Chest X ray training for physicians working in TB and HIV

high incidence countries

Dr Etienne Leroy-Terquem, Pr Pierre L’Her

Pr Pierre L’HER Military hospital Percy - Val de Grâce Paris – Working in tropical countries for 10 yearsProfessor of Internal Medicine – Pulmonologist – Tropical diseases specialistPast International relations Secretary of French Language Pulmonology Society SPLF Président of international support for pulmonology SPI / ISP and OFCPemail: plher@hotmail.com

Dr Etienne LEROY TERQUEM Centre hospitalier de Meulan les Mureaux. FrancePulmonologist, Oncologist, Internal medicine ward leaderMembre of international support for pulmonology SPI / ISPPartnair of ICAP – Columbia University and PharmAccess - “X-ray Initiative“ in Tanzania email: etiennelt@hotmail.com

Chest X ray interpretation

Cxr interpretation training is a project which has been beginning in South East Asia 20 years ago

The end point is to obtain a adapted tool which will make physicians able to read correctly CXR on the field

Teaching lung radiography analysis in Cambodian NTP ; a ten-year experience with OFCP (Organisation Franco Cambodgienne de Pneumologie).

Leroy Terquem E., Kong Kim San, Kaing Sor, Peou Satha, Chan Sarin, Guigay J., Jeanbourquin D., L’Her P. (2003).

34th IUATLD World Conference on Lung Health. Paris, France 29.10 - 02.11. 2003 Abstract in Intern J of Tuberculosis and Lung Dis.2003, 7 Suppl 2, S195

Teaching began in 1993 in Cambodia with OFCP

Continued since 2004 in Laos with SPI / ISPThen after 2007 : - Rwanda, Tanzania, Gambia (Columbia University ICAP, BMRC)- Benin, Burkina Faso, Togo, DR Congo, C. d’Ivoire, Cameroon (IUATLD, AFD)- Asiatic regional course Vientiane 2011 2013 2014 (MAEE France)

Myanmar 2014 2015 ( Expertise France and Technical Assistance for Management )- Madagascar (NTP / SPI)- Haïti (NTP / SPI)

Why CXR training for physicians in countries with high incidence of TB/HIV ?

• Because CXR is easily available, and a very usefull tool for diagnosis of TB

• Because CXR has been neglected for a long time and physicians have forgotten how to read it

• Because this training is a very strong need in countries with high incidence of TB and HIV

• Choice for this training of “ Young Seniors“, able to transmit this teaching on the field to other physicians who will use this new knowledge in their daily practise

A lot of criticism against CXR by WHO and IUATLDNon recommmended by WHO and Union for a long time

Microscopy versus chest X ray

Better specificity for microscopy better than CXR

But better sensitivity for CXR

10 p6

10 p5

10 p4

10 p3

10 p2

10 p1

0

Mycobacteria per ml of sputum

Shematic presentation of potential yeld of different techniques in diagnosing TB by number of bacilli in sputum

Poor microscopy

Excellent microscopy

Culture and Geneexpert

Chest x ray +/- clinical symptoms

TB cavity , Tb pneumonia

Small infiltrate, Pleurisy , miliary

Priorities for TB Bacteriology Services in LICs. 2007 IUATLD

CXR often make over diagnosis of TB

When physicians are not trained for CXR interpretation

Example : Cambodian 42 y. Emergency room for hemoptisy 2013 Feb.Good condition, BP 132/73 mm Hg, O2 Sat. 95%, pulse 97/min, t°37°4,

But it’snt TB

2006 S + => TB treatment No CXRDue to hemoptisy & the

abnormal image of right apex, doctors think TB

It’s typical picture ofASPERGILLOMA

AFB -

Observation Pr CHAN SarinCalmette hospital Phnom Penh

a round mass in a residual cavity topped by an air moon crescent

Then 5 TB treatments, for hemoptisy with a similar CXR

AFB positive in sputum analysis is the main and more efficient tool for

diagnosis of TB in Low inc. countries with high TB incidence

(and genexpert if available)

But Smear ( -) are numerous

• “pauci-bacillar cases“, < 5000 bacilli/ml in sputum :– nodular TB (with no cavities)– Miliary– TB adenopathies

• Too weak patients unable to produce efficient sputum for AFB analysis or non cooperating (salivary sputum )

• Some medication active against TB before sputum analysis (carefull with quinolones !!)

• Technical mistake in sputum analysis

“True Smear negative TB“

M 30 y old. Past history of tight amputation

M 60 y old smoker , hemoptysis M hemoptysis & recurrentPulm. infections AFB -

Physicians in charge of TB program should be educated to correct CXR interpretation

Many False S(-)TB : physician’s mistakes

Metastasis Bronchial cancer

bronchiectasis

Bronchiectasis

Role of the chest-X-ray in National TB Program (1)

Rich and developped countries :Respiratory symptoms = chest-X-ray

Developing countries : The chest-X-ray was not recommended as first-line

(OMS et IUATLD recommendations) If smear + : TB treatment without CXR

If smear - x 3 (2) and persistance of symptoms after non-specific antibiotic the NTP recommends CXR

But, in emergency situation, CXR must be performed early (acute respiratory failure, acute respiratory disease in HIV +...)

Role of the chest-X-ray in National TB Program (2)

The radiography cannot make as microscopy a definite diagnosis of TB because radiological aspects are varied and often non specific

Chest X ray is essentiel for diagnosis of S(-) TB. But physicians must be able to make a correct analysis

S(-) TB diagnosis is often made in excess causing a futile treatment & preventing the true diagnosis

Three distinct situations:

• CXR strongly suggests TB

• CXR is not suggestive for TB

• CXR could suggest TB, but differential diagnosis are certainly possible

Always confront clinical signs,

bacteriology and radiology

Physician must use all the tools he had for TB diagnosis

• Past history and notion of possible contagion• Clinical signs• Skin test• Chest X ray• Anatomopathology• Biological examination• Bacteriological examination

Ex pleural effusion : is pleural biopsy available ? pathologist available ?

Sputum analysis for AFB X 2 or 3

Classical clinical signs, But non specific

Hemoptisis = strongly indicative of TBBut other possible etiologies:

Bronchial cancer Bronchiectasis inactive sequellaAspergillomaParagonimiasis bacterial non tb Pneumonia Pulmonary embolism Mitral stenosis, acute pulmonary edema…

From Crofton “clinical TB“

Cough> 3 weeks Fever and sweet

Haemoptisy

Weigh loss

Thoracic pain

Chest X ray does not make alone TB diagnosis because pictures are very rarely specific :

But some pictures can be strongly suggestive of TB :Nodules, macronodules, cavited nodules, infiltrates and cavities.The association of such pictures are very indicative of TB In any cases = AFB research in sputum is recommended

Some pictures are not suggestive of TB (ex : not excavated round opacity >3cm)

CXR is very usefull for diagnosis in case of S(-) TB especially in case of AIDS.

Actually CXR is not recommended at the end of TB treatment. But it can be very usefull for sequella assesment.

AFB neg.Healed TB after treatment

Do not confuse with (S-) TB

TBAFB +

Radiological diagnosis of TB is more and more important.

CXR is now recommmended By WHO

http://www.who.int/entity/tb/publications/2006/tbhiv_recommendations.pdf

The National TB prevalence surveysespecially in Asia (Cambodia, Myanmar, Laos) clearly show the interest of CXR

From Onosaki

From Onosaki

Most TB cases detected by CXR and not just by symptom screening

Most TB cases are smear negative

TB prevalence surveys show the interest of CXREx Lao Prevalence Survey 50 randomized clusters representative of the country

Only 51% have TB symptoms

Only 30% of TB Culture + cases hadsymptoms and smear positive !!

57% are Smear - MTB

49% cases detected by CXR only

43% are smear + MTB

TB case finding strategy in Lao PDRSymptomatic patients => Sputum exam.

If smear + it’s TBBUT

Limitation of the current diagnostic strategy :Culture confirmed TB cases (N = 223)

But radiological aspects of thoracic TB are very diverse

If smear is negative the physician must decide if the patient with symptoms and anormal CXR is TB or not

and non-specific with many differential diagnosis, especially in cases of HIV

Nodules InfiltratesCavitary TBPneumoniaMiliaryPleuresy, PericarditisAdenopathiesTB sequelae (Inactive or reactivated)

© OFCP © OFCP

Infiltrate Cavities Milliary

TB pneumonia TB adenopathies HIV- TB pericarditisSmear +

Smear +Smear+/-

Smear - Smear -

Smear -

Active or inactive?Anti-TB treatment or not?

And the big problem of TB sequelae

What about Computed aided detection ? (CAD 4 TB)

CAD objectives & uses:- Fit for rapid triage in high risk groups- Sensitivity & specificity equal or better than trained human reader

Computers improve quality & efficiency of screening90% of lesions initially missed by human readers were visible

less than 50% of lesions <1cm are seen by human reader

4TB

aaa

WHO recommendation

CAD4TBaaaaaaaaaaaaaa

?

In this 2 cases CAD 4TB will flash on thes 2 apical pictures

BA

CAD can help not trained physician to recognise The typical retro clav. Infiltrate on the right (A)

But could be very dangerous to identify as tb the typical picture of cancer (B)

Woman 27 y TB,in houseold asymptomatic

In this 3 cases CAD4 TB will flash on the cavities but will not recognise Bronchiectasis on right, Tb sequella on the middle, bacterial abcess on the left

NO ACTIVE TB IN THESE 3 CASES

In this 3 cases confrontation between clinical, radiological and bacteriological datas are

essential for diagnosis

5 days planningNormal CXR / Silhouette sign .

Rx Syndromes Reminder

Pulmonary TB

Intra thoracic Extra pulm TB

TB / HIV Pulmonary TB in children

Alveolar syndrromBronchial syndrom Intestitial syndrom Mediastinal.syndromVascular syndrom

Nodules-Infiltrate Cavitation Pneumonia

MiliaryAdenopathies.Pleura and pericardium

Pre test

DVD rom given to participants with :

- The training course - Auto-exercices - Documentation

Post test

Many interactive exercicesfrom each chapter

TB sequelaeTB sequelae