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Milliary TB PDF
Milliary TB PDF
Study objective: To assess the efficacy of the chest radiograph in identifying patients with miliary
tuberculosis.
Design: Retrospective case-controlled review by three independent blinded chest radiologists.
Setting: Provincial tuberculosis control center.
Patients: Population-based sample, including all proved cases of miliary tuberculosis diagnosed in
the Province of British Columbia, Canada, between November 1982 and November 1992. One
hundred cases of miliary tuberculosis were identified, of which 71 had chest radiographs available
for review. Forty-four normal chest radiographs and 20 chest radiographs of patients with localized
pulmonary tuberculosis were also included as controls.
Main outcome measures: The primary outcome of measurements was the sensitivity and interob-
server variability of the chest radiograph in the diagnosis of miliary tuberculosis. The observers were
also asked to describe the pattern and extent of pulmonary abnormalities based on the International
Labor Organization (ILO) classification of pneumoconioses.
Results: The three independent observers identified 42, 44, and 49 of the 71 cases of miliary tuber-
culosis, respectively (sensitivity, 59 to 69%). The three observers incorrectly diagnosed miliary tu-
berculosis in 2, 0, and 2 of the 64 controls, respectively (specificity, 97 to 100%). There was good
interobserver agreement (90%, kappa=O. 77). The nodules measured less than 3 mm in diameter in
90% of cases in which miliary tuberculosis was correctly identified. In 10% of cases, the nodules
measured greater than 3 mm in diameter. The ILO profusion scores ranged from mild (profusion
score 1) in 45% of cases, through moderate (profusion score 2) in 27%, and severe (profusion score
3) in 28%.
Conclusions: The chest radiograph allowed identification of 59 to 69% of cases of miliary tubercu-
losis with a high specificity and good interobserver agreement. (CHEST 1996; 110:339-42)
Key words: lung diseases; lung radiography; tuberculosis, miliary; tuberculosis, pulmonary
There is concern regarding rising rates of tubercu- radiograph in 30 to 93% of cases. 7-15 These studies
losis (TB), including disseminated or miliary TB, were not population-based, lacked control subjects,
which is a more common condition in HIV infection. 1·2 and, with the exception of one study from South Afri-
In addition, miliary TB is often underdiagnosed in the ca, 15 were published more than 20 years ago. The
elderly, resulting in autopsy diagnosis of unsuspected purpose of this study was to determine the efficacy of
disseminated TB. 3 the chest radiograph in the diagnosis of miliary TB
The chest radiograph plays an important role in the based on a review of all cases diagnosed over 10 years
initial detection and final diagnosis of miliary TB. The in the province of British Columbia, Canada, inclusion
characteristic radiographic findings consist of a large of a group of control subjects, and interpretation by
number of nodular opacities measuring 1 to 3 mm in three independent blinded observers.
diameter scattered diffusely throughout both lungs.4-6
Previous studies have reported widely variable results, MATERIALS AND METHODS
with miliary lesions being identified on the chest The records from the TB registry for the Province of British
Columbia, Canada, were reviewed for cases of miliary TB from
*From the Departments of Radiology and Medicine, Respiratory November 1982 to November 1992. Only patients who had a good
Division, University of British Columbia and Vancouver Hospital quality posteroanterior or anteroposterior chest radiograph as de-
and Health Sciences Centre, Vancouver, BC, Canada, Centre for termined by an independent expert chest radiologist were included
Disease Control, Division of TB, Ministry of Health, British Co- in the study. Patients with only poor quality portable radiographs
lumbia.
Manuscript received September 26, 1995; revision accepted (n=2), and patients without radiographs obtained prior to com-
January 5: mencement of treatment (n=2) were excluded from the study. Of
sitivity in our series and the sensitivity from previous We conclude that the chest radiograph allows iden-
reports may largely be attributed to differences in tification of 59 to 69% of cases of miliary TB with a high
reader bias in previous studies. It should be noted, specificity and good interobserver agreement. Because
C H EST
{1996}
WORLD CONGRESS