Опубликовано04.03.2019 в 07:46АвторYozshuzragore

Diagnostic Laparoscopic - Tuberculosis Abdomen

PDF To the Editors: Tuberculosis TB is the leading cause of morbidity and mortality in HIV-infected patients in sub-Saharan Africa 1 , in part because limited availability of diagnostic tests hinders early, directed treatment. Studies have demonstrated a substantial yield of bronchoscopy for diagnosing HIV-associated opportunistic pulmonary diseases, but few studies have explicitly considered whether bronchoscopy adds to the sensitivity of sputum culture in identifying Mycobacterium tuberculosis, or whether bronchoscopy shortens the time needed to diagnose TB.

Although bronchoscopy is unavailable in many HIV and TB endemic settings, where it is available its usefulness for TB diagnosis is uncertain.

Thus, we examined the performance of bronchoscopy to diagnose TB and other pulmonary diseases in HIV-infected inpatients with cough in Kampala, Uganda. After providing informed consent, patients underwent a standard evaluation including chest radiography, sputum acid-fast bacillus AFB microscopy and bronchoscopy with bronchoalveolar lavage BAL if they were AFB smear-negative, according to previously described protocols 2.

Bronchoscopy is commonly used for investigating patients with possible pulmonary tuberculosis (TB) when spontaneous sputum is smear negative. However.

Specific pneumonia treatment was recorded. Patients were seen at a 2-month follow-up visit, after which a pulmonologist and a medical officer assigned final diagnoses based on all diagnostic information and according to a standardised protocol. Among the 86 patients who did not undergo bronchoscopy, 24 patients had an alternate diagnosis established, 26 refused the procedure and 20 died before bronchoscopy could be performed. Baseline demographic and clinical characteristics were similar among patients who underwent and who did not undergo bronchoscopy.

Median time from enrolment to bronchoscopy was 4 days interquartile range IQR 2—6 days. There were no important procedural complications arising from bronchoscopy. Six patients had more than one diagnosis. A final diagnosis of pulmonary TB was made in 39 patients and definitively excluded in 39 patients.

For the remaining 29 patients, 2-month follow-up information was not available e. However, these two strategies identified different but intersecting sets of individuals: The median time from enrolment to TB diagnosis was 5.

Four out of 10 TB patients with normal chest radiographs were diagnosed with TB by bronchoscopy alone. View popup Table 1— The contribution of sputum and bronchoalveolar lavage BAL to the diagnosis of smear-negative tuberculosis TB This study demonstrates that fiberoptic bronchoscopy is useful in HIV-infected, AFB sputum smear-negative patients with persistent cough in Uganda.

It increased the diagnostic yield for pulmonary TB and decreased the time required for a microbiologically confirmed diagnosis of TB. These findings are important for clinicians caring for HIV-infected patients in settings with access to bronchoscopy and provide a clear rationale for its use in these settings.

These findings are also important for clinical investigators choosing reference standards for studies of novel TB diagnostics in countries with high prevalences of HIV and TB.

Our findings are consistent with previous studies demonstrating a high yield of bronchoscopy in HIV-infected TB suspects in high-burden countries 3. In the current study, bronchoscopy with BAL diagnosed about half of all TB cases, and in one-quarter of all TB cases, BAL smear reduced average time to a microbiologically confirmed diagnosis by up to 3 weeks. Earlier diagnosis is shown to have important implications both for improved individual patient outcomes and for tuberculosis infection control 4 , particularly in areas where TB-drug resistance and HIV infection are frequent 5.

Sputum culture detected less than half of all TB cases in our study, and one-third of all TB diagnoses was based on a clinical response to treatment alone. These findings emphasise the need for more sensitive diagnostic tests for TB in HIV-infected patients.

In our study, we found bronchoscopy safe, without significant complications. However, bronchoscopy is expensive and the requisite personnel and equipment are not widely available in countries like Uganda. This may limit the generalisability of these results. As an alternative approach, some studies suggest that induced sputum greatly enhances the diagnosis of TB 6 and that the yield of serial induced sputa for TB diagnosis may be similar to or better than that of bronchoscopy 7 , 8.

Because sputum induction has a lower sensitivity than BAL for PCP and other pulmonary diseases diagnosed by bronchoscopy, this should be further examined in prospective studies. This study also provides important information about the limitations of sputum culture on solid media as a TB reference standard, especially in HIV-infected patients. In a TB diagnostics study, these differences would lead to substantial increases in study power and substantial decreases in the number of patients with indeterminate or misclassified diagnoses.

This further emphasises the need to improve the gold standard for TB diagnosis in HIV-infected populations. There are some limitations to our study. One-quarter of these died before bronchoscopy, a statistic which reflects the severity of illness among hospitalised patients with pneumonia. Secondly, we performed mycobacterial cultures only on solid media and not in liquid media.

J Bras Pneumol. Mar-Apr;38(2) Bronchoscopy for the diagnosis of pulmonary tuberculosis in patients with negative sputum smear microscopy.

While the decrease in time-to-diagnosis of TB reported for liquid culture compared with solid culture is substantial, it is less than the day decrease which we observed for BAL smear compared to solid culture Future studies of the overall yield and cost-effectiveness of bronchoscopy compared to sputum induction would help to determine the best strategy for routine evaluation of HIV-infected smear-negative TB suspects in resource-limited countries.

Acknowledgments This work was performed at Mulago National Referral Hospital in Kampala, Uganda, and the authors wish to thank the patients who participated in this study, the Mulago Hospital staff and administration, and the laboratory technicians at the Uganda National Tuberculosis Reference Laboratory.

Cattamanchi , K23 AI J. Davis , K24 HL L.

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