Authors: Bary Rabinovitch, MD, FRCP(C)—Author; Madhukar Pai, MD, PhD—co-author and Series Editor
Number of pages: 9
Download (2018, pdf, 259kb)
Overview: Every GP in India will need to consider TB as a differential diagnosis in persons with cough lasting two weeks or more, or with unexplained chronic fever and/or weight loss. Chest radiography is very widely used in India. Chest x-rays serve as an invaluable adjunct in the diagnosis and follow-up of TB. However, TB may mimic other diseases on x-rays, and non TB conditions may look like TB. Thus, chest x-rays are neither specific nor sensitive, and so remain a supplement to microbiological tests such as microscopy, PCR and culture. Treatment of TB purely on the basis of x-rays can result in significant over-treatment with adverse consequences for patients. Therefore, all persons with chest radiographic findings suggestive of TB should have sputum specimens submitted for microbiological examination. This article provides a series of x-rays that serve to educate the provider about radiological interpretation of TB and common pitfalls and errors in interpretation.
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Interpretation of Chest X-rays in Tuberculosis
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Question 1 of 5
1. Question
Which of these statements is NOT true about chest radiology for TB diagnosis?
Correct
The correct answer is (a). Chest x-rays are not specific for TB) Many lung infections and conditions can cause radiological abnormalities. This is why all persons with radiographic abnormalities suggestive of TB should have sputum specimens submitted for microbiological examination. Only microbiological examination can confirm the diagnosis of TB).
Reference:
Hopewell PC, Pai M, Maher D, Uplekar M, Raviglione MC) International standards for tuberculosis care. Lancet Infect Dis 2006;6:710-25.
Pai M. Diagnosis of pulmonary tuberculosis: what every GP should know. GP Clinics 2013;3:22-8.
Incorrect
The correct answer is (a). Chest x-rays are not specific for TB) Many lung infections and conditions can cause radiological abnormalities. This is why all persons with radiographic abnormalities suggestive of TB should have sputum specimens submitted for microbiological examination. Only microbiological examination can confirm the diagnosis of TB).
Reference:
Hopewell PC, Pai M, Maher D, Uplekar M, Raviglione MC) International standards for tuberculosis care. Lancet Infect Dis 2006;6:710-25.
Pai M. Diagnosis of pulmonary tuberculosis: what every GP should know. GP Clinics 2013;3:22-8.
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Question 2 of 5
2. Question
The commonest radiologic finding in TB is:
Correct
The correct answer is (b). Although TB can cause any of the radiologic findings listed, upper lobe disease with or without cavitation is the most common.
Reference:
Pinto L, Dheda K, Theron G, et al. Development of a Simple Reliable Radiographic Scoring System to Aid the Diagnosis of Pulmonary Tuberculosis. PLoS One 2013;8(1): :e54235.
Pinto LM, Pai M, Dheda K, Schwartzman K, Menzies D, Steingart KR. Scoring systems using chest radiographic features for the diagnosis of pulmonary tuberculosis in adults: a systematic review. Eur Respir J 2012.
Incorrect
The correct answer is (b). Although TB can cause any of the radiologic findings listed, upper lobe disease with or without cavitation is the most common.
Reference:
Pinto L, Dheda K, Theron G, et al. Development of a Simple Reliable Radiographic Scoring System to Aid the Diagnosis of Pulmonary Tuberculosis. PLoS One 2013;8(1): :e54235.
Pinto LM, Pai M, Dheda K, Schwartzman K, Menzies D, Steingart KR. Scoring systems using chest radiographic features for the diagnosis of pulmonary tuberculosis in adults: a systematic review. Eur Respir J 2012.
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Question 3 of 5
3. Question
TB cannot occur in the:
Correct
The correct answer is (e). Although TB most commonly occurs in the upper lobes it can occur in any part of the lung.
Incorrect
The correct answer is (e). Although TB most commonly occurs in the upper lobes it can occur in any part of the lung.
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Question 4 of 5
4. Question
A patient presents with a 10 day history of high fever, cough and purulent sputum. A CXR shows a dense consolidation in the RUL. The next step is:
Correct
The answer is (c). CXR’s must be interpreted in the clinical context. An acute presentation suggests acute bacterial infection. Sputum specimens should be obtained before starting conventional antibiotics. Fluoroquinolones should be avoided if TB is at all suspected as they will result in temporary improvement because TB is sensitive to this class of drugs, leading to delay in diagnosis.
Incorrect
The answer is (c). CXR’s must be interpreted in the clinical context. An acute presentation suggests acute bacterial infection. Sputum specimens should be obtained before starting conventional antibiotics. Fluoroquinolones should be avoided if TB is at all suspected as they will result in temporary improvement because TB is sensitive to this class of drugs, leading to delay in diagnosis.
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Question 5 of 5
5. Question
A 55 year old 40 pack year smoker consults with you for a 2 month history of cough and blood tinged sputum (no fever). He reports that his sister had TB 10 years ago. The CXR shows a cavitary mass in the RUL. What is the next step?
Correct
The answer is (c). Although TB must be suspected in anyone with an upper lobe cavitary mass, in a heavy smoker with a 2 month history of cough and bloody sputum, in the absence of infectious symptoms, lung cancer must be suspected) A bronchoscopy can obtain specimens for AFB but at the same time, can make the diagnosis of cancer.
Incorrect
The answer is (c). Although TB must be suspected in anyone with an upper lobe cavitary mass, in a heavy smoker with a 2 month history of cough and bloody sputum, in the absence of infectious symptoms, lung cancer must be suspected) A bronchoscopy can obtain specimens for AFB but at the same time, can make the diagnosis of cancer.
