Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.
ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.
Eur Respir J. 2019 Oct 1;54(3). doi: 10.1183/13993003.00312-2019. Print 2019 Sep.
Sensitive tools are needed to accurately establish the diagnosis of tuberculosis (TB) at death, especially in low-income countries. The objective of this study was to evaluate the burden of TB in a series of patients who died in a tertiary referral hospital in sub-Saharan Africa using an in-house real time PCR (TB-PCR) and the Xpert MTB/RIF Ultra (Xpert Ultra) assay.Complete diagnostic autopsies were performed in a series of 223 deaths (56.5% being HIV-positive), including 54 children, 57 maternal deaths and 112 other adults occurring at the Maputo Central Hospital, Mozambique. TB-PCR was performed in all lung, cerebrospinal fluid and central nervous system samples in HIV-positive patients. All samples positive for TB-PCR or showing histological findings suggestive of TB were analysed with the Xpert Ultra assay.TB was identified as the cause of death in 31 patients: three out of 54 (6%) children, five out of 57 (9%)maternal deaths and 23 out of 112 (21%) other adults. The sensitivity of the main clinical diagnosis to detect TB as the cause of death was 19.4% (95% CI 7.5-37.5) and the specificity was 97.4% (94.0-99.1) compared to autopsy findings. Concomitant TB (TB disease in a patient dying of other causes) was found in 31 additional cases. Xpert Ultra helped to identify 15 cases of concomitant TB. In 18 patients, DNA was identified by TB-PCR and Xpert Ultra in the absence of histological TB lesions. Overall, 62 (27.8%) cases had TB disease at death and 80 (35.9%) had TB findings.The use of highly sensitive, easy to perform molecular tests in complete diagnostic autopsies may contribute to identifying TB cases at death that would have otherwise been missed. Routine use of these tools in certain diagnostic algorithms for hospitalised patients needs to be considered. Clinical diagnosis showed poor sensitivity for the diagnosis of TB at death.
需要敏感的工具来准确确定结核病（TB）的诊断，尤其是在低收入国家。本研究的目的是使用内部实时 PCR（TB-PCR）和 Xpert MTB/RIF Ultra（Xpert Ultra）检测评估撒哈拉以南非洲一家三级转诊医院一系列死亡患者的 TB 负担。在莫桑比克马普托中央医院，对一系列 223 例死亡患者（56.5%为 HIV 阳性）进行了完整的诊断性尸检，包括 54 名儿童、57 名孕产妇死亡和 112 名其他成人。TB-PCR 用于所有 HIV 阳性患者的肺、脑脊液和中枢神经系统样本。对所有 TB-PCR 阳性或组织学检查提示 TB 的样本进行 Xpert Ultra 检测。TB 被确定为 31 例患者的死亡原因：54 名儿童中有 3 例（6%），57 名孕产妇死亡中有 5 例（9%），112 名其他成人中有 23 例（21%）。主要临床诊断检测 TB 作为死亡原因的敏感性为 19.4%（95%CI 7.5-37.5），特异性为 97.4%（94.0-99.1），与尸检结果相比。还发现了 31 例并发 TB（死于其他原因的患者中的 TB 疾病）。Xpert Ultra 有助于确定 15 例并发 TB。在 18 例患者中，在不存在组织学 TB 病变的情况下，TB-PCR 和 Xpert Ultra 检测到 DNA。总的来说，62 例（27.8%）患者在死亡时患有 TB 疾病，80 例（35.9%）患者有 TB 发现。在完整的诊断性尸检中使用高度敏感、易于操作的分子检测可以帮助识别否则可能被遗漏的死亡时的 TB 病例。需要考虑在某些住院患者的诊断算法中常规使用这些工具。临床诊断对死亡时的 TB 诊断敏感性差。
