Radiological manifestations of thoracic tuberculosis, a study in Damascus Hospital

doi:10.21203/rs.3.rs-3873597/v1

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Radiological manifestations of thoracic tuberculosis, a study in Damascus Hospital

https://doi.org/10.21203/rs.3.rs-3873597/v1

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Objective: To review the radiological manifestations of thoracic tuberculosis.

Study design: A cross-sectional study in the period between January 1\1\2023 and January 1\1\2024.

Setting: Damascus (Al-Mujtahid) Hospital, Damascus, Syria

Patients: Eight hundred and fifty-nine patients had pulmonary tuberculosis.

Results: The ratio of males/females was approximately 2/1, the percentage of chronic cough producing phlegm was 87%, the percentage of positive tuberculin reaction test was 95%, the percentage of upper lobes being infected with tuberculosis was 86%, and the percentage of presence of angulation mark on CT and chest images (67%, 54%). ) respectively, and the sign of pleural effusion (85%, 60%) respectively, and pericardial effusion (15%, 35 respectively), the density of pleural fluid more than 20 units is the highest 65%, the percentage of presence of Conn's complex on the tomography is 95%, while The chest image was 77%, and the second stage cases represented 34%. The percentage of upper lobe involvement with primary tuberculosis was 85%. The percentage of nodular hyperplasia on the chest image was 77%, while on the axial tomography it was 98%. Nodules measuring 15-20 mm are the most common, and the percentage of nodules Hypodense phlegmon is the highest (75%), the percentage of nodules showing peripheral enhancement is the highest (87%), the percentage of phlegmatic nodules in the right umbilicus is the highest (98%), most of the phlegmatic nodules were distributed in the umbilicus at a rate of 66%, and the percentage of lobular condensation is The highest percentage is (55%), the percentage of calcification is the highest (70%), the percentage of the presence of a single cave is the highest (75%), and the percentage of the presence of 1-3 mm smoking nodules is the highest (97%).

Conclusion: Although significant improvements have been made in the diagnosis and treatment of TB over the past three decades, TB remains one of the deadliest infectious diseases worldwide. TB is still present in all regions of the world, and has a greater impact in developing countries. Review This research examines the most common imaging manifestations of primary and post-primary tuberculosis, their complications, and the crucial role of imaging in diagnosing and following up infected patients.

Pulmonology

Radiological manifestations

pulmonary tuberculosis

Damascus Hospital

Introduction

March 24 is World Tuberculosis Day, which is considered the oldest disease known to humanity and is still one of the causes of death around the world. It is usually associated with poor societies and is responsible for the largest number of deaths related to infectious diseases in adults, as about 10 million new cases appear annually. It is still Controlling the disease is a major challenge in large parts of the world. However, Syria has made noteworthy strides in combating tuberculosis through several initiatives such as the National Tuberculosis Control Program in 1991 and the United Nations Development Support Structure in 2006. These efforts have led to a decline in infection rates from 86 One new case per 100,000 individuals in 1990 to only 23 cases per 100,000 individuals in 2006. Since 2011, many factors have contributed to the spread of the disease again, including displacement and overpopulation, which is a major risk factor for the transmission of tuberculosis, lack of sterilization methods and food, and damage caused This has affected the health system and the lack of diagnostic methods, despite it being reported that the number of new cases reached approximately 3,800 cases in 2021, according to the Syrian Health Organization, at a rate of 18 cases per 100,000 people, which is less than before. The decrease in the number of new infections may be the reason for the decline in methods. Detection of the disease. In Damascus, modern diagnostic methods are available that are not available in the rest of the governorates, because relying on x-ray imaging and the appearance of symptoms alone is not sufficient to establish a diagnosis and does not detect infections that require treatment, in addition to the lack of experience in the field of tuberculosis in Syria after 2011.Dealing with infections to treat tuberculosis represents a major reality in Syria, especially in the northwestern regions of Syria, where ideal conditions are suitable for the development of resistance. On the other hand, after it was a standard procedure in infant care, the administration of the tuberculosis vaccine (BCG) has deteriorated, as recent data showed a decrease from 99% in the year 2011 to only 66% in 2017, Tuberculosis is considered one of the most dangerous infectious diseases that has spread again in recent times. After more than 40 years of controlling this disease and the decline in death rates resulting from infection to the lowest levels, it has returned to constitute a threat threatening humanity and annually causes the death of increasing numbers of people in various countries. parts of the world, The following factors are considered the most important reasons for the re-spread of tuberculosis from one another at the global level:

1- The spread of AIDS infection worldwide, as there is a large percentage that does not share AIDS with tuberculosis, which causes deaths.

2- The inadequate level of health services and weak anti-tuberculosis programs in many countries of the world, and failure to treat patients with tuberculosis with appropriate medications or failure to complete the treatment period may lead to the emergence of new types of bacilli that are resistant to traditional medications.

The most dangerous types of tuberculosis bacilli are those known as drug-resistant tuberculosis:

Multidrug – resistant TB (M.DR – TB)

This type has begun to increase in some countries, especially the Soviet Union and third world countries, especially India and Bangladesh.

It is scientifically known that not giving a TB patient treatment is much better than giving him inappropriate or incomplete treatment, as the latter leads to the transformation of TB microbes into the drug-resistant type, which spreads from the patient to his contacts, and thus the spread of drug-resistant TB cases increases.

Treating treatment-resistant types of tuberculosis takes longer, exhausts many resources and efforts, and constitutes a major burden on patients and the state.

3- Movement between individuals and groups has increased, as the movement of people has increased in recent decades between countries and societies, whether for the purpose of trade or for other reasons, as well as the increase in the number of refugees and mass displacement, which has contributed to the spread of tuberculosis, as well as the increase in groups of homeless people in the late last century. The World Health Organization has alerted to this coming danger. Specifically, in 1993, it launched an unprecedented initiative to declare tuberculosis (a global emergency), and the World Health Organization announced that the number of people infected with tuberculosis is expected to rise until 2023, with one and a half billion people infected with tuberculosis. (1,2,3).

Study design:

A cross-sectional descriptive study to identify the radiological manifestations of pulmonary tuberculosis, among patients who visited Damascus Hospital during the period 1/1/2023 and 1/1/2024.

Patients:

The study included 859 patients who were admitted to Damascus Hospital with a diagnosis of pulmonary tuberculosis.

Methods:

A group of patients who were admitted to Damascus Hospital were studied according to the following inclusion criteria.

All patients with pulmonary tuberculosis.

Accepting patients who have symptoms and signs suggesting a diagnosis of pulmonary tuberculosis or who have clinical and radiological suspicion of it.

While the exclusion criteria were as follows:

Patients with lung cancer, asthma, pulmonary infections other than tuberculosis, and chronic lung diseases whose diagnosis is mixed with tuberculosis.

Damaged patient records and records in which there is insufficient information to serve our study.

Information was collected according to the research form to set the inclusion and exclusion criteria. Information was recorded in detail, which included: gender, clinical symptoms, and results of the chest and CT scan. All required measurements were taken with the equipment present in the hospital, and the radiological signs that were monitored with the help of medical radiology reports and a radiologist. A radiologist and a thoracic internist. Pulmonary condensation, cavitation, granuloma formation, miliary tuberculosis, pleural effusion, lymphadenopathy, pericardial effusion, and the presence of a parenchymal nodule or using the term pulmonary mass according to radiological and thoracic sources was considered a measurement or diameter of the lesion less than 3 cm or 30 mm as a parenchymal nodule. While a lesion diameter greater than 3 cm or 30 mm was considered a pulmonary mass.

Statistical analysis methods used:

The data was completed from the forms into an Excel file, and special simple statistics were conducted. The results were summarized and explained with tables and charts. The Spss-28 statistics program was used, and descriptive statistics were reviewed based on percentages and graphical shapes, in addition to measures of central tendency (arithmetic mean and standard deviation).statistical analysis

Ethical considerations:

Ethical approval was obtained from the Institutional Review Board (IRB) Faculty of Medicine, Syrian Private University and director of Damascus Hospital.

The number of males was (559), with a percentage of (65%), while the number of females was (300), with a percentage of (35%). The percentage of the presence of a chronic cough that produces sputum was 87%, the percentage of the presence of a chronic non-sputum-producing cough was 23%, and the percentage of the presence of respiratory depression. Non-continuous 55%, the percentage of fever raises with sweating was 57%, the percentage of general fatigue and weakness was 66%, and the percentage of lack of appetite to varying degrees was 75%. It was found that 95% of the patients had a positive test for tuberculin, while 5% of the patients had Negative tuberculin test, a simple X-ray was done for 100% of patients, a CT scan was done for 100% of patients, a simple chest X-ray was done for monitoring in 88% of patients, and a simple chest X-ray was done after treatment to confirm recovery in 95%. The rate of involvement of the pulmonary lobes radiographically, as it was found that the rate of involvement of the pulmonary lobes was 86%, and the rate of involvement of more than one lung lobe was 65%. The sign of bronchial angulation appeared in 67% on a plain chest X-ray, 54% on a CT scan, and the percentage of pleural effusions on a CT scan. The percentage of pleural effusions on a CT scan is 85%, the percentage of pericardial effusions on a simple chest scan is 3%, and the percentage of pericardial effusions on a CT scan is 15%. The percentage of patients with a pleural fluid density of less than 10 units is 10%. While the percentage of patients who had a pleural fluid density of 10 to 20 units was 25%, and the percentage of patients who had a pleural fluid density of more than 20 units was 65%, and all patients who had a pericardial effusion had a density of more than 20 units. The study of the stages of tuberculosis on radiology shows We have: The first stage: The infection lasts from 3 to 8 weeks in 66%, and it was diagnosed radiographically with a complex complex. An alveolar complex with lymph node involvement was seen on the plain chest x-ray in 77%, while on a CT scan in 95% of the first-stage cases.The second phase lasted for about 3 months, where plain chest radiographs and CT scans showed tuberculous millet lesions. Cases in the second phase constituted 34%, and from this sample, the presence of tuberculous millet nodules was noted on the entire plain scan and CT scan for all patients in this stage. The third phase, in which the active infection appeared to extend up to 7 months, and some cases continued up to 1.5 years, when the pleural infection appeared radiographically.Primary tuberculosis: The rate of involvement of the upper lobe on both sides is 85%, the rate of involvement of the middle lobe is 10%. The accuracy of the simple image does not generally show all radiological cases diagnosed with tuberculosis and does not exceed 75% according to our study, and it matches international studies that reached 76% in the most prestigious centers. High-resolution multi-slice CT, the accuracy and sensitivity exceed 96%. The detection rate of enlarged umbilical lymph nodes on a simple chest X-ray is 77%, the percentage on CT is 98%, and the remaining percentage is due to the lack of technical quality of the CT scan (technical defect), and enlarged phlegmatic nodes in both navels by 95% Enlarged phlegmatic nodes in a single umbilicus 5%, the diameters of phlegm nodules detected by CT were distributed as follows: where the percentage of presence of phlegm nodules on the CT image with a diameter of 5–7 mm is 10%, the percentage of presence of phlegm nodules on the CT image with a diameter of 7–10 mm is 12%, and the percentage of presence of nodules on the CT image with a diameter of 7–10 mm is 12%. Phlegm on a CT scan with a diameter of 10–15 mm is 55%, and the percentage of presence of phlegm nodules on a CT scan with a diameter of 15–20 mm is 63%, the percentage of presence of high-density phlegm nodules is 10%, while the percentage of presence of low-density phlegm nodules is 75%, and the percentage of presence of nodules Phlegmatic caseous 15%, the presence of umbilical phlegmatic nodes without contrast enhancement by 5%, the percentage of presence of phlegmatic nodes showing peripheral enhancement by 87%, the percentage of presence of lymph nodes showing slight enhancement by 8%, the percentage of presence of a single phlegmatic node in the right flank or navel 98%, and the percentage of the presence of a single phlegm nodule on the left side or navel is 2%. The focus is on the appearance of post-primary pulmonary tuberculosis and the appearance of syrinx or tuberculous cavernosum. The percentage of lung caverns appearing is 33% of the sample, and the cavernos are located in the upper lobes by 87%.The appearance of calcifications in the phlegm nodules on a simple chest x-ray was studied at 3%, while on a CT scan it was 36% before treatment, while the percentage was 35% after treatment. The distribution of the prevalence of enlarged phlegm nodules in tuberculosis was studied: It was found that the prevalence of enlarged phlegm nodules was at The umbilical cord was 66%, while the prevalence of enlarged phlegm nodules at the subbranchial level of the trachea was 15%, and the prevalence of enlarged phlegm nodules at the level around the trachea and its branches was 19%. Pulmonary parenchyma injury was studied in tuberculosis, where pulmonary parenchyma injury constituted 88%, and the patterns of parenchymal injury were studied. Where the presence of lobar syrinx was found at a rate of 35%, the rate of presence of lobular condensation was 55%, the rate of presence of mild infiltrates was 5%, and the rate of presence of nodular infiltrates was 5%, a study to monitor phlegm nodules after applying the treatment, where the decline occurred by 42%, and shrinkage occurred by 52%, The appearance of the nodes was found to be heterogeneous in 63%, the presence of calcifications in 70%, the upper lobes were affected by 75%, while the lower lobes were affected by 25%, and the destructive lesion was 35%. The percentage of the presence of a single tuberculous cave was found to be 75%. The percentage of presence of multiple tuberous caves is 13%, the percentage of caves with thin walls is 45%, the percentage of caves containing gaseous liquid levels is 25%, the percentage of caves with regular walls is 45%, the percentage of caves with irregular walls is 13%, and the presence of smoking nodules that measure 1–3 mm 97%, the percentage of diffuse localization is 30%, and the percentage of localization under the pleural space is 60%.

In the results section, we talked about the number of patients in the sample reaching 859, and we emphasized the necessity of writing down the radiological findings for both the chest image and the CT scan. It was revealed in our study that the percentage of males (65%) is greater than the percentage of females (35%), and this means that tuberculosis is a disease that affects males more. Among females, we found in our study when reviewing the records that the most common clinical manifestation in patients with pulmonary tuberculosis is a chronic cough that produces sputum, where the percentage of patients was 87%, and the second most common symptom in pulmonary tuberculosis is lack of appetite, which represented 75%, and when studying a positive tuberculin test, we found It is positive in 95% of patients. The percentage of pulmonary lobes being affected was the highest, and the percentage was about 86%. We found in our study that the percentage of presence of the angulation sign indicating syringomyelia on a CT scan is higher than its presence on a simple chest scan. This means that the CT scan is positive. Sensitivity and high efficiency in diagnosing this sign. Also, CT had a higher degree of efficiency in diagnosing pleural effusion and pericardial effusion from the simple image, as the percentage of presence of pleural effusion and pericardial effusion on the CT image was 85%, and the percentage of presence of pericardial effusion on the CT image was 15%. Referring to measuring the density of the side using a tomogram, it was found that the percentage of those with a density higher than 20 was the highest, and the percentage constituted 65%. When studying the stages of tuberculosis on x-rays, it was found that

The first phase: The lesion extends from 3 to 8 weeks in a rate of 66%, and it was diagnosed radiographically with a complex of alveolar lesions with lymph node involvement on a simple chest x-ray in 77%, while on a CT scan in 95% of cases of the first phase. The second phase extends about 3 months, when plain chest radiographs and CT scans showed tuberculous millet lesions, and the second stage cases constituted 34%. Of this sample, the presence of tuberculous millet nodules was observed on the entire plain and CT scan of all patients for this stage. The third stage, in which the active infection appeared to extend until 7 months. Months and some cases lasted up to 1.5 years, as pleural involvement and primary tuberculosis appeared radiographically. The rate of injury to the upper lobe on both sides is 85%, the rate of injury to the middle lobe is 10%. The accuracy of the simple image does not generally show all the radiological cases diagnosed with tuberculosis, and does not exceed 75% according to our study, and it corresponds to International studies that reached the most prestigious centers reach 76%, and the high-resolution multi-slice CT has an accuracy and sensitivity rate exceeding 96%.

The detection rate of enlarged umbilical lymph nodes on a simple chest X-ray was 77%, the rate on a CT scan was 98%, and the remaining percentage was due to the lack of technical quality of the CT scan (technical defect). As for the diameters of phlegm nodules detected by CT, the rate of detection of phlegm nodules measuring 15 to 20 mm was the highest, representing 63%. Cases were detected in proportion in a decreasing manner as the lesion became smaller. Most of the phlegm nodules that appeared on the CT image were hypodense phlegm nodules and formed The percentage is 75%, and when studying the phlegmatic nodes after the injection of contrast material, it was found that the percentage of nodes that showed peripheral enhancement of the contrast material was the highest, and the percentage was 87%, and the percentage of presence of phlegmatic nodes in the right navel was the highest, and the percentage was 98%, and the percentage of tuberculous caverns appearing was 33%. The upper lobes were the most affected. Calcification appeared on the CT scan at a rate of 36%. The nodular hyperplasia was mainly located in the umbilicus and accounted for 66%. The percentage of lobular condensation was the highest at 55%, followed by lobar condensation at 35%. Most of the nodes showed calcification. There is a heterogeneous appearance upon follow-up after treatment. The rate of involvement of the parenchyma of the upper lobes is the highest, at 75%, the rate of the presence of a single tuberculous cave is the highest, at 75%, and smoking nodules that measure 1–3 mm are the highest, at 97%.

Ethics approval and consent to participate:

The Research Ethics Committee in the Syrian Private University and the ethical committees in the concerned Syrian private university approved the study protocol. Verbal informed consent was obtained from every participant before participation. All procedures performed in studies involving human participants were by the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Consent for publication:

Not applicable.

Availability of data and materials:

All data related to this paper’s conclusion are available and stored by the authors. All data are available from the corresponding author on a reasonable request.

Conflict of interest:

The authors declare that they have no conflict of interest

Funding:

This research received no specific grant from SPU or any other funding agency in the public, commercial or non-profit sectors.

Authors’ contributions:

M.K and K.K conceptualized the study, M.K and K.K wrote the study protocol, performed the statistical analysis, participated in data collection, and did the literature search. M.K and K.K participated in the literature search, interpret the results, wrote the main manuscript H.B. revised the draft. All authors read and approved the final draft.

Acknowledgments:

We are thankful to the management of the Syrian Private University and for their support in the field of medical training and research. And the medical staff at Al-Mujtahid Hospital We would also like to thank Dr. Housam Bardan for his help and supervision in the paper.

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Abbara A, Al mallam, Al masri, Akabbani H, Karahn, El Amin Wetal, the challenges at tulerclosis contral in protected conflict: the case of Syria international jounal of infections Disen 2020 (citel 2023) Mar 18:90: 53-9
Furiu J, cox H, pai M, Talerculosis. The Lancet (2023) June 7: 393 Wanld Health organization WHO gldal tuleculosis. Switzerland: WHO 2022 Dec Jindal SK, ed. (2011). Textbook of pulmonary and critical care medicine. New Delhi: Jaypee Brothers Medical Publishers. p. 242. ISBN 978-93-5025-073-0. Archived from the original on 2016-04-24.

The authors declare no competing interests.

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Radiological manifestations of thoracic tuberculosis, a study in Damascus Hospital

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Abstract

Introduction

Materials and methods

Results

Discussion

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References

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