The silent pandemic in South Africa: Extra-pulmonary tuberculosis from head to heel

Extra-pulmonary tuberculosis (EPTB), caused by Mycobacterium tuberculosis, is the leading cause of communicable disease-related deaths in people with human immunodeficiency virus (HIV) worldwide and in South Africa. Mycobacterium tuberculosis disseminates haematogenously from an active primary lung focus and may affect extra-pulmonary sites in up to 15% of patients. Extra-pulmonary TB may present with a normal chest radiograph, which often causes a significant diagnostic dilemma. This review describes the main sites of involvement in EPTB, which is illustrated by local imaging examples.

Comparison of Latent Tuberculosis Infections among General versus Tuberculosis Health Care Workers in Myanmar

Health care workers (HCWs) in high tuberculosis (TB) prevalence countries have to care for many cases, thus increasing their risk of infection. The objective of the study was to compare the prevalence of latent TB infection (LTBI) between general HCWs and TB HCWs, and also to explore the associated factors. A cross-sectional study was conducted in Nay Pyi Taw, Myanmar from September 2019 to January 2020. Staff working at two general hospitals were recruited. Those allocated for TB care were classified as TB HCWs, while the remaining were classified as general HCWs. Participants were interviewed using a structured questionnaire, and screened for LTBI using a tuberculin skin test (TST). Individuals who had an induration of 10 mm or more with normal chest radiograph were regarded as having LTBI. The prevalence of LTBI among general HCWs was 2.04 times higher than that of TB HCWs (31.2% vs. 15.3%, p < 0.001). The associated factors for LTBI included low education level, duration of work experience ≥ 10 years, a low knowledge of regular TB screening, and teaching cough etiquette to TB patients. The higher prevalence of LTBI in the general HCWs in this study was due to confounding by education and experience. After adjustment for these, we have no evidence to support that either group of HCWs had higher LTBI risk.

Diagnosis of pulmonary cement embolism using only the bone window setting on computed tomography: a case report

Pulmonary cement embolism (PCE) is one of several complications of percutaneous vertebroplasty and kyphoplasty. Generally, PCE can be easily diagnosed based on typical chest radiograph findings such as single or multiple radiographically dense opacities with a tubular or branch shape in the lung field along with a recent history of percutaneous vertebroplasty or kyphoplasty. These findings can be alarming and may be encountered on routine chest radiographs, even in asymptomatic patients. One study showed that PCEs that were not visualized on chest radiograph were also not shown on chest computed tomography. However, we encountered a patient with dyspnea who had normal chest radiograph findings but was diagnosed with PCE through only the bone window setting on chest computed tomography. The present case will be beneficial to all physicians examining older patients with dyspnea.

Measurement of the Sub-carinal Angle on the Normal Chest Radiograph of Adult at BPKIHS, Dharan, Nepal

Background: The sub-carinal angle is an angle formed between the main right bronchus and leftbronchus clearly seen in adequately exposed chest radiograph, normally at the level of 5th thoracicvertebrae. Objective: To measure sub-carinal angle in relationship to different age, sex and body mass index inthe adult. Methods: A cross-sectional study was carried out in the Department of Radio diagnosis and Imaging at BPKIHS, Dharan from 27th April to 6th August 2017. Sub-carinal angle was measured on the normal chest radiograph in 392 adult patients. The data were analyzed using SPSS Version 11.5 and descriptive statistics percentage, Mean, Standard Deviation were calculated. For inferential statistics, Independent ‘t’ test and Pearson’s correlation were applied. Results: The sub-carinal angle ranged from 39°- 81.1° with mean value 60.17°+7.81°. The mean subcarinalangle for the male was 59.17°+8.19° and for female was 60.62°+7.49°. The mean sub-carinalangle was wider in female than male in our study; however, the difference in sub-carinal angle between male and female was statistically not significant (p> 0.05). There was negative correlationbetween sub-carinal angle and age (r= -0.168, p <0.01). The sub-carinal angle was positivelycorrelated with BMI (r= 0.100, p< 0.05). Conclusion: In our study, the mean sub-carinal angle was 60.17° ± 7.81°. The mean sub-carinal angle difference between male and female was statistically non-significant. There was negative correlation of sub-carinal angle with age and positive correlation with BMI. The reference value obtained from this study will be helpful to diagnose abnormal sub-carinal angle due to various pathologies.

Drowning

Drowning is a major preventable cause of death, most frequently in children and in developing countries. Aspiration (whether of salt or fresh water) is usual in drowning and near-drowning (known as non-fatal, or submersion injury) and leads to cardiac arrest within a few minutes. Death or severe neurological impairment occurs after submersion for more than 5–10 min, but much longer durations may be tolerated in hypothermic conditions. Prognosis cannot reliably be predicted, but cardiovascular status is a better prognostic indicator than neurological presentation. Patients who are neurologically responsive at the scene of immersion, in sinus rhythm and with reactive pupils, have good outcomes. Those who are asystolic on arrival at hospital and remain comatose for more than 3 h have a poor prognosis unless they are hypothermic. Patients with a normal chest radiograph on admission usually survive.

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a progressive chronic systemic autoimmune disorder characterized by symmetric deforming erosive synovitis. Pulmonary involvement may occur in 18% of all patients with RA, is one of the most common extra-articular manifestations of the disease and is a major cause of morbidity and mortality. The most common pleuropulmonary manifestations of RA are rheumatoid-associated interstitial lung disease (RA-ILD), drug related lung disease, infection secondary to immunosuppression, necrobiotic nodules, organizing pneumonia, upper and lower airway disease, pulmonary vascular disease and serositis. A normal chest radiograph does not exclude RA-ILD. As disease progresses, radiographic abnormalities may become more apparent. Thin-section or high resolution computed tomography (HRCT) remains the study of choice to assess RA-ILD. Patients with RA-ILD have a slightly increased incidence of lung cancer, and radiologists must carefully scrutinize images looking for discrete nodules and masses.

Systemic Sclerosis

Systemic sclerosis (SSc), or scleroderma is a chronic autoimmune disorder of small vessels and connective tissue characterized by organ fibrosis, small vessel vasculopathy and disease-specific antibodies. It results in multi system organ fibrosis. The skin, lungs, heart, gastrointestinal tract and kidneys are frequently affected. Skin involvement is typical. Clinically evident pulmonary disease is seen in 25% of affected patients, but autopsy reports demonstrate some degree of pulmonary involvement in all patients with the systemic form of the disease. Pulmonary disease is second only to esophageal fibrosis and has surpassed renal disease as the leading cause of death. Systemic sclerosis associated-interstitial lung disease (SSc-ILD) and pulmonary vascular disease are the two major lung manifestations of SSc. Pulmonary hypertension is the leading cause of death. A normal chest radiograph does not exclude SSc-ILD. High resolution CT (HRCT) should be part of the initial evaluation of patients with SSc, even when pulmonary symptoms are not present. The radiologist should be able to recognize signs of early pulmonary fibrosis and pulmonary hypertension on radiography and HRCT due to the proven benefit of adequate therapy in overall outcome and mortality.

The Immunocompromised Patient: Non-AIDS

Immunosuppression may be primary (i.e. congenital) or secondary (i.e acquired). Because immunodeficiencies constitute an extensive and highly heterogenous group of diseases, imaging interpretation must be performed in light of the underlying condition and/or treatment timeline whenever possible. Secondary immunodeficiencies include those occurring in bone marrow transplant (BMT) and solid organ transplant recipients and in patients on chronic corticosteroid therapy. Familiarity with the time course of immune dysfunction following BMT is essential for providing a narrow differential diagnosis in cases of opportunistic infection. Opportunistic infections in BMT recipients can be categorized based on the post-transplant phase: Neutropenic phase (<30 days, before engraftment); Early phase (30-100 days, after engraftment); Late phase (>100 days). A normal chest radiograph does not exclude infection in immunocompromissed patients with respiratory symptoms; further assessment with chest CT should always be considered in order to detect subtle imaging abnormalities. Infectious bronchiolitis manifesting with centrilobular nodules and diffuse ground-glass opacities on CT is commonly seen in immunocompromised patients.