Presentation on theme: "TB Diagnostics Chest X-Ray Hello"— Presentation transcript:
1TB Diagnostics Chest X-Ray Hello I want to say first of all that I have never been trained in reading XRays, so I apologise if I get anything wrong. However, hopefully this means that I can explain these XRays to you in layspeak rather than doctor speak, which I think everyone always finds hard to understand….As Pam has explained, we diagnose TB differently according to context. I’m going to start by illustrating three cases, where the information gained by CXR wasn’t particularly helpful. It’s useful to always think about a multitude of factors before you diagnose TB.
2Typical Chest XrayTypical upper lobe cavitation, where the diagnosis of TB was easy. The patient also had all the classic signs – haemoptysis, weight loss, and night sweats.BUT sometimes it isn’t so straightforward.
3Patient 1 18 year old female Somalian UK 6 months Non productive cough and Chest PainSHOWS: Relatively subtle left mid zone abnormality on the Xray. The right lung appears clear. The pleural space is clear.Reported by radiology but not flagged up by the GP so no urgency was made over the referral.Our consultants saw it however, and took into account that she was a recent arrival from Somalia, and that the chest XRAY was not normal so they decided to do a CT scan.
4Patient 1 contd.Slice from CT showing how that relatively subtle abnormality actually reflected extensive consolidation with cavitation in the left lower lobe(the latter a major risk factor for infectivity)There are large necrotic lymph nodes here also.By this stage she was coughing phlegm, so we sent off samples to the lab.
5Outcome of Patient 1TB should always be actively excluded in anyone with suggestive symptoms and epidemiological risk (e.g. from high prevalence country)The outcome of this was that the patient had MDR-TBLived with 13 family membersWas actually married – in secret – she didn’t tell us this until 6 months into treatmentWas at college learning English3 of her family on treatment – two under 2 who have to have IV antibiotics the whole time and are very sickThe others are being tested for TB every three months for 2 years.She has broken up with the boyfriend, and we are unable to get in touch with him.
6Patient 2 17 years, Bangladeshi female Outbreak of TB at school Cough, HaemoptysisCXR showed left lower lobe consolidation10 weeks into treatment still having haemopysis, and culture negative and IGRA negativeDecided to do a CT scan found a 2.5 cm carcinoid tumourIn this case we had assumed that because of her epidemiological factors she had TB , but in fact she didn’t.
7Patient 3 79 year old Polish Living in Garage Diagnosed in A+E Consolidation in the right upper lobe with what appears to be a large cystal cavity at the apex.Also found to have smear positive TBSent home with treatment to take himself.
8Patient 3 contd. Malnourished Intermittent Treatment A large patchy opacity is noted in the right upper zone. The possibility of atypical infection should also be considered4 months check up later we saw immediately that his CXR was worseTurned out that he has very malnourished, and had not been taking his treatment properly.Sent off more sputums and found to have MDR TB.In this case, the CXR was very helpful, as we could see immediate deterioration
9Further Difficulties – Patient 4 Sudden onset of cough, breathlessness and foul phlegmPleural thickening on each side due to prior asbestos exposureSputum grew KlebsiellaDIAGNOSIS:Bacterial chest infectionHIV+ve since 2004, had previously had PTB but had completed treatment successfullyPus in pleural space - Got bacteria out of space with needle and initially got better with antibiotics before feeling worse again
10Patient 4 contd.Fever ↑, Weight Loss, WBC↑, CRP ↑, so referred for VATS↑ Pleural FluidDid not settle after antibiotics:Video Assisted ThoracoscopyNeedle in again – got fluid out of it
11Patient 4 contd. HIV+ does not mean you won’t get TB again Normal inflammatory response is different, subtle appearanceCXR can change quicklyWhilst waiting for the tests to come back 10 days after the VAT had another CXR. This showed significant worsening and Miliary shadowing (Miliary means bird seed )Around the same time Pleural Biopsy showed AFB and Pleural Fluid when cultured grew TBIn this case opportunity for intervention was missed because with HIV patients the normal inflammatory response is different, and there is a very subtle appearance. When a patient deterioraties the CXR can change quickly which it did in this case. CXR can change quicklyImportant to remember that if you are HIV+ and have TB it does not mean you won’t get TB again
12Patient 5 Mobile XRay screening unit Strongly positive Mantoux test CHAOTIC patientHepatitis C, IV user, no IV Access, just come out of prison, street drugs, no english, homelessReport said old fibrosis and slight cahnge, but because of Mantoux we followed it upWe have A LOT of difficult patients who we lose to follow up and often this is worse, so we tried to get an organism – also because high risk for MDRTB, interacts with methadone, and toxicity with hep c
13Patient 5 contd. DNA X 6 (bronchoscopy) Abdominal pain ↑, weight loss ↑, fevers ↑Refused empirical treatmentRefused CT scan because of IV accessRefused Biopsy because of IV accessU/S showed TB changes but still no organisms…So…we tried….He would turn up at the wrong times and tell us he was feeling worse – turned out he was scared of invasive proceduresSo we offered empirical treatment but he refused that saying he was in too much pain and because we didn’t have a diagnosis, only this poor XRay, we had to try and find other ways of diagnosis
14Patient 5 contd. 4 months later - sputum grew TB Biopsy showed granuloma changesNow has extensive disease and treatment is difficultBecause of pain but we are wooing him with incentives for adherence and hope that he will see it through…..If we had had organisms earlier we could have started him earlier. First XRAY was not helpful and even mildly better than one he had had before.