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 years Pulmonologist – Tropical diseases specialist Professor of Internal Medicine – Pulmonologist – Tropical diseases specialist SPLF Past International relations Secretary of French Language Pulmonology Society SPLF SPI / ISP and OFCP Président of international support for pulmonology SPI / ISP and OFCP Dr Etienne LEROY TERQUEM Centre hospitalier de Meulan les Mureaux. France Pulmonologist, Oncologist, Internal medicine ward leader SPI / ISP Membre of international support for pulmonology SPI / ISP Partnair of Partnair of ICAP – Columbia University and PharmAccess - “X-ray Initiative“ in Tanzania 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). 34 th IUATLD World Conference on Lung Health. Paris, France 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 / ISP  Then 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 (MAEE France) Myanmar ( 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 IUATLD Non 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 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, O 2 Sat. 95%, pulse 97/min, t°37°4, But it’snt TB 2006 S + => TB treatment No CXR Due to hemoptisy & the abnormal image of right apex, doctors think TB It’s typical picture of ASPERGILLOMA 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 : “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 )Too weak patients unable to produce efficient sputum for AFB analysis or non cooperating (salivary sputum ) Some medication active against TB before sputum analysisSome medication active against TB before sputum analysis (carefull with quinolones !!) Technical mistake in sputum analysisTechnical mistake in sputum analysis “True Smear negative TB“

M 30 y old. Past history of tight amputation M 60 y old smoker, hemoptysisM hemoptysis & recurrent Pulm. infections AFB - Physi ci ans in charge of TB program should be educated to correct CXR interpretation 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) TB treatment without CXR 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 strongly suggests TB CXR is not suggestive for TB CXR is not suggestive for TB CXR could suggest TB, but differential diagnosis are certainly possible 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 TB But other possible etiologies:  Bronchial cancer  Bronchiectasis inactive sequella  Aspergilloma  Paragonimiasis  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 TB AFB +

Radiological diagnosis of TB is more and more important. CXR is now recommmended By WHO The National TB prevalence surveys especially in Asia (Cambodia, Myanmar, Laos) clearly show the interest of CXR

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 CXR Ex Lao Prevalence Survey 50 randomized clusters representative of the country

Only 51% have TB symptoms Only 30% of TB Culture + cases had symptoms and smear positive !! 57% are Smear - MTB 49% cases detected by CXR only 43% are smear + MTB TB case finding strategy in Lao PDR Symptomatic patients => Sputum exam. If smear + it’s TB BUT Limitation of the current diagnostic strategy : Culture confirmed TB cases (N = 223)

But radiological aspects of thoracic TB are very diverse 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 If smear is negative the physician must decide if the patient with symptoms and anormal CXR is TB or not and non-specifi c with many differential diagnosis, especially in cases of HIV and non-specifi c with many differential diagnosis, especially in cases of HIV Nodules Infiltrates Cavitary TB Pneumonia Miliary Pleuresy, Pericarditis Adenopathies TB sequelae (Inactive or reactivated)

Infiltrate Cavities Milliary TB pneumoniaTB adenopathies HIV-TB pericarditis 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 screening 90% 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 B A 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 planning  Normal CXR / Silhouette sign.  Rx Syndromes Reminder  Pulmonary TB  Intra thoracic Extra pulm TB  TB / HIV  Pulmonary TB in children Alveolar syndrrom Bronchial syndrom Intestitial syndrom Mediastinal.syndrom Vascular syndrom Nodules-Infiltrate Cavitation Pneumonia Miliary Adenopathies. Pleura and pericardium  Pre test DVD rom given to participants with : to participants with : - The training course - Auto-exercices - Documentation  Post test Many interactive exercices from each chapter  TB sequelae