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䡲 THORACIC IMAGING

Tuberculosis: Value of Lateral Chest

Radiography in Pre-employment
Screening of Patients with Positive
ORIGINAL RESEARCH

Purified Protein Derivative Skin Test

Results1
Ronald L. Eisenberg, MD
Purpose: To test the hypothesis that lateral radiography adds no
Janneth Romero, MD
clinically relevant information to that acquired with pos-
Diana Litmanovich, MD
teroanterior (PA) radiography in individuals with positive
Phillip M. Boiselle, MD purified protein derivative (PPD) skin test results.
Alexander A. Bankier, MD
Materials and As part of routine practice, all 875 adults with positive
Methods: PPD skin test results at pre-employment examinations
performed at a medical center during 2007 underwent PA
and lateral chest radiography. In this institutional review
board–approved HIPAA-compliant study, the patient in-
formed consent requirement was waived. Two radiologists
retrospectively and independently interpreted each radio-
graph for evidence of abnormalities that were indicative of
acute or chronic tuberculosis (TB) infection. First, only the
PA radiograph was analyzed. Thereafter, both the PA
radiograph and the lateral radiograph were analyzed to-
gether to determine if any observed finding was identified
on only the lateral radiograph. If a finding was seen on both
images, a determination was made as to whether the find-
ing on the lateral radiograph changed the radiologist’s
decision based on the PA radiograph alone.

Results: The PA radiograph revealed abnormalities in all 91 (10.4%)

subjects with positive findings at radiography. The lateral
radiograph revealed no abnormality in 75 subjects (83.4%).
All abnormalities seen on lateral radiographs were also seen
on PA radiographs. When abnormalities were seen on both
images, the information on the lateral image never caused
the radiologist to change the decision he or she made on the
basis of the PA image alone.

Conclusion: In a pre-employment setting, one PA radiograph is suffi-

cient for TB screening of individuals with positive PPD skin
test results. Elimination of the acquisition of lateral radio-
graphs would substantially reduce radiation exposure.

娀 RSNA, 2009

1
From the Department of Radiology, Beth Israel Deacon-
ess Medical Center, 330 Brookline Ave, Boston, MA
02215. Received November 14, 2008; revision requested
January 9, 2009; revision received February 10; accepted
March 11; final version accepted March 23. Address
correspondence to R.L.E. (e-mail: rleisenb@bidmc
.harvard.edu ).

姝 RSNA, 2009

882 radiology.rsnajnls.org ▪ Radiology: Volume 252: Number 3—September 2009

THORACIC IMAGING: Value of Lateral Chest Radiography
T
he Centers for Disease Control and
the American Thoracic Society rec-
ommend that individuals with posi-
tive purified protein derivative (PPD) skin
test results undergo screening chest radi-
ography to enable physicians to confirm
or exclude a diagnosis of pulmonary tu-
berculosis (TB) (1). These organizations
advocate that screening consist of the ac-
quisition of one posteroanterior (PA) ra-
diograph but add that “additional radio-
graphs should be performed at the physi-
cian’s discretion” (1). However, the high
number of patients with positive PPD skin
test results who are referred for chest
radiography and the need for efficient
throughput in specialized centers make it
impractical to evaluate the potential need
to acquire a lateral radiograph in each
patient. Therefore, both PA and lat-
eral radiographs continue to be com-
monly obtained during radiographic
screening for TB.
Acquisition of only one PA radiograph
has the potential to reduce patient irradi-
ation and examination costs and increase
patient throughput. Whereas the findings
of one study (2) showed the diagnostic
value of acquiring a lateral radiograph in
children and young adults suspected of
having TB, the researchers who con-
ducted another study in adults with posi-
tive PPD skin test results generated the
hypothesis that lateral radiographs pro-
vided no relevant diagnostic information
(3). Because of its potential to reduce ra-
diation dose, health care costs, and radio-
logic work flow, we aimed to further in-
vestigate this matter in a pre-employment
occupational health setting. The purpose
of our study was to test the hypothesis
that lateral radiography adds no clinically
relevant information to that acquired
with PA radiography in individuals with
positive PPD skin test results.
Advance in Knowledge
䡲 In a pre-employment setting, ac-
quisition of one posteroanterior
radiograph is sufficient for tuber-
culosis screening of individuals
with abnormal purified protein
derivative (PPD) skin test results.
Radiology: Volume 252: Number 3—September 2009 ▪ radiology.rsnajnls.org
Materials and Methods
Institutional Review Board Approval
This retrospective study was approved by
the institutional review board of Beth Is-
rael Deaconess Medical Center. The need
to obtain written informed patient con-
sent was waived. Patient confidentiality
was maintained in accordance with
Health Insurance Portability and Ac-
countability Act guidelines.
Subjects
We included all 875 adults evaluated in
the employee health division of our ter-
tiary care hospital and its affiliated outpa-
tient sites who underwent chest radiogra-
phy because of positive PPD skin test re-
sults obtained during pre-employment
examinations between January 1, 2007,
and December 31, 2007. According to
our hospital’s employee health protocol,
all asymptomatic individuals with positive
PPD skin test results routinely undergo
direct digital chest radiography in PA and
lateral projections as part of their medical
evaluation. Patients were excluded if they
were pregnant (in accordance with our
institutional policy, pregnant women rou-
tinely undergo only PA radiography) (n ⫽
0) or younger than 18 years (n ⫽ 3).
Thus, our final study group included 875
individuals with positive PPD skin test re-
sults (483 women; mean age, 37 years ⫾
11 [standard deviation]; age range,
18 – 65 years; 392 men; mean age, 38
years ⫾ 11; age range, 18 – 65 years). Pa-
tient numbers and radiographic interpre-
tation algorithms are summarized in
Figure 1.
Image Interpretation
All PA and lateral chest radiographs were
available for reading at a picture archiving
and communication system workstation
(Centricity, version 2.1; GE Medical Sys-
tems, Milwaukee, Wis) in our depart-
ment. Radiographs were interpreted by
Implication for Patient Care
䡲 Eliminating the acquisition of lat-
eral radiographs in the screening
of individuals with positive PPD
skin test results will substantially
reduce radiation exposure.
Eisenberg et al
two attending chest radiologists (R.L.E.,
J.R.; 30 and 6 years of experience, re-
spectively, in interpreting chest radio-
graphs of patients suspected of having
TB). One radiologist (R.L.E.) knew the
overall purpose of this study, whereas the
other (J.R.) was aware only that the ef-
fect of detection of abnormalities with lat-
eral radiography was being assessed. The
two radiologists were blinded to the orig-
inal radiologic report but were aware that
all individuals had been referred because
they had positive PPD skin test results.
The two radiologists independently as-
sessed the radiographs for evidence of
abnormalities suggestive of acute or
chronic TB infection by using established
radiographic criteria (1). The most im-
portant indicators of chronic disease are
calcified granulomas and lymph nodes,
apical pleural thickening, fibrosis, and
nodules.
At first, only the PA radiographs were
analyzed, without access to the lateral ra-
diographs. Thereafter, PA and lateral ra-
diographs were analyzed together, with
specific note made as to whether any ob-
served finding was identifiable only on the
lateral radiograph or if it was present on
both images. In all cases, a determination
was made as to whether the findings on
the lateral radiograph changed the deci-
sion made on the basis of findings on the
PA radiograph. If there was a discrepancy
between the findings of the radiologists,
an attempt was made to reach a consen-
sus in a third reading session that in-
Published online before print
10.1148/radiol.2523082019
Radiology 2009; 252:882– 887
Abbreviations:
PA ⫽ posteroanterior
PPD ⫽ purified protein derivative
TB ⫽ tuberculosis
Author contributions:
Guarantor of integrity of entire study, R.L.E.; study con-
cepts/study design or data acquisition or data analysis/
interpretation, all authors; manuscript drafting or manu-
script revision for important intellectual content, all au-
thors; manuscript final version approval, all authors;
literature research, R.L.E., J.R., D.L., A.A.B.; clinical stud-
ies, R.L.E., J.R., A.A.B.; statistical analysis, R.L.E., A.A.B.;
and manuscript editing, all authors
Authors stated no financial relationship to disclose.
883
THORACIC IMAGING: Value of Lateral Chest Radiography Eisenberg et al

cluded only the cases in which there were
discrepancies. If there was continued dis-
agreement, a third attending chest radiol-
ogist (A.A.B., 15 years of experience in
interpreting chest radiographs obtained
in patients suspected of having TB), who
was blinded to the findings of the other
two radiologists, served as the arbitrator
and made the final diagnosis.
Statistical Analysis
All statistical analyses were performed by
using commercially available software
packages (SPSS, version 16.0, SPSS, Chi-
cago, Ill; MedCalc, version 9.6.4.0, Med-
Calc Software, Mariakerke, Belgium).
We first determined the frequency of
positive findings identified separately on
the PA and lateral radiographs on the ba-
sis of the final interpretations. For lateral
radiographs, we analyzed how often the
image (a) revealed an abnormality that
was not apparent on the PA radiograph
or (b) changed the interpretation of any
abnormality seen on the PA radiograph.
Agreement between readers was as-
sessed by using the ␬ statistic (4). The
95% confidence intervals for the ␬ val-
ues were calculated (4,5). A ␬ value of
0.20 or less indicated poor agreement; a
␬ value of 0.21– 0.40, fair agreement; a
␬ value of 0.41– 0.60, moderate agree-
ment; a ␬ value of 0.61– 0.80, good
agreement; and a ␬ value of 0.81–1.00,
excellent agreement (4,6).
cases. Almost all of the disputed cases
were related to whether there was apical
pleural thickening (considered present by
the arbitrator in eight cases) or a small
nodule (deemed absent by the arbitrator
and attributed to a vessel seen on end in
10 cases).
On the basis of the final interpreta-
tions, PA radiographs showed at least one
abnormality in 91 (10.4%) of 875 sub-
jects; three subjects had two abnormali-
ties. In these 91 subjects, a calcified
lymph node or granuloma was seen in 36
(40%) subjects, apical pleural thickening
was seen in 24 (26%), at least one non-
calcified nodule was seen in 23 (25%),
and fibrous scarring was seen in 11 (12%)
(Fig 2). No subject had radiographic find-
ings indicative of active TB.
Lateral radiographs showed no ab-
normality in 75 (82%) of the 91 subjects
(Fig 3). Abnormalities were seen on the
lateral radiograph in 16 (18%) of the 91
subjects (calcified lymph nodes or gran-
ulomas in 13 subjects, noncalcified nod-
ules in three). These findings repre-
sented 36% of the calcified lymph nodes
Figure 1
and/or granulomas and 13% of the non-
calcified nodules seen on the PA radio-
graphs. No cases of fibrous scarring or
apical pleural thickening were identified
on the lateral radiographs. None of the
784 subjects with a normal PA radio-
graph had an abnormality that was sug-
gestive of TB on the lateral radiograph.
All abnormalities seen on lateral ra-
diographs were also seen on PA radio-
graphs. When abnormalities were seen
on both images, in no instance did the
information yielded by the lateral radio-
graph change the decision made on the
basis of findings on the PA image alone.
Interobserver Agreement
The ␬ values are shown in the Table. For
PA chest radiographs, the consensus
reading and arbitration shifted ␬ values
from good to excellent. This shift was
caused by increased agreement in sub-
jects with positive findings, whereas the
agreement in subjects with negative find-
ings remained unchanged. For lateral
chest radiographs, the consensus reading
again shifted ␬ values from good to excel-

Results

Comparison of PA and Lateral

Radiographs
In the first reading session, in which only
PA radiographs were interpreted, at least
one reader deemed findings positive for
TB in 103 (11.8%) of the 875 subjects.
Disagreements between the two readers
that required the arbitrator to make the
final decision occurred in 21 (20.4%) of
these 103 subjects. The arbitrator deter-
mined that there was an abnormal finding
in nine subjects and no abnormal finding
in the remaining 12. In the latter group,
none of the suggested findings were seen
on lateral radiographs. The arbitrator
agreed with the more experienced radiol-
Figure 1: Flow diagram for the study population.
ogist in 17 (81%) of the 21 disputed

884 radiology.rsnajnls.org ▪ Radiology: Volume 252: Number 3—September 2009

THORACIC IMAGING: Value of Lateral Chest Radiography
lent, with this shift being caused by in-
creased agreement in cases with negative
findings. The agreement in cases with
positive findings remained unchanged.
Discussion
In this study of 875 individuals with ab-
normal PPD skin test results who under-
went both PA and lateral chest radiogra-
phy, we determined that it is not neces-
sary to obtain lateral radiographs for this
indication because these images do not
yield additional diagnostic information.
The most common abnormalities de-
tected in our study were calcified lymph
nodes or peripheral granulomas, apical
pleural thickening, and noncalcified nod-
ules. In the 91 subjects with abnormal
findings, all findings were identified on PA
radiographs; only 16 abnormal findings
(18%) were seen on lateral radiographs.
To our knowledge, only one study has
addressed the value of lateral radiographs
in screening chest radiography of adults
with positive PPD skin test results (3). In
an urban population of 535 individuals at
Figure 2
Figure 2: Chest radiographs in a 44-year-old man with positive PPD skin test results. (a) PA image shows several calcified granulomas in the lung apices. (b) Lateral
image helps confirm the presence of granulomas (arrow) but does not provide any additional diagnostic information.
Radiology: Volume 252: Number 3—September 2009 ▪ radiology.rsnajnls.org
high risk for TB, 81 (15%) subjects had
abnormal findings. There were two
(0.4%) subjects in whom calcified granu-
lomas were seen only on lateral radio-
graphs; however, these findings did not
alter treatment. In all other subjects, ab-
normalities seen on lateral radiographs
only served to confirm the findings on the
PA radiographs. However, there was no
specific mention of the percentage of the
81 subjects in whom an abnormality was
seen on the lateral radiograph. There are
salient differences between the method
Meyer et al (3) used and the method we
used. First, Meyer et al surveyed a high-
risk urban population, whereas we fo-
cused on a low-risk pre-employment pop-
ulation in the occupational medicine divi-
sion of the Beth Israel Deaconess Medical
Center and its affiliated outpatient sites.
Second, our study cohort was larger, and
the span of our study was longer. Third,
Meyer et al used hard-copy images,
whereas we used soft-copy images that
were displayed on a picture archiving and
communication system and obtained with
a state-of-the art digital radiographic
Eisenberg et al
technique. Despite the design differences
between the two studies, the comparable
results further challenge the utility of lat-
eral radiography in chest screening exam-
inations of subjects with positive PPD
skin test results in the pre-employment
setting.
There are several potential benefits to
eliminating the acquisition of lateral ra-
diographs in screening examinations of
individuals with positive PPD test results.
Of these, the most important is a reduc-
tion in radiation exposure. On the basis of
data from the National Radiological Pro-
tection Board of the United Kingdom that
indicate that the radiation dose from PA
and lateral chest radiography is 0.02 and
0.04 mSv, respectively (7), eliminating
the acquisition of lateral images would re-
duce the overall radiation exposure per
examination by approximately 67%.
In addition, some cost savings would
result from eliminating the acquisition of
lateral images in these individuals. This
would include expenses related to person-
nel, equipment, and image storage.
Meyer et al (3) reported a savings of $18
885
THORACIC IMAGING: Value of Lateral Chest Radiography Eisenberg et al

Figure 3

Figure 3: Chest radiographs in a 23-year-old man with positive PPD skin test results. (a) PA radiograph shows a small calcified granuloma (arrow) in the right apex.
(b) Lateral radiograph does not show this abnormality.

per study in a non–picture archiving and

communication system environment;
however, we anticipate a much lower sav- Interobserver Agreement
ings per subject in the digital environment
Agreement PA Chest Radiographs Lateral Chest Radiographs
because there are no film costs. Nonethe-
less, considering the worldwide magni- Original reading
tude of examinations performed for this ␬ Value 0.770 (0.697, 0.842) 0.795 (0.654, 0.937)
indication, there would likely be substan- Agreement on negative cases 767 851
tial health care savings on a global basis. Agreement on positive cases 71 16
Potential indirect cost savings of a single- Nonagreement 37 8
view study come in the form of the re- Consensus reading
duced amount of time spent by the radi- ␬ Value 0.853 (0.796, 0.910) 0.839 (0.710, 0.967)
ologist and technologist acquiring and in- Agreement on negative cases 767 853
terpreting images. Agreement on positive cases 83 16
Nonagreement 25 6
Our study had several limitations.
Postarbitration reading
First, it was restricted to an asymptom-
␬ Value 0.860 (0.804, 0.915) NA
atic pre-employment population and, sub-
Agreement on negative cases 781 NA
sequently, there was a low incidence of
Agreement on positive cases 94 NA
findings consistent with old TB disease
Nonagreement 0 NA
that could have been a source of selection
bias. Second, a potential source of bias Note.—Unless otherwise indicated, data are numbers of cases. Data in parentheses are 95% confidence intervals. NA ⫽ not
applicable.
was that the readers focused only on the
issue of TB. Third, the readers were in-
formed about the positive PPD skin test
results of the patients being examined. when interpreting the lateral images; are reviewed together. A final limitation
Fourth, some bias could have been intro- however, this is more reflective of the that could have introduced bias was that
duced because the readers were not actual clinical practice of radiology, in one reader knew the purpose of the
blinded to the results of PA radiography which both PA and lateral radiographs study, whereas the other reader was

886 radiology.rsnajnls.org ▪ Radiology: Volume 252: Number 3—September 2009

THORACIC IMAGING: Value of Lateral Chest Radiography
aware only that we were assessing the
effect of information seen on the lateral
radiographs.
It also must be stressed that our find-
ings are applicable to only the defined
study population of individuals with ab-
normal PPD test results at pre-employ-
ment examinations. Our results may not
apply to children younger than 18 years
or to cohorts of patients who are at high
risk for mediastinal TB, such as those in-
fected with the human immunodeficiency
virus. Moreover, the acquisition of im-
ages in the lateral projection remains an
integral part of the diagnostic evaluation
of patients for most other indications.
Nevertheless, the similarity between the
prevalence of abnormalities on the PA im-
ages in this study and that in similar pop-
ulations in other studies (1) suggests that
our results could be applied to pre-
employment programs across the nation.
In conclusion, in a pre-employment
Radiology: Volume 252: Number 3—September 2009 ▪ radiology.rsnajnls.org
setting, acquisition of one PA radiograph
is sufficient for TB screening of individuals
with abnormal PPD skin test results and
will substantially reduce radiation expo-
sure in this population. The acquisition of
a lateral radiograph provides no addi-
tional diagnostic value. In light of this ev-
idence, at our institution, we have elimi-
nated the acquisition of a lateral radio-
graph from the chest screening examina-
tion performed in patients with positive
PPD skin test results, and we encourage
physicians at other institutions to follow
this recommendation.
Acknowledgments: We acknowledge the sec-
retarial assistance of Nancy Williams and the
support of Dieter W. Affeln, MD, Director of the
Occupational Medicine Division, Beth Israel Dea-
coness Medical Center.
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