Reading chest x-rays

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Chest radiographs and TB

• Graham Bothamley
• Jean-Paul Zellweger

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Plan of session

• The typical chest x-ray of TB
• Atypical chest x-rays
• Extrapulmonary TB on the chest x-ray
• Inactive tuberculosis
• The normal chest x-ray with CPTB
• Differential diagnoses

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What are the typical features of tuberculosis on
a chest x-ray?
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Chest x-rays
Improvement only if gt20,000 films read annually.
Nakamura et al. Kekkaku 1970 45121
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Conclusions from mass x-ray surveys

• Sudden, symptomatic onset as common as insidious
  onset
• Disease extent unrelated to duration (extensive
  SPTB within first 3-6 m)
• Cavitation is not a late occurrence its
  frequency is nearly the same at all temporal
  stages of the disease

Toman. Case finding and chemotherapy. WHO,
Geneva, 1979
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Atypical TB

• Lower zone
• No cavitation
• (miliary)

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Atypical TB

• Female
• Diabetes
• HIV
• Elderly

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Extrapulmonary TB

• Mediastinal lymph nodes
• Pleural effusions
• Paraspinal abscess
• Spinal disease

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Pleural effusion
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Pericardial TB
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TB of the spine
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Inactive or self-healed tuberculosis

• Primary focus/calcified granuloma
• Coin lesion
• Fibrosis

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The normal chest radiograph with a positive M.tb
culture

• Single isolate or repeated?
• Lab contamination strain typing
• CT scan
• Treat?

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Differential diagnosis

• Non-tuberculous mycobacterial disease
• Sarcoidosis
• Fungal disease

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M. xenopi
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NTMD

• Background of COPD
• Thicker pleural reaction

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M. fortuitum
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Bronchiectasis
Tree in bud
Nodules
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Mycobacterium spp. Runyon group III
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The Quiz

• Estimate the probability of the diagnosis of
  tuberculosis and indicate whether you think the
  person will be sputum smear-positive
• Read the histories and estimate a prior
  probability of TB
• Look at the CXRs again in a different order
  this time and again estimate the probability of
  TB and whether the sputum smear will be positive

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Exercise 20 CXRsEstimate the probability of TB
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