Chest Imaging Interpretation for Tuberculosis Screening
Lab test Interpretation:
Chest imaging
Dana Kissner
Wayne State University
Detroit Tuberculosis Clinic
2
0
2
3
M
D
H
H
S
W
o
r
l
d
T
B
D
a
y
M
a
r
c
h
2
4
,
2
0
2
3
Disclosure
No
one
involved
in
the
planning or
presentation of
this
activity
has
any
relevant financial
relationships
to
disclose.
Western
Michigan
University
Homer
Stryker
M.D.
School
of
Medicine
adheres
to
the
ACCME’s
Standards
for
Integrity
and
Independence
in
Accredited
Continuing Education.
Any
individuals
in
a
position
to
control
the
content of
a
CE
activity,
including
faculty,
planners, reviewers
or
others
are
required
to
disclose
all
relevant
financial
relationships
with
ineligible
entities
(commercial
interests).
All
relevant
conflicts
of
interest
have
been mitigated
prior
to
the commencement
of
the
activity.
Accreditation
In
support
of
improving
patient
care,
this
activity
has
been
planned
and
implemented
by
Western
Michigan
University
Homer
Stryker
M.D.
School
of
Medicine
and
MDHHS.
Western
Michigan
University
Homer
Stryker
M.D.
School
of
Medicine
is
jointly
accredited
by
the
Accreditation
Council
for
Continuing
Medical
Education
(ACCME),
the
Accreditation
Council
for
Pharmacy
Education
(ACPE),
and
the
American
Nurses
Credentialing
Center
(ANCC),
to
provide
continuing
education
for
the
healthcare
team.
Credit
amount
subject
to
change.
I
n
t
e
r
p
r
o
f
e
s
s
i
o
n
a
l
C
o
n
t
i
n
u
i
n
g
E
d
u
c
a
t
i
o
n
This
activity
was
planned
by
and
for
the
healthcare
team,
and
learners
will
receive
5.0
Interprofessional Continuing
Education
(IPCE)
credits
for
learning
and
change.
P
h
y
s
i
c
i
a
n
s
Western
Michigan
University
Homer
Stryker
M.D.
School
of
Medicine
designates
this
live
activity
for
a
maximum
of
5.0
AMA
PRA
Category
1
Credits
™.
Physicians
should
claim
only
the
credit
commensurate
with
the
extent
of
their
participation
in
the
activity.
N
u
r
s
e
s
Western
Michigan
University
Homer
Stryker
M.D.
School
of
Medicine
designates
this
activity
for
5.0
contact
hours
for
nurses.
Nurses
should
claim
only
credit
commensurate
with
the
extent
of
their
participation
in
the
activity.
Transmission
Airborne droplets
Primary
tuberculosis
Progressive
primary
tuberculosis
10%
90%
5 - 10%
CXR may be
abnormal due
to
something
else.
“Chest radiography, or chest X-ray (CXR), is
an important tool for
triaging
and
screening
for pulmonary TB, and it is also useful to aid
diagnosis
when pulmonary TB cannot be
confirmed bacteriologically.”
2016
Terms used by radiologists in 97 chest reports:
38
Consecutive TB cases 2017- March 24, 2021
24/97
24/97
Case 1:
(Like Dr. Dickson’s case 1) An 18-year-old man from China is
a new student at a college in the Detroit region.
PPD (TB) skin test
was positive
. IGRA not done due to cost. After treatment completion,
IGRA was done and was negative.
He answers “no” to having symptoms. Further questioning reveals:
1. He has always been
under weight
.
2. He
coughs,
but attributes it to allergies.
•
Red
arrows -“nodule, opacity,
density”
•
Blue
arrow -“linear, nodular,
fibrotic, old, healed, scar”
•
Yellow
arrows – calcification,
can be ignored
•
Note upper lobe location
•
Primary TB usually mid to lower
lobe disease
•
Upper lobe, superior segment
of lower lobe are common sites
for “reactivation TB.”
•
TB can be anywhere in lung
Look at CXR in context of
TB risk factors
(China)
and
carefully
obtained medical history
(underweight, cough)
Negative IGRA does not exclude TB
!
Patient has symptoms of TB & needs CXR and sputum tests
Screening for risk factors & symptoms is key
Next step is to
collect adequate sputum.
Treat for TB
after
adequate
sputum is collected. And complete
treatment.
Percentage TB Cases by Case Verification Criteria,
United States, 2021
(N=7,882)
*
NAA=nucleic acid amplification
A 47-year-old male with a history of
living in shelters has hemoptysis
and unexplained weight loss.
Should he be screened?
No.
Done
Should he be tested? Yes.
+ Chest x-ray
+ Sputum
+/- IGRA? Yes, but least
essential
Case 2: Dr. Dickson’s case annotated
Screening has already
been done by symptom
review
Air filled oval or round spaces
Walls are thin to moderate in thickness
Contain little to no fluid
Contain many rapidly reproducing TB
organisms
Often highly contagious
Cavities caused by TB:
Cavities: Other TB examples
Cavity forming in
consolidation
Consolidation
: homogeneous translucent
opacity,
made up of fluid, cells,
pus, or blood
Air-filled bronchi form
air bronchograms
Overlapping cavities
Cavities: Other examples
Cavity forming in
consolidation
Consolidation:
homogeneous opacity
,
made up of fluid, cells,
pus, or blood
Air-filled bronchi form
air bronchograms
Overlapping cavities
Circles
are cavities
Arrows
are air
bronchograms in
consolidation
A 35 year old woman, in septic
shock in ICU
Fever of 40 degrees C
Low blood pressure
High heart rate
Elevated lactic acid
While in prison 10 years ago, she
had a positive PPD, untreated
Case 3:
Small
nodule
is old, probably the initial
focus of her
TB
(red arrow)
Miliary TB is difficult to see early on
A medical emergency
Miliary TB
Resembles millet seeds
Multiple small nodules, uniform in size 1-5 mm
A 55-year-old alcoholic is short of
breath. He has had weight loss and
cough over the past month.
Arrows show free flowing fluid
forming a meniscus
Case
4
:
Pleural effusion
Can be 1
st
sign of
primary TB
More opaque than consolidation
Fluid is exudative (high protein, LDH) in TB
Effusion
can be small to massive, yellow to bloody, free flowing or loculated
Fluid should be tapped (thoracentesis) and tested for TB
15-year-old boy from Africa with
difficulty swallowing, weight loss,
fevers, and sweats.
Case 5:
Yellow arrow
– narrowed
esophagus
Purple arrow
narrowed
right mainstem bronchus
Mediastinal & hilar lymphadenopathy
Frequently seen in
primary TB
Can surround and close off
s
tructures such as esophagus
Can erode into heart, esophagus,
trachea, and bronchi
Blue
arrow points to dye lighting
up (bright white) rim of the lymph nodes,
surrounding air in the middle caused by
necrosis (cell death). Radiologists use the term rim
enhancement and low attenuation centrally.
A 60 year man complains of cough,
sputum production, loss of appetite,
weight loss, night sweats, and
hemoptysis
Tree-in-bud pattern
S
een best with high resolution CT
scans
Case 5:
Pattern recognition & AI
What comes next?
Chest imaging plays a crucial role in screening for pulmonary tuberculosis (TB). This activity, led by Dana Kissner from Wayne State University Detroit Tuberculosis Clinic, focuses on interpreting chest imaging results to aid in the diagnosis and management of TB cases. The content includes information on radiological terms used in TB cases, the importance of chest radiography, and case studies illustrating TB screening and treatment strategies. Participants can earn continuing education credits through this informative session.
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Presentation Transcript
Lab test Interpretation: Chest imaging Dana Kissner Wayne State University Detroit Tuberculosis Clinic
2023 MDHHS World TB Day March 24, 2023 Disclosure No one involved in the planning or presentation of this activity has any relevant financial relationships to disclose. WesternMichigan University Homer Stryker M.D. School of Medicine adheres to the ACCME s Standards for Integrity and Independence in Accredited Continuing Education. Any individuals in a position to control the content of a CE activity, including faculty, planners, reviewers or others are required to disclose all relevant financial relationships with ineligible entities (commercial interests). All relevant conflicts of interest have been mitigated prior to the commencement of the activity. Accreditation In support of improving patient care, this activity has been planned and implemented by WesternMichigan University Homer Stryker M.D. School of Medicine and MDHHS. Western Michigan University Homer Stryker M.D. School of Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Credit amount subject to change. Interprofessional Continuing Education This activity was planned by and for the healthcare team, and learners will receive 5.0 Interprofessional Continuing Education (IPCE) credits for learning and change. Physicians WesternMichigan University Homer Stryker M.D. School of Medicine designates this live activity for a maximum of 5.0 AMA PRA Category 1 Credits . Physicians should claim only the credit commensurate with the extent of their participation in the activity. Nurses WesternMichigan University Homer Stryker M.D. School of Medicine designates this activity for 5.0 contact hours for nurses. Nurses should claim only credit commensurate with the extent of their participation in the activity.
Transmission 10% Airborne droplets Progressive primary tuberculosis Primary tuberculosis 90% CXR may be abnormal due to something something else. else. 5 - 10% Active tuberculosis (disease) Latent tuberculosis infection
Chest radiography, or chest X-ray (CXR), is an important tool for triaging and screening for pulmonary TB, and it is also useful to aid diagnosis when pulmonary TB cannot be confirmed bacteriologically. 2016 2016
Terms used by radiologists in 97 chest reports: 38 Consecutive TB cases 2017- March 24, 2021 24/97 24/97
Case 1: (Like Dr. Dicksons case 1) An 18-year-old man from China is a new student at a college in the Detroit region. PPD (TB) skin test was positive. IGRA not done due to cost. After treatment completion, IGRA was done and was negative. He answers no to having symptoms. Further questioning reveals: 1. He has always been under weight. 2. He coughs, but attributes it to allergies.
Red arrows -nodule, opacity, density Blue arrow - linear, nodular, fibrotic, old, healed, scar Yellow arrows calcification, can be ignored Note upper lobe location Primary TB usually mid to lower lobe disease Upper lobe, superior segment of lower lobe are common sites for reactivation TB. TB can be anywhere in lung
Look at CXR in context of TB risk factors (China) and carefully obtained medical history (underweight, cough) Negative IGRA does not exclude TB! Patient has symptoms of TB & needs CXR and sputum tests Screening for risk factors & symptoms is key Next step is to collect adequate sputum. Treat for TB after adequate sputum is collected. And complete treatment.
Percentage TB Cases by Case Verification Criteria, United States, 2021 (N=7,882) Positive culture 79% Positive IGRA or PPD + clinical/radiographic findings No microbiologic confirmation Clinical case 13% Clinical &/or radiographic findings only & treated for TB disease No microbiologic confirmation Provider diagnosis 4% Positive NAA* test 3% Positive smear <1% *NAA=nucleic acid amplification
Case 2: Dr. Dicksons case annotated A 47-year-old male with a history of living in shelters has hemoptysis and unexplained weight loss. Screening has already been done by symptom review Should he be screened? No. Done Should he be tested? Yes. + Chest x-ray + Sputum +/- IGRA? Yes, but least essential
Cavities caused by TB: Air filled oval or round spaces Walls are thin to moderate in thickness Contain little to no fluid Contain many rapidly reproducing TB organisms Often highly contagious
Cavities: Other TB examples Cavity forming in consolidation Consolidation: homogeneous translucent opacity, made up of fluid, cells, pus, or blood Overlapping cavities Air-filled bronchi form air bronchograms
Cavities: Other examples Cavity forming in consolidation Consolidation: homogeneous opacity, made up of fluid, cells, pus, or blood Circles are cavities Arrows are air bronchograms in consolidation Overlapping cavities Air-filled bronchi form air bronchograms
Case 3: A 35 year old woman, in septic shock in ICU Fever of 40 degrees C Low blood pressure High heart rate Elevated lactic acid While in prison 10 years ago, she had a positive PPD, untreated
Miliary TB Small nodule is old, probably the initial focus of her TB (red arrow) Multiple small nodules, uniform in size 1-5 mm Miliary TB is difficult to see early on A medical emergency Resembles millet seeds
Case 4: A 55-year-old alcoholic is short of breath. He has had weight loss and cough over the past month. Arrows show free flowing fluid forming a meniscus
Pleural effusion Can be 1st sign of primary TB More opaque than consolidation Fluid is exudative (high protein, LDH) in TB Effusion can be small to massive, yellow to bloody, free flowing or loculated Fluid should be tapped (thoracentesis) and tested for TB
Case 5: 15-year-old boy from Africa with difficulty swallowing, weight loss, fevers, and sweats. Yellow arrow narrowed esophagus Purple arrow narrowed right mainstem bronchus
Mediastinal & hilar lymphadenopathy Frequently seen in primary TB Can surround and close off structures such as esophagus Can erode into heart, esophagus, trachea, and bronchi Blue arrow points to dye lighting up (bright white) rim of the lymph nodes, surrounding air in the middle caused by necrosis (cell death). Radiologists use the term rim enhancement and low attenuation centrally.
Case 5: A 60 year man complains of cough, sputum production, loss of appetite, weight loss, night sweats, and hemoptysis Tree-in-bud pattern Seen best with high resolution CT scans
