Noninvasive testing of asymptomatic bilateral hilar adenopathy

• Published in: Journal of general internal medicine : JGIM Vol. 5; no. 2; pp. 138 - 146
• Main Authors: Carr, P L, Singer, D E, Goldenheim, P, Bernardo, J, Mulley, A G
• Format: Journal Article
• Language: English
• Published: United States 01-03-1990
• Subjects: BACTERIAL DISEASES; Bayes Theorem; BODY; Bronchoscopy; Coccidioidomycosis - epidemiology; COUNTING TECHNIQUES; DIAGNOSIS; DISEASES; ENZYMES; GALLIUM ISOTOPES; Gallium Radioisotopes; Histoplasmosis - epidemiology; Humans; HYDROLASES; IMMUNE SYSTEM DISEASES; INFECTIOUS DISEASES; ISOTOPES; Lung Diseases - epidemiology; Lung Diseases, Fungal - epidemiology; LUNGS; Lymphatic Diseases - epidemiology; Lymphatic Diseases - etiology; Lymphoma - epidemiology; LYMPHOMAS; NEOPLASMS; ORGANIC COMPOUNDS; ORGANS; PATIENTS; PEPTIDE HYDROLASES; Peptidyl-Dipeptidase A - blood; Prevalence; PROTEINS; RADIOISOTOPE SCANNING; RADIOLOGY AND NUCLEAR MEDICINE; RESPIRATORY SYSTEM 550601 > Medicine > Unsealed Radionuclides in Diagnostics; RESPIRATORY SYSTEM DISEASES; Sarcoidosis - epidemiology; SENSITIVITY ANALYSIS; Sensitivity and Specificity; SPECIFICITY; Tuberculin Test; TUBERCULOSIS; Tuberculosis, Pulmonary - epidemiology
• ISSN: 0884-8734; 1525-1497
• DOI: 10.1007/BF02600516

The diagnostic strategy for asymptomatic patients with persistent bilateral bilar adenopathy often involves invasive procedures. The authors used Bayesian analysis to: 1) estimate the relative prevalences of diseases causing bilateral bilar adenopathy; 2) assess changes in the prevalence of disease by race, the presence of other clinical symptoms, and geography; and 3) determine the value of relevant noninvasive tests, including the angiotensin-converting enzyme (ACE) assay, gallium scan, and purified protein derivative (PPD), in order to assess when a strategy of watchful waiting is appropriate. The analysis indicated that the ACE assay, particularly when paired with the PPD, can identify many patients who might safely be managed without immediate invasive biopsy. Patients who are ACE+ and PPD- have an estimated probability of sarcoidosis of 0.95 or greater; patients who are ACE- and PPD+ have a probability of tuberculosis of 0.86 if black, 0.79 if white. In contrast, gallium scanning has no diagnostic role in this clinical situation. Bronchoscopic or mediastinoscopic biopsy has a limited role for patients who are ACE+ PPD- or ACE- PPD+ because of limited sensitivity. Patients who are both ACE- and PPD-, particularly if white, may have a high enough risk of lymphoma to consider invasive biopsy.