Imaging of thoracic tuberculosis in children: current and future directions

Giant cerebral tuberculoma mimicking tumor in a pediatric patient: A case report

Tuberculosis (TB) is an infection caused by Mycobacterium tuberculosis, an infectious disease endemic in developing countries. Indonesia is ranked second only to India in terms of TB incidence in the world. TB generally manifests in the respiratory system, which can then spread hematogeneously or lymphogeneously to extrapulmonary organs. Intracranial tuberculoma is a rare manifestation of TB when compared to the overall TB presentation. Central nervous system involvement ranges from 2-5% and increases to 15% in cases of AIDS-related TB, with the percentage of tuberculoma findings around 1% in other intracranial TB cases. The most common manifestation is tuberculous meningitis. Central nervous system (CNS) involvement is a severe manifestation of TB, with high mortality and neurological morbidity. In this case report, the author presented a 6-year-old girl with giant cerebral tuberculoma, which, at the time of surgery, resembled a neoplasm with a nonspecific history of TB. MRI can visualize abnormalities with specific characteristics; Clinically and radiologically, CNS TB can mimic other infections or noninfectious conditions such as neoplasms. Therefore, clinicians can take appropriate management actions in order to prevent mortality and disability due to sequelae in CNS TB cases.

A systematic review and meta-analysis of diagnostic test accuracy of chest ultrasound in diagnosing pediatric pulmonary tuberculosis

INTRODUCTION

Despite medical advancement, pediatric pulmonary tuberculosis (PTB) still has high morbidity and mortality, due to challenging detection in clinical practice. Ultrasound has been touted as the next best diagnostic tool but currently, this claim is unfounded. Therefore, this study aims to systematically review the diagnostic parameters of chest ultrasound in diagnosing pediatric PTB.

METHODS

The literature search started and ended on December 23, 2023. We searched MEDLINE, Cochrane Library, Pubmed, Science Direct, and Google Scholar. Our research question could be formulated as "In pediatric patients who present with signs and symptoms of PTB such as fever, cough, and poor weight gain, how accurate is chest ultrasound in ruling in and ruling out pediatric PTB when the diagnosis is compared to culture, PCR or CXR?" This systematic review adhered to the PRISMA-DTA guidelines while the meta-analysis was conducted with STATA program using the "midas" and "metandi" commands.

RESULTS

There are five studies included with 137 positive PTB children. The combined sensitivity is 84% (95% confidence interval [CI]: 76-89), specificity of 38% (95% CI: 24-54), and summary receiver operating curve yields an area under the curve of 0.83 (95% CI: 0.80-0.86). The I2 value is 24% (95% CI: 0-100) with a p-value of 0.13. The combined negative predictive value is 0.68 (95% CI: 0.58-0.79), and the positive predictive value is 0.57 (95% CI: 0.51-0.63). The positive likelihood ratio is 1 with a 6% increase from the baseline while the negative likelihood ratio is 0.43 with a 12% decrease from the baseline.

CONCLUSION

Chest ultrasound is sensitive but currently could neither exclude nor confirm pediatric PTB.

Diagnostic performance of a novel ESAT6-CFP10 skin test for tuberculosis infection in school tuberculosis outbreak in China

Background

The ESAT6-CFP10 (EC) skin test is recommended by the World Health Organization for latent tuberculosis infection (LTBI). However, it is still unknown how the EC skin test performs in students during a school tuberculosis outbreak.

Methods

We conducted an epidemiological investigation to assess the performance of the EC skin test in this high-risk population.

Results

A total of 9 active student patients were confirmed in the same class as the index case, with an incidence rate of 18.0% (9/50). Among the 50 close contacts, 14 (28%) were over 15 years old and had a chest X-ray (CXR), and none of them had abnormal CXR findings. The rates of positive tuberculin skin test (TST) ≥ 5 mm and < 10 mm, ≥ 10 mm and < 15 mm, and ≥ 15 mm were 12.0% (6/50), 16.0% (8/50), and 10.0% (5/50), respectively. On the second screening, 44 students with the same class as the index case had the EC skin test, of which 31 (70.5%) had positive EC tests. All patients had negative sputum smear results, of whom 4 (44.4%) had positive Xpert results; three had a TST induration diameter between 5 mm and 10 mm, but all of them had an EC diameter > 15 mm; 5 (55.6%) had abnormal CXR results, but all the confirmed patients had abnormal CT results; Except for four cases that were diagnosed by Xpert, the remaining five were confirmed by CT scan.

Conclusion

The novel EC skin test performed well in students during the school tuberculosis outbreak. In some special conditions, such as when the index case is bacteriologically positive for tuberculosis and the rate of LTBI is higher than the average for the local same-age group, secondary screening is recommended 2-3 months after the first screening. Furthermore, we cannot ignore the role of CT in the diagnosis of early student tuberculosis.

Imaging Features of Pediatric Sarcoidosis

Sarcoidosis is a granulomatous inflammatory disease of uncertain cause. It occurs most commonly in young and middle-aged adults and less frequently in children; therefore, few data on pediatric sarcoidosis exist in the literature. The diagnosis and management of sarcoidosis remain challenging because of diverse and often nonspecific clinical and imaging findings. In addition, the clinical picture varies widely by age. Prepubertal and adolescent patients often present with adult-like pulmonary disease; however, early-onset sarcoidosis is typically characterized by the triad of arthritis, uveitis, and skin rash. Sarcoidosis is mostly a diagnosis of exclusion made by demonstrating noncaseating granulomas at histopathologic examination in patients with compatible clinical and radiologic findings. Although sarcoidosis often affects the lungs and thoracic lymph nodes, it can involve almost any organ in the body. The most common radiologic manifestation is pulmonary involvement, characterized by mediastinal and bilateral symmetric hilar lymphadenopathies with perilymphatic micronodules. Abdominal involvement is also common in children and often manifests as hepatomegaly, splenomegaly, and abdominal lymph node enlargement. Although neurosarcoidosis and cardiac sarcoidosis are rare, imaging is essential to the diagnosis of central nervous system and cardiac involvement because of the risky biopsy procedure and its low diagnostic yield due to focal involvement. Being familiar with the spectrum of imaging findings of sarcoidosis may aid in appropriate diagnosis and management. ©RSNA, 2023 Test Your Knowledge questions are available in the supplemental material.

Ultrasound and magnetic resonance imaging in thoracic tuberculosis in the pediatric population: moving beyond conventional radiology

Imaging is crucial in the diagnostic work-up and follow-up after treatment in children with thoracic tuberculosis (TB). Despite various technological advances in imaging modalities, chest radiography is the primary imaging modality for initial care and in emergency settings, especially in rural areas and where resources are limited. Ultrasonography (US) of the thorax in TB is one of the emerging applications of US as a radiation-free modality in children. Magnetic resonance imaging (MRI) is the ideal radiation-free, emerging imaging modality for thoracic TB in children. However, only limited published data is available regarding the utility of MRI in thoracic TB. In this pictorial review, we demonstrate the use of US and rapid lung MRI in evaluating children with thoracic TB, specifically for mediastinal lymphadenopathy and pulmonary complications of TB.

Artificial Intelligence in Paediatric Tuberculosis

Tuberculosis (TB) continues to be a leading cause of death in children despite global efforts focused on early diagnosis and interventions to limit the spread of the disease. This challenge has been made more complex in the context of the coronavirus pandemic, which has disrupted the "End TB Strategy" and framework set out by the World Health Organization (WHO). Since the inception of artificial intelligence (AI) more than 60 years ago, the interest in AI has risen and more recently we have seen the emergence of multiple real-world applications, many of which relate to medical imaging. Nonetheless, real-world AI applications and clinical studies are limited in the niche area of paediatric imaging. This review article will focus on how AI, or more specifically deep learning, can be applied to TB diagnosis and management in children. We describe how deep learning can be utilised in chest imaging to provide computer-assisted diagnosis to augment workflow and screening efforts. We also review examples of recent AI applications for TB screening in resource constrained environments and we explore some of the challenges and the future directions of AI in paediatric TB.

Global resources in the fight against tuberculosis

Tuberculosis continues to be a significant cause of mortality and morbidity worldwide, particularly in developing countries. Diagnosis and treatment of paediatric patients presents a challenge that can only be improved by the joint efforts of the international community, working together in cooperation and partnership. This article reviews global resources available to doctors and healthcare professionals in the fight against TB, including international programmes, policies and healthcare pathways. Special attention is paid to the role of international paediatric radiology in improving diagnostics, including available educational resources and support on a global, regional, national and individual level.

Imaging recommendations and algorithms for pediatric tuberculosis: part 1-thoracic tuberculosis

Tuberculosis (TB) remains a global health problem and is the second leading cause of death from a single infectious agent, behind the novel coronavirus disease of 2019. Children are amongst the most vulnerable groups affected by TB, and imaging manifestations are different in children when compared to adults. TB primarily involves the lungs and mediastinal lymph nodes. Clinical history, physical examination, laboratory examinations and various medical imaging tools are combined to establish the diagnosis. Even though chest radiography is the accepted initial radiological imaging modality for the evaluation of children with TB, this paper, the first of two parts, aims to discuss the advantages and limitations of the various medical imaging modalities and to provide recommendations on which is most appropriate for the initial diagnosis and assessment of possible complications of pulmonary TB in children. Practical, evidence-based imaging algorithms are also presented.

Tuberculosis revisted: classic imaging findings in childhood

Tuberculosis (TB) remains one of the major public health threats worldwide, despite improved diagnostic and therapeutic methods. Tuberculosis is one of the main causes of infectious disease in the chest and is associated with substantial morbidity and mortality in paediatric populations, particularly in low- and middle-income countries. Due to the difficulty in obtaining microbiological confirmation of pulmonary TB in children, diagnosis often relies on a combination of clinical and radiological findings. The early diagnosis of central nervous system TB is challenging with presumptive diagnosis heavily reliant on imaging. Brain infection can present as a diffuse exudative basal leptomeningitis or as localised disease (tuberculoma, abscess, cerebritis). Spinal TB may present as radiculomyelitis, spinal tuberculoma or abscess or epidural phlegmon. Musculoskeletal manifestation accounts for 10% of extrapulmonary presentations but is easily overlooked with its insidious clinical course and non-specific imaging findings. Common musculoskeletal manifestations of TB include spondylitis, arthritis and osteomyelitis, while tenosynovitis and bursitis are less common. Abdominal TB presents with a triad of pain, fever and weight loss. Abdominal TB may occur in various forms, as tuberculous lymphadenopathy or peritoneal, gastrointestinal or visceral TB. Chest radiographs should be performed, as approximately 15% to 25% of children with abdominal TB have concomitant pulmonary infection. Urogenital TB is rare in children. This article will review the classic radiological findings in childhood TB in each of the major systems in order of clinical prevalence, namely chest, central nervous system, spine, musculoskeletal, abdomen and genitourinary system.

Update on the diagnosis and treatment of tuberculosis

According to World Health Organization estimates, more than 1 million patients aged less than 15 years develop tuberculosis (TB) each year worldwide. In some regions, up to 25% of new TB cases are caused by drug-resistant strains. Although Spain is considered a low-incidence country, several hundred children and adolescents develop TB each year. The importance of paediatric TB has been minimized for years due to the lack of microbiological confirmation in many patients and because these patients are not usually contagious. Nevertheless, in the past 15 years there have been major improvements in the epidemiological reporting of TB in children and adolescents, new immunodiagnostic tests have been developed, molecular methods that allow rapid microbiological diagnosis and detection of variants associated with drug resistance have become available, novel second-line antituberculosis drugs have been discovered, including for paediatric use, and the results of clinical trials have validated shorter courses of treatment for some patients. This document, developed by a group of experts from the Sociedad Española de Infectología Pediátrica and the Sociedad Española de Neumología Pediátrica, updates and complements the previous guidelines for the diagnostic and therapeutic management of children with TB in Spain based on the newly available scientific evidence.

Tuberculosis contact-tracing results in childhood: a retrospective study in a tertiary-care children's hospital in Turkey

BACKGROUND

Smear-positive adults with tuberculosis are the main source of childhood tuberculosis. The evaluation of children exposed to tuberculosis and determination of the disease stages are the cornerstones of managing childhood tuberculosis.

AIM

To determine the frequency of tuberculous contact, latent tuberculosis infection and tuberculosis disease in children who were in contact with smear-positive adults.

METHODS

This is a single-centre, retrospective study. The medical records of children exposed to tuberculosis (<18 years old) between 2014 and 2018 were investigated. After diagnosing the index cases, the children were referred to the hospital. To identify the children in contact with adults with tuberculosis, a careful medical history, demographic features and physical examination, tuberculin skin test, postero-anterior and lateral chest radiographs, and, if necessary, chest computed tomography and microbiological tests were undertaken. The children's final diagnosis, treatment regimens and follow-up were documented. The sensitivity, specificity and positive and negative predictive values, tuberculin skin test and chest radiograph imaging were assessed and compared with computed tomography results.

RESULTS

A total of 150 paediatric patients were exposed to 88 index cases. These were fathers in 29.3% of cases and mothers in 10% of cases. Of the children, 131 (87.3%) were asymptomatic, and physical examination was normal in all children, apart from one who had respiratory symptoms. The tuberculin skin test results were positive in 60 (43%) patients and chest radiograph was abnormal in 100 (66%) children. Findings were consistent with tuberculosis in 34 (40%) of the 84 patients who underwent computed tomography. Fifty (38.5%) of the remaining children were defined as having been in contact with a case of tuberculosis, 41 (31.5%) had latent tuberculous infection and 39 (30%) had tuberculosis disease.

CONCLUSION

Pulmonary tuberculosis is asymptomatic in most children but with meticulous use of computed tomography it can be detected in asymptomatic children who have had close contact with tuberculosis.Abbreviation: AFB: acid-fast bacilli; AUC: area under the curve; BCG: bacillus Calmette-Guérin; CI: confidence interval; CT: computed tomography; CXR: chest radiograph; HIV: human immunodeficiency virus; ICD-10: International Classification of Diseases 10; LTBI: latent tuberculosis infection; MDR-TB: multi-drug-resistant tuberculosis; NPV: negative predictive value; PCR: polymerase chain reaction; PPV: positive predictive value; ROC: receiver operating characteristics; SD: standard deviation; TB: tuberculosis; TST: tuberculin skin test; XDR-TB: extensively drug-resistant tuberculosis.

Primary lymphatic tuberculosis in children - Literature overview and case report

Tuberculosis bacilli can enter the human body through the digestive system, the skin, and the mucous membranes, although they mainly enter through the respiratory tract. TB bacilli can enter the bloodstream and attack other organs including the lymphatic system. The TB bacillus can cause miliary tuberculosis once they have entered the bloodstream and infiltrated the lymphatic system, which can then manifest as large lymph nodes in the hilum, mediastinum, and lung. Complicated primary TB infection occurs when enlarged lymph nodes compress the airways, causing a partial or complete obstruction that can lead to air retention or atelectasis. More serious complications can occur if the lymph nodes fill with pus and burst, as this can lead to TB spreading through the airways via a humoral mechanism. Making a differential diagnosis of hilar and mediastinal lymphadenopathy is often difficult because diagnostic interventions in this area are problematic. We report on a clinical case of a child with primary TB of the lymphatic system. The patient presented with mediastinal lymphadenopathy and miliary lesions in the lung, which was confirmed by a transthoracic biopsy performed under CT guidance. It is hoped that this report can provide doctors with a more comprehensive approach when diagnosing this disease.

Transthoracic mediastinal ultrasound in childhood tuberculosis: A review

Diagnosing childhood tuberculosis (TB) is challenging, and novel diagnostic tools are urgently needed. Mediastinal lymphadenopathy is a hallmark of primary pulmonary TB (PTB) in children. We aimed to summarise available methodological and diagnostic data of transthoracic mediastinal ultrasound for childhood TB. Literature review identified two prospective and three retrospective studies, a case report, and a technical report including cases. All reported on suprasternal scanning of the mediastinum; additional parasternal scanning was reported by five studies. The proportion of children with lymphadenopathy detected by mediastinal ultrasound ranged between 15% and 85%, with studies including both supra- and parasternal scanning achieving higher detection ratios. Three retrospective studies reported mediastinal lymphadenopathy on ultrasound for most cases presenting with a normal or inconclusive CXR. Data on ultrasound for mediastinal lymphadenopathy in children are limited but indicate that mediastinal ultrasound can successfully detect mediastinal lymphadenopathy in children with TB.

Chest Imaging for Pulmonary TB—An Update

The diagnosis of pulmonary tuberculosis (PTB) in children is challenging. Difficulties in acquiring suitable specimens, pauci-bacillary load, and limitations of current diagnostic methods often make microbiological confirmation difficult. Chest imaging provides an additional diagnostic modality that is frequently used in clinical practice. Chest imaging can also provide insight into treatment response and identify development of disease complications. Despite widespread use, chest radiographs are usually non-specific and have high inter- and intra-observer variability. Other diagnostic imaging modalities such as ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) can provide additional information to substantiate diagnosis. In this review, we discuss the radiological features of PTB in each modality, highlighting the advantages and limitations of each. We also address newer imaging technologies and potential use.

Practical protocol for lung magnetic resonance imaging and common clinical indications

Imaging speed, spatial resolution and availability have made CT the favored cross-sectional imaging modality for evaluating various respiratory diseases of children - but only for the price of a radiation exposure. MRI is increasingly being appreciated as an alternative to CT, not only for offering three-dimensional (3-D) imaging without radiation exposure at only slightly inferior spatial resolution, but also for its superior soft-tissue contrast and exclusive morpho-functional imaging capacities beyond the scope of CT. Continuing technical improvements and experience with this so far under-utilized modality contribute to a growing acceptance of MRI for an increasing number of indications, in particular for pediatric patients. This review article provides the reader with practical easy-to-use protocols for common clinical indications in children. This is intended to encourage pediatric radiologists to appreciate the new horizons for applications of this rapidly evolving technique in the field of pediatric respiratory diseases.

High rate of transmission in a pulmonary tuberculosis outbreak in a junior high school in China, 2020

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School tuberculosis outbreaks are common in China

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Students with PPD ≥ 15 mm are recommended to have prophylactic treatment

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More attention should be paid to students with PPD ≥ 10 mm and < 15 mm in school TB outbreaks

Background

School tuberculosis outbreaks are common in China. This study aimed to introduce a new screening process to help control outbreaks.

Methods

An epidemiological investigation into a school-based tuberculosis outbreak was conducted in order to identify the origin of the infection, and how it was transmitted.

Results

In total, 10 confirmed active tuberculosis cases were diagnosed among student contacts in the index case's class, giving an incidence rate of 19.2% (10/52). Three were found through a proactive visit and seven through screening. Of the nine secondary cases, two had purified protein derivation of tuberculin (PPD) ≥ 15 mm or blister (confirmed by computed tomography (CT) scan before preventive therapy), five had TST ≥ 10 mm and < 15 mm (two with abnormal chest radiography scan and three with positive T-SPOT tests, confirmed by CT) and two with PPD ≥ 5 mm and < 10 mm (confirmed by CT scan through proactive visit).

Conclusion

Further to our results based on this school outbreak, a new screening process is recommended that involves conducting interferon gamma release assays on those students with PPD ≥ 5 mm and < 15 mm if there are three or more active tuberculosis patients in the class with an epidemiological link. Furthermore, a CT scan is recommended for students who have had a recent tuberculosis infection before they have preventive therapy.

Screening tests for active pulmonary tuberculosis in children

BACKGROUND

Globally, children under 15 years represent approximately 12% of new tuberculosis cases, but 16% of the estimated 1.4 million deaths. This higher share of mortality highlights the urgent need to develop strategies to improve case detection in this age group and identify children without tuberculosis disease who should be considered for tuberculosis preventive treatment. One such strategy is systematic screening for tuberculosis in high-risk groups.

OBJECTIVES

To estimate the sensitivity and specificity of the presence of one or more tuberculosis symptoms, or symptom combinations; chest radiography (CXR); Xpert MTB/RIF; Xpert Ultra; and combinations of these as screening tests for detecting active pulmonary childhood tuberculosis in the following groups. - Tuberculosis contacts, including household contacts, school contacts, and other close contacts of a person with infectious tuberculosis. - Children living with HIV. - Children with pneumonia. - Other risk groups (e.g. children with a history of previous tuberculosis, malnourished children). - Children in the general population in high tuberculosis burden settings.

SEARCH METHODS

We searched six databases, including the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase, on 14 February 2020 without language restrictions and contacted researchers in the field.

SELECTION CRITERIA

Cross-sectional and cohort studies where at least 75% of children were aged under 15 years. Studies were eligible if conducted for screening rather than diagnosing tuberculosis. Reference standards were microbiological (MRS) and composite reference standard (CRS), which may incorporate symptoms and CXR.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed study quality using QUADAS-2. We consolidated symptom screens across included studies into groups that used similar combinations of symptoms as follows: one or more of cough, fever, or poor weight gain and one or more of cough, fever, or decreased playfulness. For combination of symptoms, a positive screen was the presence of one or more than one symptom. We used a bivariate model to estimate pooled sensitivity and specificity with 95% confidence intervals (CIs) and performed analyses separately by reference standard. We assessed certainty of evidence using GRADE.

MAIN RESULTS

Nineteen studies assessed the following screens: one symptom (15 studies, 10,097 participants); combinations of symptoms (12 studies, 29,889 participants); CXR (10 studies, 7146 participants); and Xpert MTB/RIF (2 studies, 787 participants). Several studies assessed more than one screening test. No studies assessed Xpert Ultra. For 16 studies (84%), risk of bias for the reference standard domain was unclear owing to concern about incorporation bias. Across other quality domains, risk of bias was generally low. Symptom screen (verified by CRS) One or more of cough, fever, or poor weight gain in tuberculosis contacts (4 studies, tuberculosis prevalence 2% to 13%): pooled sensitivity was 89% (95% CI 52% to 98%; 113 participants; low-certainty evidence) and pooled specificity was 69% (95% CI 51% to 83%; 2582 participants; low-certainty evidence). Of 1000 children where 50 have pulmonary tuberculosis, 339 would be screen-positive, of whom 294 (87%) would not have pulmonary tuberculosis (false positives); 661 would be screen-negative, of whom five (1%) would have pulmonary tuberculosis (false negatives). One or more of cough, fever, or decreased playfulness in children aged under five years, inpatient or outpatient (3 studies, tuberculosis prevalence 3% to 13%): sensitivity ranged from 64% to 76% (106 participants; moderate-certainty evidence) and specificity from 37% to 77% (2339 participants; low-certainty evidence). Of 1000 children where 50 have pulmonary tuberculosis, 251 to 636 would be screen-positive, of whom 219 to 598 (87% to 94%) would not have pulmonary tuberculosis; 364 to 749 would be screen-negative, of whom 12 to 18 (2% to 3%) would have pulmonary tuberculosis. One or more of cough, fever, poor weight gain, or tuberculosis close contact (World Health Organization four-symptom screen) in children living with HIV, outpatient (2 studies, tuberculosis prevalence 3% and 8%): pooled sensitivity was 61% (95% CI 58% to 64%; 1219 screens; moderate-certainty evidence) and pooled specificity was 94% (95% CI 86% to 98%; 201,916 screens; low-certainty evidence). Of 1000 symptom screens where 50 of the screens are on children with pulmonary tuberculosis, 88 would be screen-positive, of which 57 (65%) would be on children who do not have pulmonary tuberculosis; 912 would be screen-negative, of which 19 (2%) would be on children who have pulmonary tuberculosis. CXR (verified by CRS) CXR with any abnormality in tuberculosis contacts (8 studies, tuberculosis prevalence 2% to 25%): pooled sensitivity was 87% (95% CI 75% to 93%; 232 participants; low-certainty evidence) and pooled specificity was 99% (95% CI 68% to 100%; 3281 participants; low-certainty evidence). Of 1000 children, where 50 have pulmonary tuberculosis, 63 would be screen-positive, of whom 19 (30%) would not have pulmonary tuberculosis; 937 would be screen-negative, of whom 6 (1%) would have pulmonary tuberculosis. Xpert MTB/RIF (verified by MRS) Xpert MTB/RIF, inpatient or outpatient (2 studies, tuberculosis prevalence 1% and 4%): sensitivity was 43% and 100% (16 participants; very low-certainty evidence) and specificity was 99% and 100% (771 participants; moderate-certainty evidence). Of 1000 children, where 50 have pulmonary tuberculosis, 31 to 69 would be Xpert MTB/RIF-positive, of whom 9 to 19 (28% to 29%) would not have pulmonary tuberculosis; 969 to 931 would be Xpert MTB/RIF-negative, of whom 0 to 28 (0% to 3%) would have tuberculosis. Studies often assessed more symptoms than those included in the index test and symptom definitions varied. These differences complicated data aggregation and may have influenced accuracy estimates. Both symptoms and CXR formed part of the CRS (incorporation bias), which may have led to overestimation of sensitivity and specificity.

AUTHORS' CONCLUSIONS

We found that in children who are tuberculosis contacts or living with HIV, screening tests using symptoms or CXR may be useful, but our review is limited by design issues with the index test and incorporation bias in the reference standard. For Xpert MTB/RIF, we found insufficient evidence regarding screening accuracy. Prospective evaluations of screening tests for tuberculosis in children will help clarify their use. In the meantime, screening strategies need to be pragmatic to address the persistent gaps in prevention and case detection that exist in resource-limited settings.

Lung MRI in Children: The Road Less Travelled

Magnetic resonance imaging (MRI) of the lungs is one of the most underutilized imaging modality when it comes to imaging of thoracic diseases in children. This is largely due to less-than-optimal image quality and multiple technical challenges involved with MRI of the lungs. Advances in MRI technology along with increased awareness about optimization of MR protocol have led to it being viewed as a feasible option for evaluation of various chest diseases in children. This short review article takes the reader to the road less travelled to explore newer horizons for applications of this rapidly evolving magnetic resonance technique in the field of thoracic diseases in children.

Miliary tuberculosis in a paediatric patient with psoriasis

We present a 16-year-old girl with a history of well-controlled psoriasis, on immunosuppression, who sought evaluation in the emergency department for 4 months of fever, cough and unintentional weight loss. The patient had seen multiple providers who had diagnosed her with community-acquired pneumonia, but she was unimproved after oral antibiotic therapy. On presentation, she was noted to be febrile, tachycardic and chronically ill-appearing. Her chest X-ray showed diffuse opacities and a right upper lobe cavitary lesion concerning for tuberculosis. A subsequent chest CT revealed miliary pulmonary nodules in addition to the cavitary lesion. The patient underwent subsequent brain MRI, which revealed multifocal ring-enhancing nodules consistent with parenchymal involvement. The patient was diagnosed with miliary tuberculosis and improved on quadruple therapy. Though rates of tuberculosis are increasing, rates remain low in children, though special consideration should be given to children who are immunosuppressed.

Chest imaging in paediatric pulmonary TB

Tuberculosis (TB) remains a significant cause of death from an infectious disease worldwide. The diagnosis of pulmonary TB in children is often challenging as children present with non-specific clinical symptoms, have difficulties providing specimens and have a low bacillary load. Radiological imaging supports a clinical diagnosis of pulmonary TB in children, can assess response to treatment and evaluate complications of TB. However, radiological signs on plain radiographs are often non-specific and inter-observer variability in the interpretation contribute to the difficulties in radiological interpretation and diagnosis. The goal of this review is to discuss the advantages and features of cross-sectional imaging such as ultrasound, Computed tomography (CT) and Magnetic resonance imaging (MRI) in diagnosing pulmonary TB (PTB) and its complications in children.

Chest Tuberculosis in Children

Chest is the commonest site of involvement by tuberculosis (TB) in children; lungs being the most frequently affected region, followed by nodes, pleura and chest wall. It is difficult to diagnose TB in children due to lack of overt symptoms and difficulty in obtaining samples for microbiological confirmation. Hence various imaging modalities play an important role in diagnostic algorithm as well as in follow-up after treatment. Standardization of chest radiograph reporting in context of clinically suspected TB is the need of the hour so as to suggest a proper diagnosis and avoid over-diagnosis. This article aims to discuss the imaging features of chest tuberculosis according to the site of involvement on various imaging modalities in the pediatric population.

Diagnostic Utility of 3T Lung MRI in Children with Interstitial Lung Disease: A Prospective Pilot Study

RATIONALE AND OBJECTIVES

The objective of this study was to assess the diagnostic utility of 3-tesla (3T) magnetic resonance imaging (MRI) of lungs in the detection of interstitial lung disease (ILD) in pediatric patients.

MATERIALS AND METHODS

Twelve children (mean: 8.5 years, range: 4-12 years) with ILD were consecutively enrolled in this prospective study. HRCT and 3T lung MRI were performed in all patients within 2 days of each other. The sensitivity, the specificity, the positive predictive value, and the negative predictive value of detecting lung abnormalities related to ILD with 3T lung MRI were calculated, with high-resolution computed tomography (HRCT) as a standard of reference. Agreement between HRCT and 3T lung MRI, as well as between two reviewers, was calculated with the kappa coefficient.

RESULTS

3T lung MRI had low sensitivity (66.67%) and high specificity (97.33%) in the detection of abnormalities related to ILD when compared to HRCT in children. Although 3T lung MRI performed well in the detection of consolidation, parenchymal bands and fissural thickening with a sensitivity of 100%, the sensitivity of 3T lung MRI in the detection of septal thickening, ground-glass opacity, nodules, and cysts was relatively low (50.0%, 50.0%, 66.67%, and 25.0%, respectively). Substantial agreement was seen between HRCT and 3T lung MRI (k = 0.7), whereas perfect agreement was seen between two reviewers in detecting abnormalities related to pediatric ILD (k = 0.9-1.0).

CONCLUSIONS

In comparison to HRCT, 3T lung MRI with routinely available MRI protocols and sequences can also well detect abnormalities such as consolidation, parenchymal bands, and fissural thickening in children with ILD. However, evaluation of septal thickening, ground-glass opacity, nodules, and cysts is limited with 3T lung MRI.