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Comparison of chest radiographs against minimum intensity projection reconstruction computed tomography scans for detection of airway stenosis in children with lymphobronchial tuberculosis

  • Tuberculosis Minisymposium
  • Published:
Pediatric Radiology Aims and scope Submit manuscript

Abstract

Background

Ideally, suspected airway compression in symptomatic children with lymphobronchial tuberculosis (TB) would be diagnosed using modern computed tomography (CT) assisted by coronal minimum intensity projection (MinIP) reconstructions. However, in TB-endemic regions with limited resources, practitioners rely on conventional radiography for diagnosing TB and its complications. Furthermore, airway compression detected on conventional radiographs would upgrade a patient into the severe category according to the new World Health Organization guidelines, precluding the patient from shorter treatment protocols. The accuracy of conventional radiographs in the context of detecting airway compression in children with TB has not been specifically evaluated against an imaging gold standard.

Objective

We aimed to compare frontal chest radiographs against thick-slab angled coronal CT MinIP in identifying airway stenosis at ten specific sites and to determine observer agreement between the modalities regarding the degree of stenosis.

Materials and methods

This retrospective cross-sectional study compared chest radiographs with standardized angled coronal CT MinIP in children with symptomatic lymphobronchial TB at ten predetermined airway locations. Chest radiographs were evaluated by one pediatric radiologist and CT MinIP reconstructions were independently interpreted by three readers. Sensitivity and specificity were calculated using CT MinIP as the gold standard. Stenosis was graded as 1 for mild (1–50%), 2 for moderate (51–75%), 3a for severe (76–99%), and 3b for total occlusion (100%). Agreement between the two modalities regarding severity of stenosis was calculated using the kappa coefficient for each affected site.

Results

A total of 37 patients were included in the study. The median age of patients was 14.3 months (interquartile range 8.0–23.2). Three hundred and seventy individual bronchi (10 from each of the 37 patients) were evaluated for stenosis. Chest radiographs showed that 31 out of 37 (84%) patients had stenosis in at least one of ten evaluated sites, most commonly the left main bronchus and bronchus intermedius, and this was confirmed via CT MinIP. The gold standard (CT MinIP) demonstrated stenosis in at least one of ten sites in all 37 patients (100%). Left main bronchus stenosis was detected by chest radiography with a 92.9% sensitivity and 100% specificity. Sensitivity and specificity for bronchus intermedius stenosis were 80% and 75%, respectively. There was substantial agreement for grade of stenosis between chest radiographs and CT (kappa=0.67) for the left main bronchus and moderate agreement (kappa=0.58) for the bronchus intermedius. Severe stenosis was found in 78 bronchi on CT compared to 32 bronchi (Grade 3a: 9, Grade 3b: 23) on chest radiographs.

Conclusion

The diagnosis of pulmonary TB in children continues to rely heavily on imaging, and we have shown that in young children, chest radiographs had a high sensitivity and specificity for detecting airway stenosis at certain anatomical sites, when adequately visualized, resulting from tuberculous lymph node compression at left main bronchus and bronchus intermedius. For most sites, the interobserver agreement was poor. Stenosis of the left main bronchus and bronchus intermedius should be the focus of chest radiograph interpretation and can assist both diagnosis and classification of patients for treatment.

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Data availability

The data presented in this study is available on reasonable request from the corresponding author.

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Authors and Affiliations

  1. Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA

    Shyam Sunder B. Venkatakrishna & Savvas Andronikou

  2. Department of Diagnostic Radiology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

    Dewald Bester & Susan Lucas

  3. Department of Radiology, University of Texas Health Science Center at San Antonio - UT Health San Antonio, San Antonio, TX, USA

    Juan S. Calle-Toro

  4. Waikato District Health Board, Waikato Hospital, Hamilton, New Zealand

    Ahmed Omar Ali Krim

  5. Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa

    Pierre Goussard

  6. Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Savvas Andronikou

Authors
  1. Shyam Sunder B. Venkatakrishna
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  2. Dewald Bester
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  3. Juan S. Calle-Toro
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  4. Susan Lucas
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  5. Ahmed Omar Ali Krim
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  6. Pierre Goussard
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  7. Savvas Andronikou
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Contributions

S.A. conceived the study and design. D.B., A.O.A.K., and S.A. performed data collection. S.S.B.V., D.B., S.L., A.O.A.K., and S.A. performed data analysis. S.S.B.V., D.B., S.L., A.O.A.K., and S.A. drafted the initial manuscript. J.S.C.T. and P.G. assisted with edits and review of the drafts. S.S.B.V. and S.A. performed reviews and revisions. All authors reviewed and approved the final manuscript.

Corresponding author

Correspondence to Savvas Andronikou.

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Venkatakrishna, S.S.B., Bester, D., Calle-Toro, J.S. et al. Comparison of chest radiographs against minimum intensity projection reconstruction computed tomography scans for detection of airway stenosis in children with lymphobronchial tuberculosis. Pediatr Radiol 54, 596–605 (2024). https://doi.org/10.1007/s00247-023-05809-0

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  • DOI: https://doi.org/10.1007/s00247-023-05809-0

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