Intrathoracic tuberculous lymphadenopathy in children: a guide to chest radiography

Pediatric Radiology, Aug 2017

Making the diagnosis of pulmonary tuberculosis in children can be difficult because microbiological confirmation is not often achieved. Diagnosis is therefore often based on clinical features in combination with chest radiograph findings. Chest radiographs can demonstrate lymphadenopathy of the hilar and para-tracheal regions on the anteroposterior view, and subcarinal lymphadenopathy on the lateral view. However poor interobserver agreement has been reported for radiologist and clinician assessment of lymphadenopathy. This might reflect the lack of standardised imaging criteria for diagnosis as well as radiologists’ objectives for achieving sensitivity rather than specificity. In this paper the authors provide a pictorial aid of chest radiographs in children with culture-confirmed tuberculosis to help clinicians identify lymph node enlargement in primary pulmonary tuberculosis. This collection of images comprises chest radiographs accompanied by schematics and either CT or MRI scan confirmation of pathological lymph node enlargement at the positions commonly affected in tuberculosis.

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Intrathoracic tuberculous lymphadenopathy in children: a guide to chest radiography

Pediatr Radiol Intrathoracic tuberculous lymphadenopathy in children: a guide to chest radiography Anthony George 0 1 2 Savvas Andronikou 0 1 2 Tanyia Pillay 0 1 2 Pierre Goussard 0 1 2 Heather J. Zar 0 1 2 0 Department of Paediatrics and Child Health, Tygerberg Hospital and the University of Stellenbosch , Cape Town , South Africa 1 Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town and Medical Research Council Unit on Child and Adolescent Health , Cape Town , South Africa 2 Department of Paediatric Radiology, Bristol Royal Hospital for Children and the University of Bristol , Paul O'Gorman Building, Upper Maudlin St., Bristol BS2 8BJ , UK 3 Savvas Andronikou Making the diagnosis of pulmonary tuberculosis in children can be difficult because microbiological confirmation is not often achieved. Diagnosis is therefore often based on clinical features in combination with chest radiograph findings. Chest radiographs can demonstrate lymphadenopathy of the hilar and para-tracheal regions on the anteroposterior view, and subcarinal lymphadenopathy on the lateral view. However poor interobserver agreement has been reported for radiologist and clinician assessment of lymphadenopathy. This might reflect the lack of standardised imaging criteria for diagnosis as well as radiologists' objectives for achieving sensitivity rather than specificity. In this paper the authors provide a pictorial aid of chest radiographs in children with culture-confirmed tuberculosis to help clinicians identify lymph node enlargement in primary pulmonary tuberculosis. This collection of images comprises chest radiographs accompanied by schematics and either CT or MRI scan confirmation of pathological lymph node enlargement at the positions commonly affected in tuberculosis. Chest radiography; Children; Computed tomography; Lymph nodes; Magnetic resonance imaging; Pulmonary tuberculosis; Standardisation Introduction Making the diagnosis of pulmonary tuberculosis in children can be difficult because microbiological confirmation is not often achieved [ 1 ]. Diagnosis is therefore often based on clinical features in combination with chest radiograph findings. Recently, imaging diagnosis using CT, mediastinal US and MRI has been proposed, but the chest radiograph remains the most frequently used diagnostic imaging tool in children because it is readily available in most clinical settings [ 1 ]. With any of the imaging techniques, identification of lymphadenopathy is the major sign for diagnosing paediatric pulmonary tuberculosis [ 2 ]. However tuberculous lymphadenopathy can be difficult to diagnose with confidence on chest radiographs [ 3 ], and significant inter- and intra-observer variability has been reported for clinicians interpreting these (average weighted kappa =0.33) [ 4 ]. As a result, several chest radiograph classification systems have been devised to aid the diagnosis of pulmonary tuberculosis, and these involve assessment of the lung parenchyma and presence of intrathoracic lymphadenopathy [ 5, 6 ]. However these have not been widely included in routine use because they fail to provide adequate radiologic criteria, have not been well validated and are not backed up with a standard set of images [7]. Despite their many limitations, chest radiographs demonstrate lymphadenopathy of significant size at the hilar and para-tracheal regions on the anteroposterior view (as asymmetrical lobulated soft-tissue masses, often with sharply defined margins) and in the subcarinal region on the lateral view [ 2, 8 ]. Enlarged tuberculous lymph nodes can compress and displace the airways, offering further indirect clues for diagnosis [ 2, 5, 8 ]. Despite the known and reported features of lymphadenopathy in children with pulmonary tuberculosis, wide inter-observer variability has been reported for radiologists and clinicians identifying these on chest radiographs [4]. This might reflect the lack of standardised imaging criteria for diagnosis [ 7 ] as well as radiologists’ perceived objectives of achieving sensitivity rather than specificity [ 9 ]. CT is considered the modality of choice for identifying mediastinal and hilar lymphadenopathy [ 2, 10 ] and can demonstrate these in children with normal or equivocal chest radiographs. CT not only demonstrates lymphadenopathy to greater advantage, but it also demonstrates any calcification, parenchymal disease or complication including airway compression, air-trapping and pleural disease [10], which adds confidence for the reader. CT can therefore act as a gold standard for the presence of lymphadenopathy in children with pulmonary tuberculosis. MRI can confirm the presence of hilar and mediastinal lymphadenopathy. MRI is well-established for imaging lymphadenopathy in thoracic lymphoma, and there are also reports of MRI use for diagnosing tuberculosis and other lung infections [ 11, 12 ]. In the context of stand (...truncated)


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Anthony George, Savvas Andronikou, Tanyia Pillay, Pierre Goussard, Heather J. Zar. Intrathoracic tuberculous lymphadenopathy in children: a guide to chest radiography, Pediatric Radiology, 2017, pp. 1277-1282, Volume 47, Issue 10, DOI: 10.1007/s00247-017-3890-1