Multidisciplinary diagnosis of interstitial lung disease in Zambia using videoconferencing

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.

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 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, HWvE, JCG and KJM participated in the videoconferences. TH and KJM collected patient data. TH wrote the initial draft of the manuscript. HWvE, JCG and KJM 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