Jump to comment:

• Terminology can be life-threatening
  oscar,m jolobe
  Published on: 31 October 2018

• Published on: 31 October 2018

  Terminology can be life-threatening

  • oscar,m jolobe, retired geriatrician manchester medical society

  The terminology of the chest x-ray report can, indeed, impact on the timeliness of the eventual validation of the diagnosis of pulmonary tuberculosis, as shown by the case report of a 75 year old man who was originally admitted with fever and backache. Chest x-ray showed "fibronodular infiltration of the left apex of the lung" (1). On the basis of magnetic resonance imaging, backache was attributed to osteomyelitis, and he was treated with antibiotics, and there was no "work-up" of the fibronodular infiltration of the lung apex. Over a period of two weeks fever persisted, and he became pancytopenic. However, it was only after a further 3 weeks, when pancytopenia became more severe, that bone marrow aspiration and bone marrow biopsy was performed. The latter showed epitheloid granulomas and acid fast bacilli. Polymerase chain reaction analysis of the bone marrow specimens was positive for M tuberculosis DNA, and his sputum was culture positive for M tuberculosis. Although antituberculous chemotherapy was initiated immediately after the bone marrow results he died 3 days after commencing treatment (2).
  Comment
  Arguably, if the term "tuberculosis" had been used to qualify the nodular infiltration seen on chest x-ray, that would have raised the index of suspicion for tuberculosis (TB), and computed tomography might have been utilised to characterise the nodularity as being TB-related (2). Two weeks later, in the light of that heightene...

  Show More

  The terminology of the chest x-ray report can, indeed, impact on the timeliness of the eventual validation of the diagnosis of pulmonary tuberculosis, as shown by the case report of a 75 year old man who was originally admitted with fever and backache. Chest x-ray showed "fibronodular infiltration of the left apex of the lung" (1). On the basis of magnetic resonance imaging, backache was attributed to osteomyelitis, and he was treated with antibiotics, and there was no "work-up" of the fibronodular infiltration of the lung apex. Over a period of two weeks fever persisted, and he became pancytopenic. However, it was only after a further 3 weeks, when pancytopenia became more severe, that bone marrow aspiration and bone marrow biopsy was performed. The latter showed epitheloid granulomas and acid fast bacilli. Polymerase chain reaction analysis of the bone marrow specimens was positive for M tuberculosis DNA, and his sputum was culture positive for M tuberculosis. Although antituberculous chemotherapy was initiated immediately after the bone marrow results he died 3 days after commencing treatment (2).
  Comment
  Arguably, if the term "tuberculosis" had been used to qualify the nodular infiltration seen on chest x-ray, that would have raised the index of suspicion for tuberculosis (TB), and computed tomography might have been utilised to characterise the nodularity as being TB-related (2). Two weeks later, in the light of that heightened index of suspicion for TB, the subsequent development of pancytopenia might have raised the index of suspicion for disseminated tuberculosis, and bone marrow studies would have been initiated at that stage. Instead there was a further 3 weeks delay before the appropriate work-up for TB "kicked in" (1).
  In the United States it is already recognised that delays in diagnosis of pulmonary TB are, in part, responsible for the paradox whereby population subgroups, such as white Americans, those in employment, and the US-born (all of them with background pulmonary TB rates of < 2 per 100,000 of the 2006 population) had higher 13-year increases in prevalence of cavitating tuberculosis than counterparts with higher background pulmonary TB rate (3). Might this phenomenon be attributable to greater prevalence of non-specific characterisation of chest x-ray images antedating cavitation in white, affluent, US-born citizens?

  References
  (1) Chien C-C., Chiou T-J., Lee M-Y., Hsiao L-T., Kwang W-K
  Tuberculosis associated hemopahgocytic syndrome in a hemodialysis patient with protracted fever
  International Journal of Hematology 2004;79:334-336
  (2) Yoy M., Ellis S
  Radiological diagnosis and follow up of pulmonary tuberculosis
  Thorax 2010;86;663-674
  (3)Wallace RM., Kammerer JS., Iademarco MF. et al
  Increasing proportions of advanced pulmonary tuberculosis reported in the United States. Are delays in diagnosis on the rise?
  Am J Respir Crit Care Med 2009;180:1016-1022

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top