U.S. Centers for Disease Control and Prevention, Division of Tuberculosis Elimination, Atlanta, GA 30333, USA.
N Engl J Med. 2010 Feb 25;362(8):707-16. doi: 10.1056/NEJMoa0907488.
Tuberculosis screening is recommended for people with human immunodeficiency virus (HIV) infection to facilitate early diagnosis and safe initiation of antiretroviral therapy and isoniazid preventive therapy. No internationally accepted, evidence-based guideline addresses the optimal means of conducting such screening, although screening for chronic cough is common.
We consecutively enrolled people with HIV infection from eight outpatient clinics in Cambodia, Thailand, and Vietnam. For each patient, three samples of sputum and one each of urine, stool, blood, and lymph-node aspirate (for patients with lymphadenopathy) were obtained for mycobacterial culture. We compared the characteristics of patients who received a diagnosis of tuberculosis (on the basis of having one or more specimens that were culture-positive) with those of patients who did not have tuberculosis to derive an algorithm for screening and diagnosis.
Tuberculosis was diagnosed in 267 (15%) of 1748 patients (median CD4+ T-lymphocyte count, 242 per cubic millimeter; interquartile range, 82 to 396). The presence of a cough for 2 or 3 weeks or more during the preceding 4 weeks had a sensitivity of 22 to 33% for detecting tuberculosis. The presence of cough of any duration, fever of any duration, or night sweats lasting 3 or more weeks in the preceding 4 weeks was 93% sensitive and 36% specific for tuberculosis. In the 1199 patients with any of these symptoms, a combination of two negative sputum smears, a normal chest radiograph, and a CD4+ cell count of 350 or more per cubic millimeter helped to rule out a diagnosis of tuberculosis, whereas a positive diagnosis could be made only for the 113 patients (9%) with one or more positive sputum smears; mycobacterial culture was required for most other patients.
In persons with HIV infection, screening for tuberculosis should include asking questions about a combination of symptoms rather than only about chronic cough. It is likely that antiretroviral therapy and isoniazid preventive therapy can be started safely in people whose screening for all three symptoms is negative, whereas diagnosis in most others will require mycobacterial culture.
为了促进艾滋病毒（HIV）感染者的早期诊断和安全启动抗逆转录病毒治疗和异烟肼预防治疗，建议对其进行肺结核筛查。虽然慢性咳嗽的筛查很常见，但没有国际公认的循证指南来确定进行这种筛查的最佳方法。
我们连续招募了来自柬埔寨、泰国和越南的 8 个门诊诊所的 HIV 感染者。对于每个患者，采集三份痰样本和一份尿液、粪便、血液和淋巴结抽吸物（对于有淋巴结病的患者）进行分枝杆菌培养。我们比较了诊断为肺结核（基于一份或多份培养阳性的标本）的患者与未患肺结核的患者的特征，以得出一种筛查和诊断的算法。
在 1748 名患者中（中位数 CD4+T 淋巴细胞计数为 242 个/立方毫米；四分位间距为 82 至 396）诊断出 267 例（15%）肺结核。在过去 4 周内，有 2 或 3 周或更长时间的咳嗽的敏感性为 22%至 33%，用于检测肺结核。在过去 4 周内，有任何时间的咳嗽、任何时间的发热或持续 3 周或更长时间的夜间盗汗的患者，其敏感性为 93%，特异性为 36%，用于肺结核。在 1199 名有这些症状之一的患者中，结合两次阴性痰涂片、正常胸片和每立方毫米 350 个或更多的 CD4+细胞计数有助于排除肺结核的诊断，而仅能对 113 名（9%）有一个或多个阳性痰涂片的患者做出阳性诊断；大多数其他患者需要进行分枝杆菌培养。
在 HIV 感染者中，肺结核筛查应包括询问一组症状，而不仅仅是慢性咳嗽。对于所有三种症状均为阴性的患者，很可能可以安全地开始抗逆转录病毒治疗和异烟肼预防治疗，而大多数其他患者的诊断则需要分枝杆菌培养。
