0
Communications to the Editor |

Chest Radiographs in HIV-Infected Persons FREE TO VIEW

Roslyn F. Schneider; Mark J. Rosen
Author and Funding Information

Affiliations: Beth Israel Medical Center, New York, NY,  New York University School of Medicine, New York, NY

Correspondence to: Roslyn F. Schneider, MD, FCCP, Associate Director, Residency Training Program, Internal Medicine, Beth Israel Medical Center, First Avenue at 16th St, New York, NY 10003; e-mail: RSchneider@BethIsraelNY.org



Chest. 2003;123(4):1316-1317. doi:10.1378/chest.123.4.1316
Text Size: A A A
Published online

To the Editor:

In the May 2002 issue of CHEST, Gold et al1 published an intriguing manuscript reviewing the significance of abnormal chest radiographic findings in HIV-1-infected individuals who did not have specific respiratory symptoms. However, we disagree with several statements, particularly those supporting the use of screening chest radiography. Comparisons with the pulmonary complications of HIV infection study of screening chest radiography are not applicable.2 Gold et al1 studied hospitalized patients with constitutional or other symptoms and abnormal chest radiograph findings who were referred for pulmonary consultation. Reviews were of the consultation service ledger rather than of the entire patient record, and pulmonary symptoms may have been missed. Their patients were symptomatic, so the radiographs were not screening studies. Rather, radiographs of patients who are febrile, losing weight, or have extrapulmonary disease are diagnostic tests. In the broadest sense, radiographs in HIV-infected persons who have been admitted to the hospital for other reasons should be considered case-finding studies, not screening studies.

Statements about our study also question whether a standard diagnostic algorithm was followed and whether diagnoses were missed. In fact, the algorithm was reported, and it included spirometry, diffusing capacity measurements, gallium scans, sputum induction tests, bronchoscopy, and close follow-up at intervals. Clinically significant diagnoses in the 2 months following the abnormal chest radiograph finding would therefore have been captured. The statement that the actual radiographic findings were not reported is also inaccurate.

The reasons for the different findings in both studies include the selection bias of studying hospitalized patients in New York City who are likely to have different demographics and illnesses than the collective group of outpatient, asymptomatic HIV-infected persons. A diagnostic approach that includes chest radiography is probably justified in any hospitalized patient with HIV infection. However, there is insufficient evidence to recommend the use of screening chest radiography in asymptomatic patients.

Gold, JA, Rom, WN, Harkin, TJ (2002) Significance of abnormal chest radiograph findings in patients with HIV-1 infection without respiratory symptoms.Chest121,1472-1477. [PubMed] [CrossRef]
 
Schneider, RF, Hansen, NI, Rosen, MJ, et al Lack of usefulness of radiographic screening for pulmonary disease in asymptomatic HIV-infected adults.Arch Intern Med1996;156,191-195. [PubMed]
 
To the Editor:

We appreciate the insightful comments by Drs. Rosen and Schneider. We agree that direct comparisons to the Pulmonary Complications of HIV Infection study cohort cannot be made due to the numerous differences in methodology noted by ourselves and by Schneider et al.1 A large reason for the discrepancy between the two trials is the specialized nature of our cohort; most of our study subjects were inpatients, the majority in psychiatric or prison wards. However, we would like to clarify several points. First, although initially identified by hospital ledgers, the entire medical record was reviewed for each patient; patients with incomplete data in their medical record were excluded. Each patient had been seen by medical staff of the Bellevue Chest Service, and both a history and physical were available. We are confident, therefore, that these patients truly had an absence of specific pulmonary symptoms.

Second, we agree with Drs. Rosen and Schneider that this study does not support the use of widespread screening chest radiograph (CXR) in HIV-1–infected individuals. We believe that such screening was proven cost ineffective both by the Pulmonary Complications of HIV Infection Cohort and by Olson et al.2 However, a directed screening of extremely high-risk individuals, as presented in our study, may still be warranted. Drs. Rosen and Schneider correctly point out that the population of our study is much different from that observed in other screening trials. While it is true that CXR should be obtained as a case finding study for those subjects with significant extrapulmonary disease and constitutional symptoms, and these subjects comprised a large percentage of our subjects, only 24% had constitutional symptoms. Furthermore, 40% of our subjects were admitted only for psychiatric reasons or had a CXR as a screening modality. Most who had received a screening CXR were prisoners and were admitted only for evaluation of their abnormal CXR findings. Since patients with psychiatric illnesses and prisoners are usually underrepresented in clinical trials, it is likely that this explains some of the differences between our study and theirs.

Finally, an important point of our study is not whether directed screening CXR should be performed in select groups of HIV-1–infected individuals, but rather that an aggressive diagnostic approach should be used to evaluate the abnormality, and such an approach will have a high diagnostic yield. Furthermore, the high incidence of pulmonary tuberculosis has significant public health implications. Last, we wished to provide the clinician the results of the diagnostic modalities we employed to make the diagnosis. The Pulmonary Complications of HIV Infection trial did mention the radiographic abnormalities present in their cohort; this was misstated in our article.

References
Schneider, RF, Hansen, NI, Rosen, MJ, et al Lack of usefulness of radiographic screening for pulmonary disease in asymptomatic HIV infected adults.Arch Intern Med1996;156,191-195. [PubMed] [CrossRef]
 
Olson, PE, Wallace, MR, Grillo, MP, et al Lack of utility of routine chest radiographs in HIV infected patients.AIDS1996;10,446-447. [PubMed]
 

Figures

Tables

References

Gold, JA, Rom, WN, Harkin, TJ (2002) Significance of abnormal chest radiograph findings in patients with HIV-1 infection without respiratory symptoms.Chest121,1472-1477. [PubMed] [CrossRef]
 
Schneider, RF, Hansen, NI, Rosen, MJ, et al Lack of usefulness of radiographic screening for pulmonary disease in asymptomatic HIV-infected adults.Arch Intern Med1996;156,191-195. [PubMed]
 
Schneider, RF, Hansen, NI, Rosen, MJ, et al Lack of usefulness of radiographic screening for pulmonary disease in asymptomatic HIV infected adults.Arch Intern Med1996;156,191-195. [PubMed] [CrossRef]
 
Olson, PE, Wallace, MR, Grillo, MP, et al Lack of utility of routine chest radiographs in HIV infected patients.AIDS1996;10,446-447. [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543