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Chest radiographs (CXR) for tuberculosis (TB) screening in children are valuable in high-burden settings. However, less certain in low prevalence contexts. In the United States, positive PPD is sufficient to treat for "latent" TB, or TB infection in asymptomatic patients. We sought to determine frequency of abnormal CXR findings after a positive purified protein derivative (PPD) test at a tertiary pediatric center in the United States. A retrospective evaluation was conducted of patients (0–18 years) with a CXR after a positive PPD (e.g., known exposure, employment, migratory requirements or before immunosuppression) between 2011 and 2021. Clinical information, demographics, and reason for PPD were recorded from health record. CXRs were evaluated using initial report and by a pediatric radiologist with special interest in TB and 8 years of experience. Of 485 patients, median [interquartile range (IQR)] age 8.5[3.3–14.4], abnormal CXRs were described in 5 (1%). Most common reasons for PPD included: close contact with someone with TB or with high risk for TB. Most patients 373 (76.9%) received treatment for latent TB, and 111 (22.9%) no treatment. One patient (0.2%) received treatment for active disease. Radiographic findings included isolated lymphadenopathy (n = 2), consolidation (n = 1), pleural fluid/thickening (n = 1) and a patient with lymphadenopathy and a calcified nodule (n = 1). In our experience, prevalence of chest radiographs findings for patients with positive PPD was very low. Moreover, no cases of severe disease were seen and those with abnormal findings would not merit treatment change under current WHO guidelines. • A retrospective assessment was conducted of chest radiographs performed on patients who had a positive PPD from 2011 to 2021 at our institution. • In our experience in a tertiary urban hospital within the United States, the prevalence of chest radiograph findings for patients with positive PPD in a low-prevalence area was very low. • We found that chest radiographs of children with positive PPD in our experience only seldomly showed any pathologic findings (1%), and findings were not suggestive of severe disease.While we recognize that our findings are not comparable with settings of different endemicity or resources, chest radiograph in our experience did not determine the decisions for treatment regime in any patient. [ABSTRACT FROM AUTHOR]