Approved Treatment Center for HIV/AIDS, Bamenda Regional Hospital, Bamenda, Cameroon.
The Roslin Institute, University of Edinburgh, Edinburgh, United Kingdom.
PLoS One. 2018 Jun 26;13(6):e0199634. doi: 10.1371/journal.pone.0199634. eCollection 2018.
Diagnosis of tuberculosis in people living with HIV is challenging due to non-specific clinical presentations and inadequately sensitive diagnostic tests. The WHO recommends screening using a clinical algorithm followed by rapid diagnosis using the Xpert MTB/RIF assay, and more information is needed to evaluate these recommendations in different settings.
From August 2012 to September 2013, consecutive adults newly diagnosed with HIV in Bamenda, Cameroon, were screened for TB regardless of symptoms by smear microscopy and culture; the Xpert MTB/RIF assay was performed retrospectively. Time to treatment and patient outcomes were obtained from routine registers.
Among 1,149 people enrolled, 940 (82%) produced sputum for lab testing; of these, 68% were women, the median age was 35 years (IQR, 28-42 years), the median CD4 count was 291cells/μL (IQR, 116-496 cells/μL), and 86% had one or more of current cough, fever, night sweats, or weight loss. In total, 131 people (14%, 95% CI, 12-16%) had sputum culture-positive TB. The WHO symptom screening algorithm had a sensitivity of 92% (95%CI, 86-96%) and specificity of 15% (95%CI, 12-17%) in this population. Compared to TB culture, the sensitivity of direct smear microscopy was 25% (95% CI, 18-34%), and the sensitivity of Xpert was 68% (95% CI, 58-76); the sensitivity of both was higher for people reporting more symptoms. Only one of 69 people with smear-negative/culture-positive TB was started on TB treatment prior to culture positivity. Of 71 people with bacteriologically-confirmed TB and known outcome after 6 months, 13 (17%) had died, including 11 people with smear-negative TB and 6 people with both smear and Xpert-negative TB.
Use of the most sensitive rapid diagnostic test available is critical in people newly diagnosed with HIV in this setting to maximize the detection of bacteriologically-confirmed TB. However, this intervention is not sufficient alone and should be combined with more comprehensive clinical diagnosis of TB to improve outcomes.
由于临床表现不典型和诊断检测不够敏感，艾滋病毒感染者结核病的诊断具有挑战性。世卫组织建议采用临床算法进行筛查，然后使用 Xpert MTB/RIF 检测进行快速诊断，需要更多信息来评估这些建议在不同环境中的效果。
从 2012 年 8 月至 2013 年 9 月，喀麦隆巴门达新诊断出艾滋病毒的连续成年人均接受了结核病筛查，无论症状如何均进行了涂片镜检和培养；Xpert MTB/RIF 检测是回顾性进行的。从常规登记处获得治疗开始时间和患者结局。
在纳入的 1149 人中，940 人（82%）产生了用于实验室检测的痰液；其中 68%为女性，中位年龄为 35 岁（IQR，28-42 岁），中位 CD4 计数为 291 个细胞/μL（IQR，116-496 个细胞/μL），86%有一个或多个当前咳嗽、发烧、夜间出汗或体重减轻的症状。共有 131 人（14%，95%CI，12-16%）的痰液培养阳性结核病。在该人群中，世卫组织症状筛查算法的敏感性为 92%（95%CI，86-96%），特异性为 15%（95%CI，12-17%）。与结核培养相比，直接涂片镜检的敏感性为 25%（95%CI，18-34%），Xpert 的敏感性为 68%（95%CI，58-76%）；对于报告更多症状的人群，两种方法的敏感性均更高。在培养阳性之前，仅有 69 例涂片阴性/培养阳性结核病患者中的 1 人开始接受结核病治疗。在 71 例经细菌学证实的结核病患者中，有 6 个月后已知结局的 71 例中，有 13 人（17%）死亡，其中包括 11 例涂片阴性结核病患者和 6 例涂片和 Xpert 均阴性结核病患者。
在这种情况下，对新诊断出的艾滋病毒感染者使用最敏感的快速诊断检测至关重要，以最大限度地发现经细菌学证实的结核病。然而，仅使用这种干预措施是不够的，还应结合更全面的结核病临床诊断来改善结局。
