Thorax 2010;65:863-869 doi:10.1136/thx.2010.

136242

Tuberculosis

A simple, valid, numerical score for grading chest x-ray severity in adult smear-positive pulmonary tuberculosis
1. Anna P Ralph1,2, 2. Muhamed Ardian3,4,5, 3. Andri Wiguna4,5, 4. Graeme P Maguire6, 5. Niels G Becker2, 6. Glen Drogumuller7, 7. Michael J Wilks8, 8. Govert Waramori4, 9. Emiliana Tjitra9, 10. Sandjaja9, 11. Enny Kenagalem3,10, 12. Gysje J Pontororing10, 13. Nicholas M Anstey1,11, 14. Paul M Kelly1,2 + Author Affiliations 1. Global Health Division, Menzies School of Health Research and Charles Darwin University, Australia 2. 2National Centre for Epidemiology and Population Health Research, College of Medicine, Biology and Environment, Australian National University, Australia 3. 3District Health Authority, Timika, Papua Province, Indonesia 4. 4International SOS, Timika, Papua Province, Indonesia 5. 5Public Health & Malaria Control Department, PT Freeport Indonesia, Papua Province, Indonesia 6. 6School of Medicine and Dentistry, James Cook University, Queensland, Australia 7. 7Department of Radiology, Royal Darwin Hospital, Northern Territory, Australia 8. 8Radiology Department, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia 9. 9National Institute of Health Research and Development, Jakarta, Indonesia 10. 10Menzies School of Health Research-National Institute of Health Research and Development Research Program, and District Ministry of Health, Timika, Papua Province, Indonesia 11. 11Division of Medicine, Royal Darwin Hospital, Darwin, Australia 1. Correspondence to Dr Anna Ralph, International Health Division, Menzies School of Health Research, PO Box 41096, Casuarina, Northern Territory, 0811, Australia; anna.ralph@menzies.edu.au
1

Received 8 February 2010 Accepted 30 June 2010

Abstract
Background The grading of radiological severity in clinical trials in tuberculosis (TB) remains unstandardised. The aim of this study was to generate and validate a numerical score for grading chest x-ray (CXR) severity and predicting response to treatment in adults with smear-positive pulmonary TB. Methods At a TB clinic in Papua, Indonesia, serial CXRs were performed at diagnosis, 2 and 6 months in 115 adults with smear-positive pulmonary TB. Radiographic findings predictive of 2-month sputum microscopy status were used to generate a score. The validity of the score was then assessed in a second data set of 139 comparable adults with TB, recruited 4 years later at the same site. Relationships between the CXR score and other measures of TB severity were examined. Results The estimated proportion of lung affected and presence of cavitation, but not cavity size or other radiological findings, significantly predicted outcome and were combined to derive a score given by percentage of lung affected plus 40 if cavitation was present. As well as predicting 2-month outcome, scores were significantly associated with sputum smear grade at diagnosis (p<0.001), body mass index, lung function, haemoglobin, exercise tolerance and quality of life (p<0.02 for each). In the validation data set, baseline CXR score predicted 2month smear status significantly more accurately than did the proportion of lung affected alone. In both data sets, CXR scores decreased over time (p<0.001). Conclusion This simple, validated method for grading CXR severity in adults with smearpositive pulmonary TB correlates with baseline clinical and microbiological severity and response to treatment, and is suitable for use in clinical trials.

Scoring systems using chest radiographic features for the diagnosis of pulmonary tuberculosis in adults: a systematic review
1. 2. 3. 4. 5. 6. Lancelot M Pinto*,#, Madhukar Pai*,#, Keertan Dheda, Kevin Schwartzman*,+, Dick Menzies*,#,+ and Karen R Steingart

+ Author Affiliations 1. 2. 3. 4. 5.
*

Respiratory Epidemiology & Clinical Research Unit, Montreal Chest Institute, Montreal, Canada # Dept of Epidemiology and Biostatistics, McGill University, Montreal, Canada University of Cape Town Lung Institute, Cape Town, South Africa + Respiratory Division, Dept of Medicine, McGill University, Montreal, Canada Dept of Health Services, University of Washington School of Public Health, Seattle, USA

1. Karen R Steingart, Dept of Health Services, University of Washington School of Public Health, Seattle, USA, E-mail: karenst@uw.edu

Abstract
Chest radiography for the diagnosis of active pulmonary tuberculosis (PTB) is limited by poor specificity and reader inconsistency. Scoring systems have been employed successfully for improving the performance of chest radiography for various pulmonary diseases. We conducted a systematic review to assess the diagnostic accuracy and reproducibility of scoring systems for PTB. We searched multiple databases for studies that evaluated the accuracy and reproducibility of chest radiograph scoring systems for PTB. We summarized results for specific radiographic features and scoring systems associated with PTB. Where appropriate, we estimated pooled performance of similar studies using a random effects model. Thirteen studies were included in the review, nine of which were in low TB burden settings. No scoring system was based solely on radiographic findings. All studies used systems with various combinations of clinical and radiologic features. Eleven studies involved scoring systems that were used for making decisions concerning hospital respiratory isolation. None of the included studies reported data on intra-reporter or inter-reporter reproducibility. Upper lobe infiltrates (pooled diagnostic odds ratio [DOR] 3.57, 95% CI 2.38 to 5.37, five studies) and cavities (DOR range, 1.97 to 25.66, 3 studies) were significantly associated with PTB. Sensitivities of the scoring systems were high (median 96%, IQR 9398%), but specificities were low (median 46%, IQR 3550%).

Chest radiograph scoring systems appear useful in ruling-out PTB in hospitals, but their low specificity precludes ruling-in PTB. There is a need to develop accurate scoring systems for people living with HIV and for outpatient settings, especially in high TB burden settings.