Sputum smear negative pulmonary tuberculosis: sensitivity and specificity of diagnostic algorithm

Hedwiga F Swai,Ferdinand M Mugusi,Jessie K Mbwambo

doi:10.1186/1756-0500-4-475

Abstract

BackgroundThe diagnosis of pulmonary tuberculosis in patients with Human Immunodeficiency Virus (HIV) is complicated by the increased presence of sputum smear negative tuberculosis. Diagnosis of smear negative pulmonary tuberculosis is made by an algorithm recommended by the National Tuberculosis and Leprosy Programme that uses symptoms, signs and laboratory results.The objective of this study is to determine the sensitivity and specificity of the tuberculosis treatment algorithm used for the diagnosis of sputum smear negative pulmonary tuberculosis.MethodsA cross-section study with prospective enrollment of patients was conducted in Dar-es-Salaam Tanzania. For patients with sputum smear negative, sputum was sent for culture. All consenting recruited patients were counseled and tested for HIV. Patients were evaluated using the National Tuberculosis and Leprosy Programme guidelines and those fulfilling the criteria of having active pulmonary tuberculosis were started on anti tuberculosis therapy. Remaining patients were provided appropriate therapy. A chest X-ray, mantoux test, and Full Blood Picture were done for each patient. The sensitivity and specificity of the recommended algorithm was calculated. Predictors of sputum culture positive were determined using multivariate analysis.ResultsDuring the study, 467 subjects were enrolled. Of those, 318 (68.1%) were HIV positive, 127 (27.2%) had sputum culture positive for Mycobacteria Tuberculosis, of whom 66 (51.9%) were correctly treated with anti-Tuberculosis drugs and 61 (48.1%) were missed and did not get anti-Tuberculosis drugs. Of the 286 subjects with sputum culture negative, 107 (37.4%) were incorrectly treated with anti-Tuberculosis drugs. The diagnostic algorithm for smear negative pulmonary tuberculosis had a sensitivity and specificity of 38.1% and 74.5% respectively. The presence of a dry cough, a high respiratory rate, a low eosinophil count, a mixed type of anaemia and presence of a cavity were found to be predictive of smear negative but culture positive pulmonary tuberculosis.ConclusionThe current practices of establishing pulmonary tuberculosis diagnosis are not sensitive and specific enough to establish the diagnosis of Acid Fast Bacilli smear negative pulmonary tuberculosis and over treat people with no pulmonary tuberculosis.

Highlights

The diagnosis of pulmonary tuberculosis in patients with Human Immunodeficiency Virus (HIV) is complicated by the increased presence of sputum smear negative tuberculosis
With the sharp rise of pulmonary tuberculosis (PTB) in countries which are worst affected by the HIV epidemics, the number of patients with suspected PTB who are sputum smear negative has increased [5]
A cross-sectional study with prospective enrollment was conducted at Muhimbili National Hospital (MNH), a university teaching and national referral hospital, and at out-patient tuberculosis clinics at the Infectious Disease Clinic (IDC), Mwananyamala, Temeke and Ilala district hospitals, from September 2000 to December 2000

Summary

Introduction

The diagnosis of pulmonary tuberculosis in patients with Human Immunodeficiency Virus (HIV) is complicated by the increased presence of sputum smear negative tuberculosis. There has been a sharp rise in the incidence of pulmonary tuberculosis (PTB) worldwide since the mid 1980’s, in the Sub-Saharan African region This has been attributed mainly to the appearance and wide spread of Human Immunodeficiency Virus (HIV) infection on the continent [1,2,3]. It has always been recognized that a proportion of patients are sputum smear negative using the Ziehl-Nelseen (ZN) stain, the commonly used stain in most laboratories in the region to detect AFB in sputum. This is a simple, rapid and cheap test but lacks sensitivity of a single sputum test [4]. With the sharp rise of PTB in countries which are worst affected by the HIV epidemics, the number of patients with suspected PTB who are sputum smear negative has increased [5]

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