Imaging errors
==============

* John Clark

I have read with interest the recent CMAJ series on tuberculosis. As a radiologist, however, I feel compelled to comment on the article on extrapulmonary tuberculosis. [1]

Figure 1does not show left mid-ureteral narrowing and upper tract dilatation. It shows multifocal right ureteral disease and irregularity of the urinary bladder wall. There may be upper urinary tract dilatation, but this is mostly obscured.

Figure 2does not show narrowing of the L3-L4 disk, nor does it show a filling defect in the intrathecal contrast. The narrowing is at L4-L5, where there are changes associated with discitis. The intrathecal contrast shows extrinsic compression on the thecal sac at this level; a filling defect implies an intrathecal abnormality.

Figure 3does not show miliary nodules. These may be present on the original film but are not evident on this poorly reproduced image. A magnified view of one portion of the lung, carefully reproduced, would be necessary to show miliary nodules.

Figure 4shows a destructive process within the bone rather than inflammation of the meninges. The meninges are not seen on bone-windowed CT images. Inflamed meninges can generally be seen only on contrast-enhanced MRI scans.

Given the importance of imaging to modern diagnosis, and the ease with which high-quality images can be made and reproduced in the electronic era, there is no excuse for poor reproductions and errors such as these. The title page affirms that this article has been peer reviewed; I assume that none of these peers has expertise in imaging. Perhaps CMAJ would be better served by ensuring review of diagnostic images by a radiologist before publication.

John Clark, MD CM

St. Michael's Hospital; Toronto, Ont.

## References

1.  1. Fanning A. Tuberculosis: 6. Extrapulmonary disease. CMAJ1999;160(11):1597-603.
    
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