyses of the independent influences, so there may be confounders.

Conclusions

In conclusion, we found a significant association between active secondary pulmonary tuberculosis and PTE. We recommend that physicians should be cautious of the possibility of PTE when they follow patients with active tuberculosis, especially for patients with high Padua score, poor nutritional status, high inflammatory index and severe pulmonary tuberculosis, they should include tuberculosis in their evaluation of thromboembolism risk.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

ATB:

Active tuberculosis

PTE:

Pulmonary thromboembolism

CTPA:

Computer tomography pulmonary angiography

TB:

Tuberculosis

VTE:

Venous thromboembolism

DVT:

Deep venous thrombosis

PE:

Pulmonary embolism

WBC:

White blood cell count

NEUT:

Neutrophil percentage

CRP:

C-reactive protein

PCT:

Platelet crit

BNP:

Brain natriuretic peptide

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Acknowledgements

The authors wish to acknowledge information department for support with data curation .The study was founded by Tianjin second batch of health industry high-level talent selection and training project.

Funding

This study was supported by Tianjin second batch of health industry high-level talent selection and training project (TJSJMYXYC-D2-012).

Author information

Author notes

  1. Yue Jia, Haimei Bo and Liang Tang contributed equally to this work.

Authors and Affiliations

  1. Haihe Hospital, Tianjin University, Tianjin, China

    Hongzhi Yu

  2. Haihe Clinical College, Tianjin Medical University, Tianjin, China

    Yue Jia, Hongzhi Yu & Qi Wu

  3. Department of Tuberculosis, Tianjin Haihe Hospital, Tianjin, China

    Zhiling Li & Zhili Hou

  4. Department of Radiology, Tianjin Haihe Hospital, Tianjin, China

    Liang Tang

  5. TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin Haihe Hospital, Tianjin, China

    Zhili Hou

  6. Tianjin Institute of Respiratory Diseases, Tianjin, China

    Liang Tang & Hongzhi Yu

  7. North China University of Science and Technology, Hebei, China

    Haimei Bo & Ziyi Yu

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Contributions

HZL and YHZ had the idea for and designed the study. JY, LZL and YZY collected the data. WQ and TL had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. JY, BHM and HZL drafted the paper. JY ,TL and HZL did the analysis, and all authors critically revised the manuscript for important intellectual content and gave final approval for the version to be published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Correspondence to Zhili Hou, Hongzhi Yu or Qi Wu.

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This human study was approved by the Ethics Committee of Haihe Hospital, Tianjin University. This study was performed in accordance with the Declaration of Helsinki. Oral informed consent was obtained from all patients involved in this study.

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The participants of the study gave their consent to publish.

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The authors declare no competing interests.

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Jia, Y., Bo, H., Tang, L. et al. Clinical characteristics of active tuberculosis with pulmonary thromboembolism. BMC Pulm Med 25, 156 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12890-025-03602-3

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12890-025-03602-3

Keywords

BMC Pulmonary Medicine

ISSN: 1471-2466

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