1. TB 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.

2. Typical Chest Xray
Typical 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.

3. Patient 1 18 year old female Somalian UK 6 months
Non productive cough and Chest Pain
SHOWS: 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.

4. Patient 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.

5. Outcome of Patient 1
TB 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-TB
Lived with 13 family members
Was actually married – in secret – she didn’t tell us this until 6 months into treatment
Was at college learning English
3 of her family on treatment – two under 2 who have to have IV antibiotics the whole time and are very sick
The 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.

6. Patient 2 17 years, Bangladeshi female Outbreak of TB at school
Cough, Haemoptysis
CXR showed left lower lobe consolidation
10 weeks into treatment still having haemopysis, and culture negative and IGRA negative
Decided to do a CT scan found a 2.5 cm carcinoid tumour
In this case we had assumed that because of her epidemiological factors she had TB , but in fact she didn’t.

7. Patient 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 TB
Sent home with treatment to take himself.

8. Patient 3 contd. Malnourished Intermittent Treatment
A large patchy opacity is noted in the right upper zone. The possibility of atypical infection should also be considered
4 months check up later we saw immediately that his CXR was worse
Turned 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

9. Further Difficulties – Patient 4
Sudden onset of cough, breathlessness and foul phlegm
Pleural thickening on each side due to prior asbestos exposure
Sputum grew Klebsiella
DIAGNOSIS:
Bacterial chest infection
HIV+ve since 2004, had previously had PTB but had completed treatment successfully
Pus in pleural space - Got bacteria out of space with needle and initially got better with antibiotics before feeling worse again

10. Patient 4 contd.
Fever ↑, Weight Loss, WBC↑, CRP ↑, so referred for VATS
↑ Pleural Fluid
Did not settle after antibiotics:
Video Assisted Thoracoscopy
Needle in again – got fluid out of it

11. Patient 4 contd. HIV+ does not mean you won’t get TB again
Normal inflammatory response is different, subtle appearance
CXR can change quickly
Whilst 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 TB
In 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 quickly
Important to remember that if you are HIV+ and have TB it does not mean you won’t get TB again

12. Patient 5 Mobile XRay screening unit Strongly positive Mantoux test
CHAOTIC patient
Hepatitis C, IV user, no IV Access, just come out of prison, street drugs, no english, homeless
Report said old fibrosis and slight cahnge, but because of Mantoux we followed it up
We 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

13. Patient 5 contd. DNA X 6 (bronchoscopy)
Abdominal pain ↑, weight loss ↑, fevers ↑
Refused empirical treatment
Refused CT scan because of IV access
Refused Biopsy because of IV access
U/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 procedures
So 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

14. Patient 5 contd. 4 months later - sputum grew TB
Biopsy showed granuloma changes
Now has extensive disease and treatment is difficult
Because 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.