Objective：To screen specimens with high qPCR positive rates based on hematoxylin and eosin（HE）histopathological characteristics for the rapid，accurate，and economical diagnosis of pulmonary tuberculosis. Methods：A retrospective analysis was conducted on the clinical data and CT findings of 189 patients with pulmonary granulomatous disease. Formalin - fixed paraffin - embedded（FFPE）specimens were initially screened by HE staining，followed by Ziehl -Neelsen（Z -N）staining and qPCR assay for further verification. Results：Based on CT findings，189 specimens were divided into two groups：the peripheral nodular group predominantly showed hilar and mediastinal lymphadenopathy（87/149，58.4%），lobulation sign（66/149，44.3%），and spiculation sign （63/149，42.3%）；and the central occupancy group mainly exhibited bronchial obstruction（31/40，77.5%）and atelectasis（29/40， 72.5%）. These findings were often indistinguishable from neoplastic lesions，leading to delayed diagnoses. HE staining results from 95 confirmed pulmonary tuberculosis specimens revealed that the percentage of necrotic area ≥25%（χ² =41.649，P ＜ 0.001）and the maximum diameter of granulomas ≥8 mm（χ² =8.071，P=0.004）were correlated with qPCR positivity. Binary logistic regression analysis showed that the percentage of necrotic area and the maximum diameter of granulomas in pulmonary tuberculosis were independent predictors of qPCR positivity（OR=1.324，95%CI：1.202-1.460，P ＜ 0.001；OR=0.265，95%CI：0.164-0.429，P ＜ 0.001）.In FFPE specimens of pulmonary tuberculosis，the area under the curve，sensitivity，and specificity of the necrotic area percentage for qPCR positive results were 0.794，78.2% and 78.9%，while for the maximum diameter of granulomas were 0.600，88.5%，and 43.7%， respectively. Conclusion：When CT findings of peripheral nodules show hilar and mediastinal lymphadenopathy，lobulation sign，and spiculation sign，they are more likely to delay diagnosis of granulomatous diseases such as pulmonary tuberculosis. The measurement of necrotic area and the maximum diameter of granulomas can improve the sensitivity of qPCR detection. Preliminary screening with HE staining to select high-quality specimens for testing can enhance the accuracy of tuberculosis diagnosis.