title: A Novel Reading Scheme for Assessing the Extent of Radiographic Abnormalities and Its Association with Disease Severity in Sputum Smear-Positive Tuberculosis: An Observational Study in Hyderabad/India.
abstract: BACKGROUND
  Existing reading schemes for chest X-ray (CXR) used to grade the extent of disease severity at diagnosis in patients with pulmonary tuberculosis (PTB) are often based on numerical scores that summate specific radiographic features. However, since PTB is known to exhibit a wide heterogeneity in pathology, certain features might be differentially associated with clinical parameters of disease severity.
  
  
  OBJECTIVE
  We aimed to grade disease severity in PTB patients at diagnosis and after completion of DOTS treatment by developing a reading scheme based on five different radiographic manifestations and analyze their association with the clinical parameters of systemic involvement and infectivity.
  
  
  METHODS
  141 HIV-negative adults with newly diagnosed sputum smear-positive PTB were enrolled in a prospective observational study in Hyderabad, India. The presence and extent on CXRs of five radiographic manifestations, i.e., lung involvement, alveolar infiltration, cavitation, lymphadenopathy and pleural effusion, were classified using the new reading scheme by using a four-quadrant approach. We evaluated the inter-reader reliability of each manifestation, and its association with BMI and sputum smear positivity at diagnosis. The presence and extent of these radiographic manifestations were further compared with CXRs on completion of DOTS treatment.
  
  
  RESULTS
  At diagnosis, an average lung area of 51.7% +/- 23.3% was affected by radiographic abnormalities. 94% of the patients had alveolar infiltrates, with 89.4% located in the upper quadrants, suggesting post primary PTB and in 34.8% of patients cavities were found. We further showed that the extent of affected lung area was a negative predictor of BMI (β value -0.035, p 0.019). No significant association of BMI with any of the other CXR features was found. The extent of alveolar infiltrates, along with the presence of cavitation, were strongly associated with sputum smear positivity. The microbiological cure rate in our cohort after 6 months of DOTS treatment was 95%. The extent of the affected lung area in these patients decreased from 56.0% +/- 21.5% to 31.0 +/- 20% and a decrease was also observed in the extent of alveolar infiltrates from 98.4% to 25.8% in at least one quadrant, presence of cavities from 34.8% to 1.6%, lymphadenopathy from 46.8% to 16.1%, and pleural effusion from 19.4% to 6.5%.
  
  
  CONCLUSIONS
  We established a new assessment scheme for grading disease severity in PTB by specifically considering five radiographic manifestations which were differently associated with the BMI and sputum smear positivity, changed to a different extent after 6 months of treatment and exhibited an excellent agreement between radiologists. Our results suggest that this reading scheme might contribute to the estimation of disease severity with respect to differences in disease pathology. Further studies are needed to determine a correlation with short and long-term pulmonary function impairment and whether there would be any benefit in lengthening or modulating therapy based on this CXR severity assessment.
authors.affiliation: Department of Radiology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Zarko
authors.initials: Z
authors.lastname: Grozdanovic
authors.affiliation: Institute for Microbiology and Hygiene, Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany; Septomics Research Center, Jena University Hospital, Jena, Germany.
authors.forename: Luis C
authors.initials: LC
authors.lastname: Berrocal Almanza
authors.affiliation: Institute for Microbiology and Hygiene, Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Surabhi
authors.initials: S
authors.lastname: Goyal
authors.affiliation: Department of Immunology, Bhagwan Mahavir Medical Research Centre, Hyderabad, India.
authors.forename: Abid
authors.initials: A
authors.lastname: Hussain
authors.affiliation: Septomics Research Center, Jena University Hospital, Jena, Germany.
authors.forename: Tilman E
authors.initials: TE
authors.lastname: Klassert
authors.affiliation: BioControl Jena GmbH, Jena, Germany.
authors.forename: Dominik
authors.initials: D
authors.lastname: Driesch
authors.affiliation: Department of Radiology, Helios Klinikum Berlin-Buch, Berlin, Germany.
authors.forename: Viktoriya
authors.initials: V
authors.lastname: Tokaryeva
authors.affiliation: Department of Radiology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Yvonne Yi-Na
authors.initials: YY
authors.lastname: Löschmann
authors.affiliation: Department of Immunology, Bhagwan Mahavir Medical Research Centre, Hyderabad, India.
authors.forename: Gadamm
authors.initials: G
authors.lastname: Sumanlatha
authors.affiliation: Pathogen Biology Laboratory, Department of Biotechnology and Bioinformatics, University of Hyderabad, Hyderabad, India.
authors.forename: Niyaz
authors.initials: N
authors.lastname: Ahmed
authors.affiliation: Department of Immunology, Bhagwan Mahavir Medical Research Centre, Hyderabad, India; Immunology and Molecular Biology, LEPRA Society- Blue Peter Research Centre, Hyderabad, India.
authors.forename: Vijayalakshmi
authors.initials: V
authors.lastname: Valluri
authors.affiliation: Institute for Microbiology and Hygiene, Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Ralf R
authors.initials: RR
authors.lastname: Schumann
authors.affiliation: Department of Pediatric Radiology, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Germany.
authors.forename: Birgit
authors.initials: B
authors.lastname: Lala
authors.affiliation: Septomics Research Center, Jena University Hospital, Jena, Germany.
authors.forename: Hortense
authors.initials: H
authors.lastname: Slevogt
mesh_terms: D000293:Adolescent; D000328:Adult; D000904:Antibiotics, Antitubercular / Q000008:administration & dosage; D003581:Cytodiagnosis; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D007194:India; D008297:Male; D011237:Predictive Value of Tests; D013902:Radiography, Thoracic; D015203:Reproducibility of Results; D012720:Severity of Illness Index; D013183:Sputum / Q000382:microbiology*; D014397:Tuberculosis, Pulmonary / Q000000981:diagnostic imaging* / Q000188:drug therapy / Q000382:microbiology / Q000473:pathology*; D055815:Young Adult
chemical_list: D000904:Antibiotics, Antitubercular