The typical imaging features of disseminated pulmonary TB include miliary nodule shadows scattered throughout the 2 lungs, and the nodules were usually easy to recognize. However, secondary pulmonary TB typically occurred in the posterior segment of the apical superior lobe and dorsal lower lobe, and it developed more often on the right than on the left. The lung imaging features of this group of patients with disseminated pulmonary TB were atypical, and final diagnoses were based on positive blood cultures. Secondary TB lesions were mainly diffused in both lungs and involved the lower lobe. The predominant morphologies of pulmonary lesions were effusion shadows, nodule shadows, and empty shadows. There was 1 case in our study with diffused interstitial changes in both lungs. In summary, this group of patients had many atypical clinical TB symptoms. Their fever was not low-grade in the late afternoon, which is commonly seen in TB, and the imaging features demonstrated atypical manifestations of TB, presenting rare serious complications mentioned above. These atypical symptoms undoubtedly interfered with the clinicians’ abilities to correctly diagnose TB, but they also helped raise awareness of atypical TB. Cases like these provide a reminder that screening of atypical lesions should not be ignored, such as those in the lower lobe of lungs and those with morphology atypical of TB. Some researchers have suggested that routine tracheal tube brushing or bronchoalveolar lavage fluid inspection for patients suspected to be infected with TB, who have no phlegm or produce negative results in a sputum smear test, can effectively improve the rate of discovery. Yet, for severe TB patients with secondary HLH, low platelet counts and poor coagulation functions might not be able to tolerate invasive inspection and operation for the final diagnosis of TB. Therefore, if suspected, sputum examination and blood culture for TB should be carried out repeatedly, and diagnostic anti-TB treatment should be given actively to those who have no contraindication to ATT.