Skip to main content
Log in

Noninvasive testing of asymptomatic bilateral hilar adenopathy

  • Original Articles
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

The diagnostic strategy for asymptomatic patients with persistent bilateral bilar adenopathy often involves invasive procedures. The authors used Bayesian analysis to: 1) estimate the relative prevalences of diseases causing bilateral bilar adenopathy; 2) assess changes in the prevalence of disease by race, the presence of other clinical symptoms, and geography; and 3) determine the value of relevant noninvasive tests, including the angiotensin-coverting enzyme (ACE) assay, gallium scan, and purified protein derivative (PPD), in order to assess when a strategy of watchful waiting is appropriate. The analysis indicated that the ACE assay, particularly when paired with the PPD, can identify many patients who might safely be managed without immediate invasive biopsy. Patients who are ACE+ and PPD− have an estimated probability of sarcoidosis of 0.95 or greater; patients who are ACE− and PPD+ have a probability of tuberculosis of 0.86 if black, 0.79 if white. In contrast, gallium scanning has no diagnostic role in this clinical situation. Bronchoscopic or mediastinoscopic biopsy has a limited role for patients who are ACE+ PPD− or ACE− PPD+ because of limited sensitivity. Patients who are both ACE− and PPD−, particularly if white, may have a high enough risk of lymphoma to consider invasive biopsy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. McLoud TC, Meyer JE. Mediastinal metastases. Radiol Clin North Am. 1982;20:453–68.

    PubMed  CAS  Google Scholar 

  2. Fraser RG, Pare JAP. Synopsis of diseases of the chest. Philadelphia: W.B. Saunders, 1983:643.

    Google Scholar 

  3. Freidman GD. Primer of epidemiology. 2nd ed. New York: McGraw-Hill, 1980:93.

    Google Scholar 

  4. Winterbauer RH, Belic N, Moores K. A clinical interpretation of bilateral hilar adenopathy. Ann Intern Med. 1973;78:65–71.

    PubMed  CAS  Google Scholar 

  5. Hodgson CH, Olsen AM, Good CA. Bilateral hilar adenopathy: its significance and management. Ann Intern Med. 1955;43:83–99.

    PubMed  CAS  Google Scholar 

  6. Fraser RG, Pare JAP. Synopsis of diseases of the chest. Philadelphia: W.B. Saunders, 1983;42:410

    Google Scholar 

  7. Peters MV. A study of survival in Hodgkin’s Disease treated radiologically. Am J Roentgenol. 1950;63:304.

    Google Scholar 

  8. Mandell G, Douglas G, Bennett J. Principles and practice of infectious diseases. New York: John Wiley and Sons, 1979:1910.

    Google Scholar 

  9. Fraser RG, Pare JAP. Synopsis of diseases of the chest. Philadelphia: W.B. Saunders, 1983:326.

    Google Scholar 

  10. Fraser RG, Pare JAP. Synopsis of diseases of the chest. Philadelphia: W.B. Saunders, 1983:337.

    Google Scholar 

  11. Lander P, Palayew MJ. Infectious mononucleosis: a review of chest roentgenographic manifestations. J Can Assoc Radiol. 1974;25:303–6.

    PubMed  CAS  Google Scholar 

  12. James IDG. Erythema nodosum. Br Med J. 1961;1:853.

    PubMed  CAS  Google Scholar 

  13. Abrams DI, Lewis BJ, Beckstead JH, Casavant CA, Drew WL. Persistent diffuse lymphadenopathy in homosexual men: endpoint or prodrome? Ann Intern Med. 1984;100:801–8.

    PubMed  CAS  Google Scholar 

  14. Stern RG, Gamsu G, Golden JH, Hirji M, Webb WR, Abrams DI. Intrathoracic adenopathy: differential feature of AIDS and diffuse lymphadenopathy syndrome. Am J Radiol. 1984;142:489–92.

    Google Scholar 

  15. Mandell G, Douglas G, Bennett J. Principles and practice of infectious diseases. New York: John Wiley and Sons, 1979:1926.

    Google Scholar 

  16. Sartwell PE, Edwards LB. Epidemiology of sarcoidosis in the U.S. Navy. Am J Epidemiol. 1974;99:250–7.

    PubMed  CAS  Google Scholar 

  17. Robbins AB, Abeles H, Chaves AD. Prevalence and demographic characteristics of sarcoidosis in New York City. Acta Med Scand. 1963;176:149–51.

    Article  Google Scholar 

  18. Fishman AP. Pulmonary diseases and disorders. New York: McGraw-Hill, 1980:890.

    Google Scholar 

  19. Gentry JT, Nitowsky HM, Michael M. Studies on the epidemiology of sarcoidosis in the United States: the relationship to soil areas and to urban-rural residence. J Clin Invest. 1955;34:1853.

    Google Scholar 

  20. Tierstein AS, Siltzbach LE, Gabelman M, Lesser M. Socioeconomic factors influencing epidemiologic data in sarcoidosis among a mixed urban population. Sarcoidosis and other granulomatosis disorders. Paris: Ninth International Conference, August 31st–September 4th, 1981. Chretien J, pp 234–6.

  21. Fitzpatrick TB, Arndt KA, Clark WH, Eisen AZ, Van Scott EJ, Vaughan JH. Dermatology in general medicine. New York: McGraw-Hill, 1971:785.

    Google Scholar 

  22. Scheie HG, Albert DM. Textbook of Ophthalmology. 9th ed. Philadelphia: W.B. Saunders, 1977:1584.

    Google Scholar 

  23. Centers for Disease Control. Tuberculosis, final data-1986. MMMR. 1988;36:817.

    Google Scholar 

  24. Fraser RG, Pare JAP. Diagnosis of diseases of the chest. Second edition. Philadelphia: W.B. Saunders, 1977:741.

    Google Scholar 

  25. Khan MA, Kovnat DM, Bachus B, Whitcomb ME, Brody JS, Snider GL. Clinical and roentgenographic spectrum of pulmonary tuberculosis in the adult. Am J Med. 1977;62:31–8.

    Article  PubMed  CAS  Google Scholar 

  26. Fraser RG, Pare JAP. Synopsis of diseases of the chest. Philadelphia: W.B. Saunders, 1983:291.

    Google Scholar 

  27. Centers for Disease Control. Tuberculosis in the U.S. DHEW publication no. (CDC) 77–8322, August 1977.

  28. Weinstein L. Erythema nodosum. DM. 1969;6:1–30.

    Google Scholar 

  29. Scheie HG, Albert DM. Textbook of Ophthalmology. 9th ed. Philadelphia: W.B. Saunders, 1977:1594.

    Google Scholar 

  30. National Institutes of Health. Cancer rates and risks. Second ed. DHEW publication no. (NIH 75-691), 1974.

  31. Wintrobe MM. Clinical hematology. 9th ed. Philadelphia: Lea and Febiger, 1981:1689.

    Google Scholar 

  32. Chalmer RF. Erythema nodosum and Hodgkin’s disease. Br J Dermatol. 1982;106:593–6.

    Article  Google Scholar 

  33. Holland JF, Frei E III. Cancer medicine. Philadelphia: Lea and Febiger, 1973:1314.

    Google Scholar 

  34. Wheat LJ, Slama JG, Eitzen HE, Kohler RB, French MLC, Biesecter JL. A large urban outbreak of histoplasmosis: clinical features. Ann Intern Med. 1981;94:331–7.

    PubMed  CAS  Google Scholar 

  35. U.S. Bureau of the Census. Statistical abstract of the United States: 1982–83. 103rd ed. Washington, D.C., 1982:10–3.

  36. Goodwin RA, Des Prez RM, Ryder KW, Lehan PH, Furcolou ML. Epidemic histoplasmosis. J Chronic Dis. 1957;5:489–503.

    Article  Google Scholar 

  37. Goodwin RA, Des Prez RM. Personal communication.

  38. Fraser RG, Pare JAP. Diagnosis of the chest. 2nd ed. Philadelphia: W.B. Saunders, 1977:774.

    Google Scholar 

  39. Mandell G, Douglas G, Bennett J. Principles and practice of infectious diseases. New York: John Wiley and Sons, 1979:2054.

    Google Scholar 

  40. U.S. Bureau of the Census. Statistical abstract of the United States: 1982–83. 103rd ed. Washington, D.C., 1982:12.

  41. Galgiani JN. Personal communication.

  42. Drutz DJ, Catanzaro A. Coccidioidomycosis: state of the art. Am Rev Respir Dis. 1978;117:732.

    Google Scholar 

  43. Siemsen JK, Grebe SJ, Waxman AS. The use of gallium-67 in pulmonary disorders. Semin Nucl Med. 1978;VIII:3.

    Google Scholar 

  44. Fanburg BL. Serum angiotensin 1-converting enzyme in the diagnosis and determination of activity of sarcoidosis. In: Williams WJ, Davies BH, eds. Sarcoidosis and other granulomatous diseases. Cardiff Wales Alpha Omega Press, 1980;266–72.

  45. Romer FK, Emmertsen K. Serum angiotensin-converting enzyme in malignant lymphomas, leukemia and multiple myeloma. Br J Cancer. 1980;42:314–8.

    PubMed  CAS  Google Scholar 

  46. De Remee RA, Banks PM. Non-Hodgkin’s lymphoma associated with hypercalcemia and increased activity of serum angiotensinconverting enzyme. Mayo Clin Proc. 1098;61:714–8.

    Google Scholar 

  47. Lieberman J, Nosal A, Schlessher LA, Sastre-Foken A. Serum angiotensin-converting enzyme for diagnosis and therapeutic evaluation of sarcoidosis. Am Rev Respir Dis. 1979;120:329–5.

    PubMed  CAS  Google Scholar 

  48. Lieberman J, Rea TH. Serum angiotensin-converting enzyme in leprosy and coccidioidomycosis. Ann Intern Med. 1977;87:422–5.

    CAS  Google Scholar 

  49. Ryder KW, Jay SJ, Kiblawi SO, Hall MJ. Serum angiotensin-converting enzyme activity in patients with histoplasmosis. JAMA. 1983;294:1888–9.

    Article  Google Scholar 

  50. Kaupas V. Tuberculosis in a family day care home. JAMA. 1974;228:851–4.

    Article  PubMed  CAS  Google Scholar 

  51. Mandell B, Douglas G, Bennett J. Principles and practice of infectious diseases. New York: John Wiley and Sons, 1979:1931, 1927.

    Google Scholar 

  52. Centers for Disease Control. PHS/CDC 1975 Tuberculosis in the United States. U.S. DHEW publication no. (CDC) 77-8322, August 1977:20.

  53. Advani SH, Dinshaw KA, Nair CN, et al. Immune dysfunction in non-Hodgkin’s lymphoma. Cancer. 1980;45:2843–8.

    Article  PubMed  CAS  Google Scholar 

  54. Siltzbach LE, James DG, Neville E, et al. Course and prognosis of sarcoidosis around the world. Am J Med. 1974;57:851.

    Article  Google Scholar 

  55. Buechner HA, Seabury JH, Campbell CC, Geoge LK, Kaufman L, Kaplan W. The current status of serologic, immunologic and skin tests in the diagnosis of pulmonary mycosis. Chest. 1975;63:262.

    Google Scholar 

  56. Hubert M, Peterson ET, Sun SH. Evaluation of a latex particle agglutination test for coccidioidomyosis. Am J Clin Pathol. 1968;49:6.

    Google Scholar 

  57. Buechner HA, Seabury TH, Campbell CC, George LK, Kaufman L, Kaplan W. The current status of serologic, immunologic and skin tests in the diagnosis of pulmonary mycoses. Chest. 1973;63:264.

    Google Scholar 

  58. Johnson JE, De Remee RA, Kueppers F, Roberts GD. Prevalence of fungal, complement-fixing antibodies in sarcoidosis. Am Rev Respir Dis. 1977;116:145–7.

    PubMed  CAS  Google Scholar 

  59. Furculow ML, Schubert J, Josh JE, Doto IL, Lynch HJ. Serologic evidence of histoplasmosis in sanatoriums in the U.S. JAMA. 1962;180:113.

    Google Scholar 

  60. Koontz CH, Toyner LR, Nelson RA. Transbronchial lung biopsy via the fiberoptic bronchoscope in sarcoidosis. Ann Intern Med. 1976;85:64–6.

    Google Scholar 

  61. Gilman MJ, Wang KP. Transbronchial lung biopsy in sarcoidosis: an approach to determine the optimal number of biopsies. Am Rev Respir Dis. 1980;122:721–4.

    PubMed  CAS  Google Scholar 

  62. Phillips MJ, Knight RK, Green M. Fiberoptic bronchoscopy and diagnosis of pulmonary lesions in lymphoma and leukemia. Thorax. 1980;35:19–25.

    PubMed  CAS  Google Scholar 

  63. Fiberoptic bronchoscopy and sputum-negative tuberculosis. Lancet. 1983;1:337–8.

  64. Lukomsky GI, Ovchinnikov AA, Bilal A. Complications of bronchoscopy. Chest. 1981;79:316–21.

    PubMed  CAS  Google Scholar 

  65. Carlen E. Scientific papers of the American Broncho-Esophagological Association: mediastinoscopy. Ann Otol Rhinol Laryngol. 1965;74:1102–12.

    Google Scholar 

  66. Cameron EWJ. Tuberculosis and mediastinoscopy. Thorax. 1978;33:117–20.

    Article  PubMed  CAS  Google Scholar 

  67. Welsh LW, Welsh JJ. Mediastinoscopy: application for hilar adenopathy. Laryngoscope. 1973;83:576–86.

    Article  PubMed  CAS  Google Scholar 

  68. Feigal DW, Blaisdell JW. The estimation of surgical risk. Med Clin North Am. 1979;63:1131.

    PubMed  CAS  Google Scholar 

  69. Elliott RC, Boyd AD, Snyder W, Meese EH. Mediastinoscopy. Am Rev Respir Dis. 1967;96:981–9.

    PubMed  CAS  Google Scholar 

  70. Elliott RC, Boyd AD, Snyder W, Meese EH. Mediastinoscopy. Am Rev Respir Dis. 1967;96:986.

    Google Scholar 

  71. Weinstein MC, Fineberg HV. Clinical decision analysis. Philadelphia: W.B. Saunders Company, 1980:153.

    Google Scholar 

  72. Pauker SG, Kassirer JP. The threshold approach to clinical decision making. N Engl J Med. 1980;302:1109–17.

    Article  PubMed  CAS  Google Scholar 

  73. McLoud TC, Meyer JE. Mediastinal metastases. Radiol Clin North Am. 1982;20:467.

    Google Scholar 

  74. Stiris MG, Borthwick R. Computed tomography (CT) evaluation in pulmonary sarcoidosis. Eur J Radiol. 1981;1:16–9.

    PubMed  CAS  Google Scholar 

  75. Aronberg DJ, Glazer HS, Sagel SS. MRI and CT of the mediastinum: comparisons, controversies, and pitfalls. Radiol Clin North Am. 1985;3:440.

    Google Scholar 

  76. Ward JW, Grindon AJ, Feorino PM, Schable C, Parvin M, Allen JR. Laboratory and epidemiologic evaluation of an enzyme immunoassay for antibodies to HTLV-III. JAMA. 1986;256:357–61.

    Article  PubMed  CAS  Google Scholar 

  77. Groopman JF, Chen FW, Hope JA, et al. Serologic characterization of HTLV-III infection in AIDS and related disorders. J Infect Dis. 1986;153:736–42.

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Rights and permissions

Reprints and permissions

About this article

Cite this article

Carr, P.L., Singer, D.E., Goldenheim, P. et al. Noninvasive testing of asymptomatic bilateral hilar adenopathy. J Gen Intern Med 5, 138–146 (1990). https://doi.org/10.1007/BF02600516

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF02600516

Key words

Navigation