Update Chest X Ray

for Diagnosis TB
1st IMMAN 2019
WORKSHOP
Updating Knowledge on TB
Diagnostic,Treatment and Prevention to
support TB End Strategy 2030

dr Ayat Rahayu, Sp.Rad.,M.Kes

Departemen Radiologi
Fakultas Kedokteran
Universitas Islam Negeri(UIN) Syarif Hidayatullah Jakarta
11 Oktober 2019
 Background
• WHO SDG
• TB End Strategy 2030
• Action National TB Programme
• Commitment : CXR a tool (departement
of radiology )
 Fakta Kunci (WHO)
Tuberkulosis (TB) 10 penyebab utama kematian di dunia.
2017, 10 juta orang penderita TB; 1,6 juta meninggal (termasuk 0,3 juta
dengan HIV).
TB adalah pembunuh utama orang HIV-positif.
2017, 1 juta anak penderita TB dan 230.000 anak meninggal (termasuk
anak dengan HIV).
TB resistan terhadap multi-obat (TB-MDR); 558.000 kasus baru dengan
resisten terhadap Rifampisin - 82% memiliki TB-MDR.
Global, Insiden TB menurun sekitar 2% per tahun. Target dipercepat
penurunan tahunan 4-5% th. 2020 dari Strategi Akhir TB
54 juta jiwa diselamatkan dg pengobatan TB periode 2000 - 2017.
Mengakhiri Epidemi TB pada tahun 2030 (WHO’sTB End
Strategy 2030) target kesehatan - Tujuan Pembangunan
Berkelanjutan
 Kasus TB (WHO)

10,0 juta kasus baru TB ( 9,0-11,1 juta), setara dengan 133

kasus (120-148) per 100.000 penduduk.
TB mempengaruhi semua negara dan semua kelompok
umur
 2017. 90% kasus adalah orang dewasa (usia ≥ 15 tahun),
64% adalah laki-laki, 9% orang yang hidup dengan HIV
(72% dari mereka di Afrika)
 2/3 di delapan negara: India (27%), Cina (9%),Indonesia
(8%), Filipina (6%), Pakistan (5%),Nigeria (4%),
Bangladesh (4%) dan Afrika Selatan (3%).
 Hanya 6% kasus di Eropa dan 3% kasus Amerika
Countries in the three high-burden country lists for TB, TB/HIV and MDR-TB being used by WHO during the
period 2016–2020, and their areas of overlap
 RISKESDA 2013 Indonesia
• Berdasarkan media/cara penularan : via udara (Infeksi
Saluran Pernafasan Akut/ISPA, Pneumonia, dan TB paru
• Period prevalence ISPA 25,0 %.
– 5 provinsi ISPA tertinggi Nusa Tenggara Timur, Papua, Nusa
Tenggara Barat, dan Jawa Timur
• Insiden dan prevalensi Indonesia 2013: 1,8% & 4,5%.
– 5 provinsi dg Pneumonia tertinggi untuk semua umur : Nusa Tenggara Timur,
Papua, Sulawesi Tengah, Sulawesi Barat, dan Sulawesi Selatan.
• Prevalensi penduduk Indonesia terdiagnosis TB oleh Nakes
2007 dan 2013 tidak berbeda (0,4%).
– 5 provinsi TB tertinggi Jawa Barat, Papua, DKI Jakarta, Gorontalo, Banten,
dan Papua Barat.
– 44,4 persen diobati dengan obat program.
 FAKTOR DAN FAKTA KUNCI  TB (WHO)

KEMATIAN KESAKITAN

10 terbanyak di
dunia
Dewasa 10 juta tb
Anak 1 juta tb
Dewasa 1,6 juta (0,3
juta HIV)
Anak 230 ribu

TB MDR-
Rifampicin 82%
Insiden 558 ribu
WHO’s TB End
Strategy
Treatment/Health
Service
2030
Penurunan insiden
2%/tahun
Lab dan test Target 4-5%

Imaging ; Chest
Xray Penyembuhan TB • Chest radiography as a triage tool.
54 juta -2000-17 • Chest radiography as a diagnostic aid.
• Chest radiography as a screening tool.
Klinis: aktif,laten, • Technical specification, quality assurance
pulmonal-ektrapulmonal
and safety.
• Strategic planning for use of chest
radiography in national TB control.
DIAGNOSTIK DAN UPAYA TARGET DAN HASIL
KESEHATAN /ORGANISASI
WHO’s TB End Strategy 2030
GUIDELINE
•Chest radiography as a triage tool.
•Chest radiography as a diagnostic aid.
•Chest radiography as a screening tool.
•Technical specification, quality
assurance and safety.
•Strategic planning for use of chest
radiography in national TB control.
 Rekomendasi /Guideline WHO
Program TB Nasional(PTN)

I. Radiografi thoraks(CXR),sbg alat yang

penting u/
 Triase & Skrining TB paru,
 Penunjang Diagnosis TB paru, bila secara
bakteriologis (-)/tidak dapat dikonfirmasi.

II. Memastikan penggunaan CXR lebih luas &

terjamin kualitasnya ; kombinasi dg tes
diagnostik Laboratorium
FOKUS CXR (Materi INTI)

1. Utama Deteksi TB paru.

2. Deteksi/Diagnosis bentuk TB lain

(misalnya, TB miliaria atau perikardial,
atau efusi TB)

3. Teknik pencitraan lain USG, CT

scan,MRI,PET/CT scan untuk diagnosis TB,
misalnya untuk TB ektrapumonal
Pendekatan FOTO CXR
• Technique: Foto Toraks Paru
• Anatomy: Paru , mediastinum, rongga
toraks
• Clinical picture: Pattern lesi paru ,
interstitial pattern, alveolar
pattern(airspace pattern)
 Checklist Interpretation
As A Guide To Assess Chest X-ray. 
• Technique: how was the image made? (Supine, standing, AP, PA). What is the
technique? (Rotation, inspiration). Has everything been imaged?
• Artificial lines (if present): position of drains/deep venous lines/tracheal
tubes/gastric tube?
• Mediastinum: widened? (including aortic pathology, space-occupying lesion
/lymphadenopathy) Free air? (pseudomediastinum) Position of trachea/bronchi?
(when displaced: think of atelectasis) 
• Lung hili: are the hili sharp? Can all be explained by vessels? (Think of a
mass/lymphadenopathy) Lungs: Symmetric lung vessel markings? Normal tapering
towards peripheral? 
• Heart: are the heart contours sharp? Can you see through the heart? Enlarged
heart? 
• Pleura: pleural thickening? Pneumothorax?
• Subdiaphragmal: free air?Intestinal pathology? Hiatal hernia? 
• Soft tissues: subcutaneous emphysema? Are there (superimposed) abnormalities of
skin, breasts and other body parts? (fig. 13)
• Bone: ribs intact? Fracture/vertrebral collapse? Bone lesions?
Analisis CXR( sc UMUM)
Figure 1. Technique for Posterior Anterior (PA) chest X-ray.
Figure 2. Technique for Anterior Posterior (AP) chest X-ray.
Figure 3. Technique for Lateral chest X-ray.
 Inspiration:

Adequacy of inspiration
can be verified when you
can see 10 dorsal ribs, and
the 5th and 7th ventral ribs
cross the diaphragm at
mid-clavicular.  

Figure 4. Chest X-ray with Adequate Inspiration

 Non-rotated:

In a NON-ROTATED
image, the spinous
processes of the thoracic
vertebrae project in the
middle between the
medial ends of the
claviculae(simetris).

♦ Figure 5. Non-rotated chest X-ray.

 Penetration:
This refers to the amount of
radiation passing through the
body. If too much or too little
radiation is given, the
resulting image will be more
dense (= whiter) or lucent
(=blacker) than desired. There
are now standard settings to
optimize imaging

♦ Figure 6. Panetration ; whittenes/ darknes chest X-ray.

 Extrapulmonary Abnormalities

Extrapulmonary abnormalities.

Figure 6. Extrapulmonary abnormalities. A lock of hair may simulate lung pathology

NORMAL
ANATOMY
Pattern Abnormality Lung

• Lobus Paru Sekunder

td. 2 komponen:
– Alveoli (The ‘Air Bags')
– Supporting Interstitium
(structures surrounding
vessels, lymph vessels,
bronchi)

Figure 7. The secondary lobule.

 Pattern Abnormality Lung
Interstitium dibagi 5 :
• Peribronchovascular
• Centrilobular
• Intralobular
• Interlobular
• Subpleural
Interstitium.

Figure 7. The secondary lobule. Interstitial lung

 Pattern Abnormality Lung
Alveolar Disease
• the alveoli filled with materials that
produce a fluid density.  
• The material type (blood, pus, mucus,
edema, cells) cannot be ascertained on a
chest X-ray.
• the filled alveoli will always surround the
interstitium with a dense area, visible on a
chest X-ray as a cloud-like
consolidation (hazy,fluffy, fuzi)

An Alveolar Disease is often an acute

disorder (think especially of lung edema in
heart failure and pneumonia).

Figure 7. The secondary lobule.

Edema paru alveolar
Pneumonia akut
 Pattern Abnormality Lung
Interstitial Disease
Multiple presentations. In healthy people :
• the pulmonary vessels on a chest X-ray become less and
less dense towards peripheral.
• as pulmonary vessels continue to branch into smaller
vessels, making them less visible on X-ray.
• 4 types of pathological interstitial patterns, accurately on
CT scans.
1. Liner pattern (Kerley A,B line sign)
2. Reticuler pattern (penebalan,fibrosis interlobular septa
3. Noduler pattern (granuloma,noduler)
4. Reticulonoduler pattern
 Liner pattern
• thickened interlobar
septae. The interlobar
septae separate the
secondary lung lobules
from each other and
contain the pulmonary
veins and lymph
vessels

• The most common

cause is pulmonary
edema secondary to
heart failure.  

• The thickened
interlobar septae, hit
tangentially by the X-
ray beam, can be seen
on chest X-rays As
Kerley A And B Lines.
Figure 22. Linear pattern with Kerley A (central) and B (peripheral) lines.
Kerley B lines in right lower lobe in a heart failure patient.
 Reticular pattern. Collection of
small linear
dense lines,
forming a net
structure.  

This network of
lines may vary
from a fine to
crude pattern.

Reticular
abnormalities
are seen in
diseases
including lung
fibrosis and
Figure 23. Reticular pattern. A patient with extensive lung fibrosis . asbestosis.
sarcoidosis
 Nodular pattern
MULTIPLE SPHERICAL
densities varying from 1
mm to 1 cm.  

Etiology, 3 subgroups
Nodular Metastases,
Nodular Pneumoconiosis
(= inhaled dust particles)
Granulomatous Diseases
(including sarcoidosis
and arthritis). Think also
of miliary TBC.

Figure 24. Nodular pattern in sarcoidosis.

thyroid carcinoma, metastasis
 Reticonodular pattern.

TIP: with increased
interstitial markings (both
locally and diffuse) in
combination with irregular
markings (=abnormal
architecture), consider a
chronic problem, e.g. lung
fibrosis. If there are vague
increased interstitial
markings with a regular
aspect of the branching
vasculature, then an acute
disorder is more likely.
However, a more reliable
method to distinguish
between acute and
chronic lung disease is to
•A combination of a reticular and a nodular lung pattern.
review older tests. 
sarcoidosis.
  

Classifcation of Parenchymal Lung Diseases
 Tuberkulosis Paru (RISKESDA 2013)
• Penyakit menular langsung o/kuman TB (Mycobacterium
tuberculosis).
• Gejala utama : batuk selama 2 minggu atau lebih,
• Gejala tambahan:
– dahak, dahak bercampur darah,
– sesak nafas,
– badan lemas,
– nafsu makan menurun,
– berat badan menurun,
– malaise,
– berkeringat malam hari tanpa kegiatan fisik,
– demam lebih dari 1 bulan.
• Ditanyakan pd responden TB Paru:
– untuk kurun waktu ≤1 Th.
– dasar diagnosis oleh Nakes via Pem. dahak, Foto toraks atau keduanya .
 TB sc Radiologis :CXR
Indikasi Screening:
• Kontak TB berulang/kostan dengan penderita TB BTA
(+)
• Target popula­tion:
– Patients of low socioeconomic status (homeless)
– Alcoholic
– Immigrants: from Mexico, Philippines, Indochina, Haiti
– Elderly patients
– AIDS patients
– Prisoners
– Penderita DM dengan Batuk
– Susp. Ektrapulmonal TB
 RADIOPATOLOGI

PRIMARY INFECTION

Heals without complications.

Sequence of events includes:
• Pulmonary consolidation (1–7 cm); cavitation is rare; LL
(60%) > UL
• Caseous necrosis 2–10 weeks after infection
• Lymphadenopathy (hilar and paratracheal), 95%
• Pleural effusion, 10%
• Spread of a PRIMARY FOCUS Children Or
Immunosuppressed Patients.
 RADIOPATOLOGI
SECONDARY INFECTION
• Proses Aktif pada orang dewasa : reactivation of a
primary focus. Tetapi bisa terjadi tanpa primary disease
waktu anak2 (di Negara Maju)

• Distribusi lokasinya:
– Apical And Posterior Segments Of Upper Lung’s or Superior
Segments Of Lower Lung’s (High Po2?)
– Rarely in anterior segments of ULs (in contra­distinction to
histoplasmosis)
 Figure 5.3.2 Possible events following
infection by tubercle bacilli.

Figure Possible events following infection by tubercle bacilli.

 Radiographic Features

• Exudative TB
– Patchy or confluent air space disease
– Adenopathy uncommon
• Fibrocalcific TB
– Sharply circumscribed linear densities
radiating to hilum
• Cavitation, 40%
Complications TB
• Miliary TB  post primary or secondary hematogenous
spread.
• Bronchogenic spread  post the necrotic area with a
bronchus  ACINAR PATTERN (irregular nodules size
diameter 5 mm).
• Tuberculoma (1–7 cm): nodule primary or secondary TB;
with or no calcification
• Effusions often loculated.
• Bronchopleural fistula
• Pneumothorax
Radiographic Features
Radiographic Features
 Gambaran CXR Kasus TB
– Klinis: batuk lama hilang timbul > 1 bln, batuk
berdahak, darah (-), kadang disertai sesak dan
nyeri ke arah punggung belakang, demam(-)
– Riw. Batuk pilek , BAB cair
– Riw. Kontak TB berulang di RS.
– PF: pucat, anemia, batuk aktif.Lab. HB 9.1
leukosit dbn.
CXR perbercakan lunak di paru kanan tengah dan posterior basal kanan
CT SCAN THORAKS Lung Parenchymal
Retikuler
pattern

cloudlike

cloudlike

Chest X-ray showing patchy multifocal consolidation inboth lungs

Chest X-ray showing features of tuberculous mediastinal adenopathy: widening of the superior
mediastinum A . hilar adenopathy B . enlarged right hilum.
 Sinus kanan
terselubung

Chest X-ray showing large right pleural effusion, midline shift mediastinal to left
Chest X-ray (a) and axial computerised tomography (b) in miliary tuberculosis, showing widespread fine nodules
 Resume
 CXR masih menjadi Alat Pilihan Utama dalam
menuntaskan TB di seluruh dunia
 CXR berperan dalam TRIASE , SCREENING
dan MENUNJANG DIAGNOSTIK TB
sebelum atau sesudah pemeriksaan Lab.
 Peranan tenaga kesehatan(NAKES) masih
sangat diperlukan dan menunjang, mendukung
TB End Strategy 2030 melalui
kemampuan mendeteksi dan evaluasi TB aktif –
pre-post treatment melalui Foto toraks paru
Berikhtiar, Berdoa
Terima Kasih