Letter to the Editor Acta Radiologica 2015, Vol. 56(1) NP1–NP2 ! The Foundation Acta Radiologica 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0284185114551566 acr.sagepub.com
The imaging spectrum of pulmonary tuberculosis: a critical appraisal The article by Cardinale et al. (1) is greatly welcome for the considerable interest and the great clinical relevance of the chosen topic, pulmonary tuberculosis, which, nonetheless, is currently a quite neglected disease. The migratory flows, the HIV epidemics and the fallout on the general population enhance interest and research on the usefulness and potential of different diagnostic tools suitable for the evaluation of patients with tuberculosis. In our institution, the Monaldi Hospital of Naples, there is a trend toward the increase of hospital admissions, from approximately 130 new cases of tubercular infection in 2011 to approximately 160 new cases in 2013. Sixty percent of them came from the East (Europe and Asia) or North Africa (Morocco). All cases were evaluated by X-ray, multidetector computed tomography (MDCT), and thoracic ultrasound (TUS). Few statements of this review deserve, in our opinion, to be managed with a greater care, in order to improve the information without misleading concepts or recommendation. First: ‘‘the radiologic signs of the disease are often misleading. Indeed, tuberculosis may be diagnosed in about 25% of cases initially misinterpreted as lung cancer’’ (1). This is not exactly correct, since in the quoted original article it is reported: ‘‘The overwhelming majority of patients (93.3%) referred to ‘‘rule out’’ lung cancer were documented as having a neoplastic process, and only 1.3% had an infection. Fungal infections (histoplasmosis, cryptococcosis, coccidiomycosis) accounted for 46%, mycobacteria for 27%, bacteria for 22%, and parasitic lesions (dirofilariasis) for 5% of these infections’’. In other words, we understand that only a minority of patients – 1.3% – in that case series
of almost 20 years ago, even referred for lung cancer investigation were, actually, patients with pulmonary infectious disease: of them, 27% were patients with tuberculosis (2). In our experience only a minority of patients with tuberculosis are referred erroneously to further investigation for cancer or to intervention procedures; and this is true not only for a specialized institution like we are, but also for the referral from non-specialized institutions or outpatients clinics, as confirmed in more recent reviews (3). The misunderstanding of the quoted article can be misleading for many readers since seemingly is displaying concerns on the actual expertise of radiologists. Second: we perform regularly TUS in tuberculosis patients and we wonder why the authors (1) quote only a very old report (4) simply writing ‘‘Tuberculous effusions contain high quantity of proteins and often show fibrin strands and septa on thoracic ultrasound imaging. Very often septa that have been imaged by ultrasound are not detected by CT’’ (4). This description does not fully correspond to what we actually see (loculated pleural effusions are a feature of a part of such conditions) and, more important, no comment is provided for pleural thickness and nodularity, described in that report, 20 years ago, and that we also often see (4). A comment on the reliability for monitoring pleural effusions by TUS and for FNAB under appropriate TUS guidance (5) should be added to this otherwise constructive review on pulmonary tuberculosis. Conflict of interest None declared.
References 1. Cardinale L, Parlatano D, Boccuzzi F, et al. The imaging spectrum of pulmonary tuberculosis. Acta Radiol 2014 May 15. [Epub ahead of print].
Downloaded from acr.sagepub.com at Univ of Connecticut / Health Center / Library on May 22, 2015
NP2
Acta Radiologica 56(1)
2. Rolston KV, Rodriguez S, Dholakia N, et al. Pulmonary infections mimicking cancer: a retrospective, three-year review. Support Care Cancer 1997;5:90–93. 3. Prapruttam D, Hedgire SS, Mani SE, et al. Tuberculosisthe great mimicker. Semin Ultrasound CT MR 2014;35: 195–214. 4. Akhan O, Demirkazik FB, Ozmen MN, et al. Tuberculous pleural effusions: ultrasonic diagnosis. J Clin Ultrasound 1992;20:461–465. 5. Trovato GM, Sperandeo M, Catalano D. Thoracic ultrasound guidance for access to pleural, peritoneal, and pericardial space. Chest 2013;144:1735–1736.
Gaetano Rea1 and Maria D’Amato2 Radiology Section, Department of Imaging, Monaldi Hospital, Naples, Italy 2 Respiratory Medicine Division, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy 1
Corresponding author: Gaetano Rea, Radiology Section, Department of Imaging, Monaldi Hospital, Via L. Bianchi 5, 80131 Naples, Italy. Email: [email protected]
Downloaded from acr.sagepub.com at Univ of Connecticut / Health Center / Library on May 22, 2015
The imaging spectrum of pulmonary tuberculosis: a critical appraisal The article by Cardinale et al. (1) is greatly welcome for the considerable interest and the great clinical relevance of the chosen topic, pulmonary tuberculosis, which, nonetheless, is currently a quite neglected disease. The migratory flows, the HIV epidemics and the fallout on the general population enhance interest and research on the usefulness and potential of different diagnostic tools suitable for the evaluation of patients with tuberculosis. In our institution, the Monaldi Hospital of Naples, there is a trend toward the increase of hospital admissions, from approximately 130 new cases of tubercular infection in 2011 to approximately 160 new cases in 2013. Sixty percent of them came from the East (Europe and Asia) or North Africa (Morocco). All cases were evaluated by X-ray, multidetector computed tomography (MDCT), and thoracic ultrasound (TUS). Few statements of this review deserve, in our opinion, to be managed with a greater care, in order to improve the information without misleading concepts or recommendation. First: ‘‘the radiologic signs of the disease are often misleading. Indeed, tuberculosis may be diagnosed in about 25% of cases initially misinterpreted as lung cancer’’ (1). This is not exactly correct, since in the quoted original article it is reported: ‘‘The overwhelming majority of patients (93.3%) referred to ‘‘rule out’’ lung cancer were documented as having a neoplastic process, and only 1.3% had an infection. Fungal infections (histoplasmosis, cryptococcosis, coccidiomycosis) accounted for 46%, mycobacteria for 27%, bacteria for 22%, and parasitic lesions (dirofilariasis) for 5% of these infections’’. In other words, we understand that only a minority of patients – 1.3% – in that case series
of almost 20 years ago, even referred for lung cancer investigation were, actually, patients with pulmonary infectious disease: of them, 27% were patients with tuberculosis (2). In our experience only a minority of patients with tuberculosis are referred erroneously to further investigation for cancer or to intervention procedures; and this is true not only for a specialized institution like we are, but also for the referral from non-specialized institutions or outpatients clinics, as confirmed in more recent reviews (3). The misunderstanding of the quoted article can be misleading for many readers since seemingly is displaying concerns on the actual expertise of radiologists. Second: we perform regularly TUS in tuberculosis patients and we wonder why the authors (1) quote only a very old report (4) simply writing ‘‘Tuberculous effusions contain high quantity of proteins and often show fibrin strands and septa on thoracic ultrasound imaging. Very often septa that have been imaged by ultrasound are not detected by CT’’ (4). This description does not fully correspond to what we actually see (loculated pleural effusions are a feature of a part of such conditions) and, more important, no comment is provided for pleural thickness and nodularity, described in that report, 20 years ago, and that we also often see (4). A comment on the reliability for monitoring pleural effusions by TUS and for FNAB under appropriate TUS guidance (5) should be added to this otherwise constructive review on pulmonary tuberculosis. Conflict of interest None declared.
References 1. Cardinale L, Parlatano D, Boccuzzi F, et al. The imaging spectrum of pulmonary tuberculosis. Acta Radiol 2014 May 15. [Epub ahead of print].
Downloaded from acr.sagepub.com at Univ of Connecticut / Health Center / Library on May 22, 2015
NP2
Acta Radiologica 56(1)
2. Rolston KV, Rodriguez S, Dholakia N, et al. Pulmonary infections mimicking cancer: a retrospective, three-year review. Support Care Cancer 1997;5:90–93. 3. Prapruttam D, Hedgire SS, Mani SE, et al. Tuberculosisthe great mimicker. Semin Ultrasound CT MR 2014;35: 195–214. 4. Akhan O, Demirkazik FB, Ozmen MN, et al. Tuberculous pleural effusions: ultrasonic diagnosis. J Clin Ultrasound 1992;20:461–465. 5. Trovato GM, Sperandeo M, Catalano D. Thoracic ultrasound guidance for access to pleural, peritoneal, and pericardial space. Chest 2013;144:1735–1736.
Gaetano Rea1 and Maria D’Amato2 Radiology Section, Department of Imaging, Monaldi Hospital, Naples, Italy 2 Respiratory Medicine Division, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy 1
Corresponding author: Gaetano Rea, Radiology Section, Department of Imaging, Monaldi Hospital, Via L. Bianchi 5, 80131 Naples, Italy. Email: [email protected]
Downloaded from acr.sagepub.com at Univ of Connecticut / Health Center / Library on May 22, 2015
