Grutters, Jan

Hoffman, Thijs

Mateyo, Kondwelani

van Es, Wouter

PubMed

Utrecht University Repository

Article      Letter to the editors  Multidisciplinary diagnosis of interstitial lung disease in Zambia using videoconferencing  Thijs Hoffman, Wouter van Es, Jan Grutters, Kondwelani Mateyo Corresponding author: Kondwelani Mateyo, Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia. kondwelanimateyo@yahoo.co.uk Received: 24 Jan 2022 - Accepted: 04 Feb 2022 - Published: 08 Mar 2022 Keywords: Interstitial lung disease, Zambia, videoconference  Copyright: Thijs Hoffman et al. Pan African Medical Journal (ISSN: 1937-8688). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Cite this article: Thijs Hoffman et al. Multidisciplinary diagnosis of interstitial lung disease in Zambia using videoconferencing. Pan African Medical Journal. 2022;41(183). 10.11604/pamj.2022.41.183.33450 Available online at: https://www.panafrican-med-journal.com//content/article/41/183/full Multidisciplinary diagnosis of interstitial lung disease in Zambia using videoconferencing Thijs Hoffman1, Wouter van Es2, Jan Grutters3, Kondwelani Mateyo4,& 1Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands, 2Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands, 3Department of Pulmonology, Division of Heart and Lungs, University Medical Centre, Utrecht, The Netherlands, 4Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia &Corresponding author Kondwelani Mateyo, Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia To the editors of the Pan African Medical Journal     The diagnosis and management of interstitial lung diseases (ILD) are usually performed in the context of a multidisciplinary team [1]. This is associated with improved diagnostic confidence and is considered to be the gold standard for ILD diagnosis [2]. A recent study found the practice of multidisciplinary team diagnosis was widespread across the world [3]. However, this study had few responses from Africa, and it was noted that the frequency of formal multidisciplinary team meetings was lower in African centres compared to other centres. Article    Thijs Hoffman et al. PAMJ - 41(183). 08 Mar 2022.  -  Page numbers not for citation purposes. 2 Overall, there are few epidemiological data available on the prevalence of ILD in Africa [4, 5]. Factors that potentially influence prevalence of ILD in African countries are higher rates of occupational exposure to silica [6], lower prevalence of cigarette smoking [7], and a higher prevalence of tuberculosis and human immunodeficiency virus infection [8, 9]. Here we present the results of a collaboration between University Teaching Hospital in Lusaka, Zambia, and the ILD Centre of Excellence at St. Antonius Hospital in Nieuwegein, The Netherlands. Starting in December 2018 we have held bimonthly videoconferences, lasting approximately one hour. One or more pulmonologists and one or more radiologists (with >20 years of experience in ILD) from St. Antonius Hospital are present. The patients are presented by the registrars, medical students, or a pulmonologist from a University Teaching Hospital. The chest CT-scan, which was sent to St. Antonius Hospital in advance, is then described by the radiologist. The pulmonologists then discuss relevant findings and differential diagnoses. Advice is formulated with regard to further investigations and/or patient management. After the conference, a written report of the cases that were discussed is sent to the University Teaching Hospital. For this study, approval was obtained from the Zambian medical ethics committee (UNZABREC reference number 1960-2021). In total, 41 unique patients have been discussed in the course of ten videoconferences (Table 1 and Table 2). After multidisciplinary discussion and (in some cases) additional diagnostic investigations, twenty-one patients most likely had an interstitial lung disease. This included seven patients with pulmonary fibrosis (one with likely idiopathic pulmonary fibrosis, four with connective-tissue disease associated to pulmonary fibrosis, one with combined pulmonary fibrosis and emphysema, and one with drug-induced pulmonary fibrosis), as well as six patients with sarcoidosis (histopathological confirmation in three patients), two patients with hypersensitivity pneumonitis, two patients with silicosis, two patients with lymphangioleiomyomatosis, one patient with organizing pneumonia, and one patient with childhood-ILD. In patients who did not have an interstitial lung disease, the most likely diagnoses included infection or post-infectious sequelae in five patients, lung damage due to chronic aspiration in two patients, pulmonary vascular disease in two patients, heart failure in three patients, asthma in three patients, emphysema in one patient and Mounier-Kühn syndrome in one patient [10]. In three patients, no clear diagnosis could be made. Of note, eleven out of 41 patients had previously been treated for presumed tuberculosis (in the absence of positive sputum cultures). This included three patients who were eventually diagnosed with sarcoidosis (all patients had negative tuberculosis diagnostics on bronchial washings, and sarcoidosis was confirmed by histopathology in two out of three patients). Several issues were encountered that make diagnosis and treatment of ILD more difficult in Zambia. First, the quality of radiological imaging is not always optimal, which makes interpretation more difficult. However, in the last two years, we have seen a clear improvement in image quality. Second, some diagnostic tests are not (easily) available, including diffusion capacity of the lung for carbon monoxide, open lung biopsy, and nail fold capillary microscopy. Third, the patient delay is often longer, which makes treatment less effective in several types of fibrotic lung disease. Fourth, not all treatment options are (easily) available in Zambia, including antifibrotic agents, second- and third-line immunosuppressive agents, and lung transplantation. Fifth, patient follow up is often more difficult, as some patients have to travel much longer to come to the hospital. Finally, this study illustrates the dangers of giving pragmatic anti-tubercular treatment based on chest X-rays and symptoms, as many patients were treated for presumed tuberculosis, but turned out to have an ILD. This can hopefully be Article    Thijs Hoffman et al. PAMJ - 41(183). 08 Mar 2022.  -  Page numbers not for citation purposes. 3 ameliorated by an increased availability of CT-scanners and increased awareness of ILD. In the future, registries of ILD diagnoses in sub-Saharan Africa can be used for comparing prevalence of different types of ILD and the response to treatment. Registration of ILD diagnoses would provide insight into local prevalence of specific diseases, such as work-related ILD (e.g., pneumoconiosis), and this might aid with the implementation of preventive measures. Conclusion: in conclusion, the whole spectrum of ILD can be seen in sub-Saharan Africa. International collaborations could contribute to improving diagnosis and care for patients with ILD and other rare and/or complex diseases all over the world, even though they only require relatively small investments of time and infrastructure from both parties. Competing interests     The authors declare no competing interests. Authors' contributions     TH, WvE, JG and KM participated in the videoconferences. TH and KM collected patient data. TH wrote the initial draft of the manuscript. WvE, JG and KM critically reviewed the manuscript. All authors read and approved the final version of the manuscript. Tables     Table 1: overview of patients with a presumed ILD diagnosis that have been discussed at the videoconferences Table 2: overview of patients with a presumed non-ILD diagnosis that have been discussed at the videoconferences References     1. Walsh SLF. Multidisciplinary evaluation of interstitial lung diseases: Current insights. Eur Respir Rev. 2017 Jun 30;26(144). Google Scholar 2. Walsh SLF, Wells AU, Desai SR, Poletti V, Piciucchi S, Dubini A et al. Multicentre evaluation of multidisciplinary team meeting agreement on diagnosis in diffuse parenchymal lung disease: a case-cohort study. Lancet Respir Med. 2016 Jul;4(7): 557-565. PubMed| Google Scholar 3. Richeldi L, Launders N, Martinez F, Walsh SLF, Myers J, Wang B et al. The characterisation of interstitial lung disease multidisciplinary team meetings: a global study. ERJ Open Res. 2019 Apr 1;5(2): 00209-2018. PubMed| Google Scholar 4. Rivera-Ortega P, Molina-Molina M. Interstitial lung diseases in developing countries. Ann Glob Health. 2019 Jan 22;85(1): 4. PubMed| Google Scholar 5. Olaosebikan H, Adeyeye O, Akintayo R, Akpabio A, Adenitan A, Adelowo O et al. Connective tissue disease-associated interstitial lung disease: an underreported cause of interstitial lung disease in Sub-Saharan Africa. Clin Rheumatol. 2021 Sep;40(9): 3455-3460. PubMed| Google Scholar 6. Leung CC, Yu ITS, Chen W. Silicosis. Lancet. 2012 May 26;379(9830): 2008-18. PubMed| Google Scholar 7. Reitsma MB, Fullman N, Ng M, Salama JS, Abajobir A, Abate KH et al. Smoking prevalence and attributable disease burden in 195 countries and territories, 1990-2015: A systematic analysis from the global burden of disease study 2015. Lancet. 2017 May 13;389(10082): 1885-1906. PubMed| Google Scholar 8. Furin J, Cox H, Pai M. Tuberculosis. Lancet. 2019 Apr 20;393(10181): 1642-1656. PubMed Article    Thijs Hoffman et al. PAMJ - 41(183). 08 Mar 2022.  -  Page numbers not for citation purposes. 4 9. Frank TD, Carter A, Jahagirdar D, Biehl MH, Douwes-Schultz D, Larson SL et al. Global, regional, and national incidence, prevalence, and mortality of HIV, 1980-2017, and forecasts to 2030, for 195 countries and territories: A systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors Study 2017. 10. Shahin S, Hoffman T, Es W van, Grutters J, Mateyo K. Congenital tracheobronchomegaly (Mounier-Kuhn syndrome) in a 28-year-old Zambian male: a case report. Pan Afr Med J. 2021; 40: 153. PubMed| Google Scholar Lancet HIV. 2019 Dec;6(12): e831-e859. PubMed| Google Scholar                                             Article    Thijs Hoffman et al. PAMJ - 41(183). 08 Mar 2022.  -  Page numbers not for citation purposes. 5 Table 1: overview of patients with a presumed ILD diagnosis that have been discussed at the videoconferences Sex/age, relevant medical history, exposures Previous treatment for TB Chest CT findings Histopathology Most likely diagnosis (differential) Pulmonary fibrosis         F/44 Yes fNSIP, dilated oesophagus NA CTD-ILD (SSc, Sjogrens, idiopathic fNSIP) M/69, HIV No fNSIP, possibly fDIP, dilated PT NA CTD-ILD (fDIP, CHP, idiopathic fNSIP) M/58 No fNSIP, enlarged PT NA CTD-ILD (idiopathic fNSIP) F/59, presumed sarcoidosis in 2017 No Fibrosis in lower lobes consistent with fNSIP; no lymphadenopathy NA CTD-ILD (idiopathic fNSIP) F/72, HF No Pulmonary fibrosis, indeterminate for UIP NA IPF (CHP, CTD-ILD, idiopathic fNSIP) M/72, 40 PY No Emphysema in upper fields with some fibrotic changes in lower fields NA CPFE F/31, MTX for RA No fNSIP NA MTX-related lung disease (CTD-ILD) Sarcoidosis         M/59, 5PY, mineral dust Yes Diffuse subpleural and perifissural nodular abnormalities Non-caseating granulomas (TBB) Sarcoidosis (pneumoconiosis) F/65, CVA No Hilar and mediastinal lymphadenopathy, perifissural intrapulmonary nodules NA Sarcoidosis (TB) F/42 Yes Mediastinal lymphadenopathy, multiple consolidations, cavitating lesion in right upper lobe Non-specific chronic inflammatory infiltrates (TBB) Sarcoidosis, complicated by pulmonary aspergilloma F/19, Yes Mediastinal and hilar lymphadenopathy, intraparenchymal nodules in lung parenchyma also perifissural; hepatosplenomegaly Mostly non-caseating granulomas (LN) Sarcoidosis M/22 No Bilateral hilar and mediastinal lymphadenopathy with subpleural and perihilar pulmonary nodules Non-caseating granulomas (TBB) Sarcoidosis M/47, pneumonia 3 months ago No Diffuse pulmonary nodules in the perihilar subpleural regions; bilateral hilar and mediastinal lymphadenopathy Chronic inflammation with lymphocytic infiltration (TBB) Sarcoidosis Other         F/66, CKD, AF No Some fibrosis in the apices, diffuse mosaic attenuation with air-trapping; elevated right hemidiaphragm NA CHP M/51, parrot, grain silos No Diffuse ground glass and mosaic attenuation NA HP (DIP, NSIP, DAH) F/38, recurrent pneumothoraces No Cystic lung disease, suggestive of LAM NA LAM F/43, HIV No Diffuse cystic lung disease, perivascular and subpleural NA LAM (BHD, LIP) M/47, electrician in a mine, joint pains and positive ANA Yes Diffuse nodular abnormalities also perifissural, no lymphadenopathy NA Caplan syndrome M/29, gemstone cutter No Diffuse nodular abnormalities predominantly in the upper fields, some consolidative changes, subpleural thickening, enlarged PT NA Silico-proteinosis M/53, exposure to fumes as mechanic Yes Multiple ground glass areas without fibrosis NA OP, possibly due to toxic exposure at work (infection) M/15 Yes Diffuse cystic lung disease with fibrosis and traction bronchiectasis, most consistent with surfactant gene mutation NA Childhood ILD, possibly related to surfactant gene mutation F = female, M = male, fNSIP = fibrotic non-specific interstitial pneumonia, HIV = human immunodeficiency virus, TB = tuberculosis, CVA = cerebrovascular accident, PY = packyears, MTX = methotrexate, RA = rheumatoid arthritis, HF = heart failure, CKD = chronic kidney disease, AF = atrial fibrillation, NA = not available, LN = lymph node, fDIP = fibrosing desquamative interstitial pneumonia, PT = pulmonary trunk, (C)HP = (chronic) hypersensitivity pneumonitis, DAH = diffuse alveolar haemorrhage, SSc = systemic sclerosis; CTD-ILD = connective-tissue disease associated interstitial lung disease, CPFE = combined pulmonary fibrosis and emphysema, LAM = lymphangioleiomyomatosis, TBB = transbronchial biopsy, BHD = Birt-Hogg-Dubé syndrome, LIP = lymphoid interstitial pneumonia, PE = pulmonary embolism, ANA = antinuclear antibodies     Article    Thijs Hoffman et al. PAMJ - 41(183). 08 Mar 2022.  -  Page numbers not for citation purposes. 6 Table 2: overview of patients with a presumed non-ILD diagnosis that have been discussed at the videoconferences Sex/age, relevant medical history, exposures Previous treatment for TB Chest CT findings Histopathology Most likely diagnosis (differential) Related to infections or aspiration         F/34 Yes Bilateral pectoral lymphadenopathy, left axillary lymphadenopathy, no intrapulmonary abnormalities Caseating granulomas (LN) Infection (TB, possibly sarcoid-like reaction after infection) F/47, HIV No Airway disease NA Infection F/68 No Ground glass with minimal fibrosis: fNSIP NA Infection with some post-infectious sequelae (CTD-ILD, drug-induced ILD) F/29, DVT No Multiple large nodules, consolidation in right lower lobe NA Infection (OP, vasculitis) M/61, 50 PY, amiodarone No Mediastinal and hilar lymphadenopathy, diffuse ground glass and consolidations NA Infection (amiodarone toxicity, acute HP) F/64 No Bronchiectasis in right lower lobe, post-infectious sequelae in left lower lobe, dilated oesophagus NA Chronic aspiration M/65 No Bilateral consolidations, cavitating lesions in the left lung, dilated oesophagus NA Chronic aspiration (vasculitis, fungal infection) M/28, 4 PY, construction worker Yes Dilated trachea with diverticula (>30mm), dilated main bronchi, diffuse cystic bronchiectasis NA Mounier-Kühn syndrome Cardiac or pulmonary vascular disease         M/50 No Normal NA Cardiac disease (gastro-esophageal reflux) F/63, cardiomyopathy No fNSIP or hemosiderosis, dilated PT NA Hemosiderosis due to chronic heart failure (fNSIP) F/65 Yes Bilateral consolidations and pleural effusions NA Heart failure complicated by infection F/51 No Ground glass in mosaic pattern, honeycombing, consolidations, dilated PT NA CTEPH (CTD-ILD, CHP, or FPF) M/68, HIV, right ventricular mass being analyzed No Some emphysema in upper lobes, dilated PT, thrombus at wall of right pulmonary artery NA PE or pulmonary arterial sarcoma Airway diseases         M/62, HIV, 42 PY Yes Paraseptal emphysema with some fibrosis, cavitary lesion with a mass in the left upper lobe, tracheal thickening on the right NA Emphysema with aspergilloma and postinfectious changes in trachea M/48 No No abnormalities NA Asthma F/29 No Diffuse mosaic attenuation, airway disease NA Asthma M/46, HIV No Spiculated mass in left upper lobe, several small nodules in right upper lobe NA Asthma, possibly lung cancer or post-infectious changes in left upper lobe Other         M/31, pneumonia 6 months ago No Somewhat dilated pulmonary trunk, otherwise no abnormalities NA Unknown (methemoglobulinemia, sickle cell disease) M/52 No No abnormalities No abnormalities (TBB) Unknown (sarcoidosis) F/61 Yes Intrapulmonary calcifications, hepatomegaly, hyperintense liver NA Unknown (Amyloidosis, hemochromatosis, pneumoconiosis, diffuse pulmonary ossification) F = female, M = male,  HIV = human immunodeficiency virus, TB = tuberculosis, CVA = cerebrovascular accident, PY = packyears, OP = organizing pneumonia, DVT = deep vein thrombosis, MTX = methotrexate, RA = rheumatoid arthritis, HF = heart failure, CKD = chronic kidney disease, AF = atrial fibrillation, NA = not available, LN = lymph node, fDIP = fibrosing desquamative interstitial pneumonia, PT = pulmonary trunk, (C)HP = (chronic) hypersensitivity pneumonitis, DAH = diffuse alveolar haemorrhage, CTD-ILD = connective-tissue disease associated interstitial lung disease, TBB = transbronchial biopsy, FPF familial pulmonary fibrosis    

Multidisciplinary diagnosis of interstitial lung disease in Zambia using videoconferencing

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Multidisciplinary diagnosis of interstitial lung disease in Zambia using videoconferencing

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