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Imaging of Possible Tuberculosis

Variant: 1   Suspect active tuberculosis.
Procedure Appropriateness Category Relative Radiation Level
Radiography chest Usually Appropriate ☢
CT chest without IV contrast Usually Appropriate ☢☢☢
CT chest with IV contrast May Be Appropriate ☢☢☢
MRI chest without and with IV contrast Usually Not Appropriate O
MRI chest without IV contrast Usually Not Appropriate O
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢

Variant: 2   Newly positive PPD or IGRA OR positive PPD or IGRA with unknown prior status. No clinical symptoms.
Procedure Appropriateness Category Relative Radiation Level
Radiography chest Usually Appropriate ☢
CT chest with IV contrast May Be Appropriate ☢☢☢
MRI chest without and with IV contrast Usually Not Appropriate O
MRI chest without IV contrast Usually Not Appropriate O
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢

Variant: 3   PPD not available. Placement in group home or skilled nursing facility. No clinical symptoms.
Procedure Appropriateness Category Relative Radiation Level
Radiography chest Usually Appropriate ☢
MRI chest without and with IV contrast Usually Not Appropriate O
MRI chest without IV contrast Usually Not Appropriate O
CT chest with IV contrast Usually Not Appropriate ☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢

James G. Ravenel, MDa; Jonathan H. Chung, MDb; Jeanne B. Ackman, MDc; Patricia M. de Groot, MDd; Geoffrey B. Johnson, MD, PhDe; Clinton Jokerst, MDf; Fabien Maldonado, MDg; Barbara L. McComb, MDh; Robert M. Steiner, MDi; Tan-Lucien H. Mohammed, MDj.
Summary of Literature Review
Introduction/Background
Discussion of Procedures by Variant

A. Chest radiography

B. Computed tomography

C. Magnetic resonance imaging

A. Chest radiography

B. Computed tomography

C. Magnetic resonance imaging

A. Chest radiography

B. Computed tomography

C. Magnetic resonance imaging
Summary of Highlights
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

 0 mSv

☢

<0.1 mSv

<0.03 mSv

☢☢

0.1-1 mSv

0.03-0.3 mSv

☢☢☢

1-10 mSv

0.3-3 mSv

☢☢☢☢

10-30 mSv

3-10 mSv

☢☢☢☢☢

30-100 mSv

10-30 mSv

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”
References
1. LoBue PA, Enarson DA, Thoen TC. Tuberculosis in humans and its epidemiology, diagnosis and treatment in the United States. Int J Tuberc Lung Dis. 2010;14(10):1226-1232.
2. Rozenshtein A, Hao F, Starc MT, Pearson GD. Radiographic appearance of pulmonary tuberculosis: dogma disproved. AJR Am J Roentgenol. 2015;204(5):974-978.
3. Eisenberg RL, Romero J, Litmanovich D, Boiselle PM, Bankier AA. Tuberculosis: value of lateral chest radiography in pre-employment screening of patients with positive purified protein derivative skin test results. Radiology. 2009;252(3):882-887.
4. Piccazzo R, Paparo F, Garlaschi G. Diagnostic accuracy of chest radiography for the diagnosis of tuberculosis (TB) and its role in the detection of latent TB infection: a systematic review. [Review]. J Rheumatol Suppl. 91:32-40, 2014 May.
5. Wisnivesky JP, Henschke C, Balentine J, Willner C, Deloire AM, McGinn TG. Prospective validation of a prediction model for isolating inpatients with suspected pulmonary tuberculosis. Arch Intern Med. 2005;165(4):453-457.
6. Yeh JJ, Yu JK, Teng WB, et al. High-resolution CT for identify patients with smear-positive, active pulmonary tuberculosis. Eur J Radiol. 2012;81(1):195-201.
7. Matsuoka S, Uchiyama K, Shima H, et al. Relationship between CT findings of pulmonary tuberculosis and the number of acid-fast bacilli on sputum smears. Clin Imaging. 2004;28(2):119-123.
8. Ors F, Deniz O, Bozlar U, et al. High-resolution CT findings in patients with pulmonary tuberculosis: correlation with the degree of smear positivity. J Thorac Imaging. 2007;22(2):154-159.
9. Yeh JJ, Neoh CA, Chen CR, Chou CY, Wu MT. A high resolution computer tomography scoring system to predict culture-positive pulmonary tuberculosis in the emergency department. PLoS One. 2014;9(4):e93847.
10. Nakanishi M, Demura Y, Ameshima S, et al. Utility of high-resolution computed tomography for predicting risk of sputum smear-negative pulmonary tuberculosis. Eur J Radiol. 2010;73(3):545-550.
11. Lyu J, Lee SG, Hwang S, et al. Chest computed tomography is more likely to show latent tuberculosis foci than simple chest radiography in liver transplant candidates. Liver Transpl. 2011;17(8):963-968.
12. Rizzi EB, Schinina V, Cristofaro M, et al. Detection of Pulmonary tuberculosis: comparing MR imaging with HRCT. BMC Infect Dis. 2011;11:243.
13. Barreto MM, Rafful PP, Rodrigues RS, et al. Correlation between computed tomographic and magnetic resonance imaging findings of parenchymal lung diseases. Eur J Radiol. 2013;82(9):e492-501.
14. Ahmadihosseini H, Sadeghi R, Zakavi R, Kakhki VR, Kakhki AH. Application of technetium-99m-sestamibi in differentiation of active from inactive pulmonary tuberculosis using a single photon emission computed tomography method. Nucl Med Commun. 2008;29(8):690-694.
15. Raziei G, Masjedi MR, Fotouhi F, et al. The role of 99mTc-MIBI scintigraphy in the management of patients with pulmonary tuberculosis. Eur Rev Med Pharmacol Sci. 2012;16(5):622-629.
16. Kaneko K, Sadashima E, Irie K, et al. Assessment of FDG retention differences between the FDG-avid benign pulmonary lesion and primary lung cancer using dual-time-point FDG-PET imaging. Ann Nucl Med. 2013;27(4):392-399.
17. Liu SF, Liu JW, Lin MC, Lee CH, Huang HH, Lai YF. Monitoring treatment responses in patients with pulmonary TB using serial lung gallium-67 scintigraphy. AJR Am J Roentgenol. 2007;188(5):W403-408.
18. Liu Y, Weinberg MS, Ortega LS, Painter JA, Maloney SA. Overseas screening for tuberculosis in U.S.-bound immigrants and refugees. N Engl J Med. 2009;360(23):2406-2415.
19. Paquette K, Cheng MP, Kadatz MJ, Cook VJ, Chen W, Johnston JC. Chest radiography for active tuberculosis case finding in the homeless: a systematic review and meta-analysis. Int J Tuberc Lung Dis. 2014;18(10):1231-1236.
20. Jeong YJ, Lee KS. Pulmonary tuberculosis: up-to-date imaging and management. AJR Am J Roentgenol. 2008;191(3):834-844.
21. Eisenberg RL, Pollock NR. Low yield of chest radiography in a large tuberculosis screening program. Radiology. 2010;256(3):998-1004.
22. Vinkeles Melchers NV, van Elsland SL, Lange JM, Borgdorff MW, van den Hombergh J. State of affairs of tuberculosis in prison facilities: a systematic review of screening practices and recommendations for best TB control. [Review]. PLoS ONE [Electronic Resource]. 8(1):e53644, 2013.
Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.