Assuntos
Anestesia Local/métodos , Toracoscopia/métodos , Anestesia Local/efeitos adversos , Competência Clínica , Humanos , Derrame Pleural Maligno/diagnóstico , Derrame Pleural Maligno/terapia , Pleurodese/métodos , Pneumotórax/terapia , Toracoscopia/efeitos adversos , Tuberculose Pleural/diagnósticoRESUMO
PURPOSE: To retrospectively quantify the change in the diagnosis and management of suspected interstitial lung disease when thin-section computed tomography (CT) is added to pretest probabilities. MATERIALS AND METHODS: The institutional review board does not require approval or patient informed consent for retrospective study of case records and CT studies. Six pulmonologists reviewed data sheets containing clinical information and results of pulmonary function tests and chest radiographs of 168 consecutive patients (86 women and 82 men; mean age, 59.8 years; age range, 22-86 years) suspected of having interstitial lung disease. Differential diagnoses and responses to specific questions regarding patient care were recorded before and after assimilation of thin-section CT findings. Both unweighted and weighted kappa analyses were used to determine agreement between pulmonologists before and after CT. RESULTS: First-choice diagnosis changed in 520 (51%) of 1008 cases, and agreement on first-choice diagnosis increased from 0.47 to 0.72 after thin-section CT. In addition, confidence in the first-choice diagnosis increased, and there was a reduction in the number of differential diagnoses offered by all pulmonologists (P < .005 and P < .001, respectively). Agreement on diagnostic probabilities for individual disorders increased substantially, particularly for diagnoses of idiopathic pulmonary fibrosis (weighted kappa = 0.58-0.89). With CT findings, pulmonologists changed their pre-CT responses regarding the use of bronchoalveolar lavage, transbronchial biopsy, and thoracoscopic biopsy in 242 (24.0%), 282 (28.0%), and 292 (29.0%) of 1008 cases, respectively. However, agreement for the use of these investigations was low both before and after CT. The request rate for thoracoscopic biopsy in patients in whom idiopathic fibrosis was diagnosed decreased from 48 of 179 (26.8%) to 26 of 233 (11.2%) after CT. CONCLUSION: Thin-section CT resulted in a change in first-choice diagnosis in half the cases. Diagnostic confidence improved, and CT findings increased agreement between pulmonologists on diagnostic probabilities across a range of interstitial lung diseases.
Assuntos
Doenças Pulmonares Intersticiais/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Adulto , Idoso , Idoso de 80 Anos ou mais , Técnicas de Apoio para a Decisão , Feminino , Humanos , Doenças Pulmonares Intersticiais/diagnóstico , Doenças Pulmonares Intersticiais/terapia , Masculino , Prontuários Médicos , Pessoa de Meia-Idade , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodosRESUMO
A patient with tuberculosis presented with a pleural effusion that was highly positive for antinuclear antibody (ANA). The pleural fluid autoimmune profile was positive for ANA IgG at a titre of 1 : 1280. Antibodies to double-stranded DNA were not detected in the pleural fluid or in serum. The serum autoimmune profile was positive for ANA IgG at 1 : 160 and IgM at 1 : 40. Pleural fluid was positive on culture for Mycobacterium tuberculosis after 8 weeks. Pleural biopsy for histology showed chronic inflammation and culture revealed no growth. The pleural fluid resolved with the anti-tuberculous treatment, and signs and symptoms of systemic lupus erythematosus or malignancy did not occur, which suggests that tuberculous pleural effusion is one of the causes of high ANA in pleural fluid.