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Dugdale CM, Zachary KC, McEvoy DS, Branda JA, Courtney A, Craig R, Doms A, Germaine L, Green CV, Gulbas E, Hooper DC, Hurtado RM, Hyle EP, Jerry MS, Lazarus JE, Paras M, Turbett SE, Shenoy ES. Second Time's the Charm? Assessing the Sensitivity and Yield of Inpatient Diagnostic Algorithms for Pulmonary Tuberculosis in a Low-Prevalence Setting. Open Forum Infect Dis 2024; 11:ofae253. [PMID: 38872849 PMCID: PMC11170497 DOI: 10.1093/ofid/ofae253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 04/30/2024] [Indexed: 06/15/2024] Open
Abstract
Background For persons with suspected pulmonary tuberculosis, the guidelines of the Centers for Disease Control and Prevention recommend collecting 3 respiratory specimens 8 to 24 hours apart for acid-fast bacilli (AFB) smear and culture, in addition to 1 nucleic acid amplification test (NAAT). However, data supporting this approach are limited. Our objective was to estimate the performance of 1, 2, or 3 AFB smears with or without NAATs to detect pulmonary tuberculosis in a low-prevalence setting. Methods We conducted a retrospective study of hospitalized persons at 8 Massachusetts acute care facilities who underwent mycobacterial culture on 1 or more respiratory specimens between July 2016 and December 2022. We evaluated percentage positivity and yield on serial AFB smears and NAATs among people with growth of Mycobacterium tuberculosis on mycobacterial cultures. Results Among 104 participants with culture-confirmed pulmonary tuberculosis, the first AFB smear was positive in 41 cases (39%). A second AFB smear was positive in 11 (22%) of the 49 cases in which it was performed. No third AFB smears were positive following 2 initial negative smears. Of 52 smear-negative cases, 36 had a NAAT performed, leading to 23 additional diagnoses. Overall sensitivity to detect tuberculosis prior to culture positivity was higher in any strategy involving 1 or 2 NAATs (74%-79%), even without AFB smears, as compared with 3 smears alone (60%). Conclusions Tuberculosis diagnostic testing with 2 AFB smears offered the same yield as 3 AFB smears while potentially reducing laboratory burden and duration of airborne infection isolation. Use of 1 or 2 NAATs increased sensitivity to detect culture-positive pulmonary tuberculosis when added to AFB smear-based diagnostic testing alone.
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Affiliation(s)
- Caitlin M Dugdale
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Kimon C Zachary
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Infection Control, Massachusetts General Hospital and Mass General Brigham, Boston, Massachusetts, USA
| | - Dustin S McEvoy
- Clinical Informatics, Mass General Brigham, Boston, Massachusetts, USA
| | - John A Branda
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amy Courtney
- Infection Control, Massachusetts General Hospital and Mass General Brigham, Boston, Massachusetts, USA
| | - Rebecca Craig
- Infection Control, Massachusetts General Hospital and Mass General Brigham, Boston, Massachusetts, USA
| | - Alexandra Doms
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lindsay Germaine
- Clinical Informatics, Mass General Brigham, Boston, Massachusetts, USA
| | - Chloe V Green
- Infection Control, Massachusetts General Hospital and Mass General Brigham, Boston, Massachusetts, USA
| | - Eren Gulbas
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David C Hooper
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Infection Control, Massachusetts General Hospital and Mass General Brigham, Boston, Massachusetts, USA
| | - Rocio M Hurtado
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Global Health Committee, Boston, Massachusetts, USA
| | - Emily P Hyle
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Michelle S Jerry
- Infection Control, Massachusetts General Hospital and Mass General Brigham, Boston, Massachusetts, USA
| | - Jacob E Lazarus
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Molly Paras
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah E Turbett
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Erica S Shenoy
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Infection Control, Massachusetts General Hospital and Mass General Brigham, Boston, Massachusetts, USA
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Afif N, Fazio J, Gandhi S, Kamangar N, Monteiro AC. A 35-Year-Old Man with Chronic Cough and Worsening Dyspnea. NEJM EVIDENCE 2023; 2:EVIDmr2200338. [PMID: 38320024 DOI: 10.1056/evidmr2200338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
A 35-Year-Old Man with Chronic Cough and DyspneaA 35-year-old man presented for evaluation of chronic cough and worsening dyspnea. How do you approach the evaluation, and what is the diagnosis?
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Affiliation(s)
- Nawal Afif
- from the University of California, Los Angeles Pulmonary and Critical Care Fellowship Program, Olive View-University of California, Los Angeles Internal Medicine Residency Program, and University of California, San Francisco Occupational and Environmental Medicine Residency Program
| | - Jane Fazio
- from the University of California, Los Angeles Pulmonary and Critical Care Fellowship Program, Olive View-University of California, Los Angeles Internal Medicine Residency Program, and University of California, San Francisco Occupational and Environmental Medicine Residency Program
| | - Sheiphali Gandhi
- from the University of California, Los Angeles Pulmonary and Critical Care Fellowship Program, Olive View-University of California, Los Angeles Internal Medicine Residency Program, and University of California, San Francisco Occupational and Environmental Medicine Residency Program
| | - Nader Kamangar
- from the University of California, Los Angeles Pulmonary and Critical Care Fellowship Program, Olive View-University of California, Los Angeles Internal Medicine Residency Program, and University of California, San Francisco Occupational and Environmental Medicine Residency Program
| | - Ana Costa Monteiro
- from the University of California, Los Angeles Pulmonary and Critical Care Fellowship Program, Olive View-University of California, Los Angeles Internal Medicine Residency Program, and University of California, San Francisco Occupational and Environmental Medicine Residency Program
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Imtiaz S, Batubara E. Diagnostic value of bronchoscopy in sputum-negative pulmonary tuberculosis patients and its correlation with clinicoradiological features. Ann Thorac Med 2022; 17:124-131. [PMID: 35651890 PMCID: PMC9150657 DOI: 10.4103/atm.atm_487_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 01/24/2022] [Indexed: 11/07/2022] Open
Abstract
CONTEXT: Tuberculosis (TB) remains endemic in Saudi Arabia. Little local data have been reported on bronchoscopic evaluation of sputum-negative pulmonary TB patients, which poses a significant diagnostic and therapeutic challenge. AIMS: To determine the diagnostic value of bronchoscopy and bronchoalveolar lavage (BAL) and its correlation with clinical and radiological features in sputum-negative, culture-confirmed pulmonary TB patients. METHODS: We performed a retrospective analysis of patients with definite or probable pulmonary TB with overall negative (smear and/or polymerase chain reaction [PCR]) or scanty sputum that had undergone bronchoscopy with BAL over a period of 5 years. Patients’ symptoms, radiological features, lung lobe lavaged, BAL acid-fast bacilli (AFB) stain, Mycobacterium TB (MTB)-PCR, and mycobacterial cultures were analyzed. Mycobacterial cultures (either sputum or BAL) were used as a reference standard. RESULTS: Out of 154 patients, 49 (32%) were overall sputum negative and underwent a diagnostic bronchoscopy. Dry cough and fever were the most common symptoms. Uncontrolled diabetes mellitus was the most frequent comorbidity identified in 15 (31%) patients. Fifty-nine percent of the patients had diffuse lung infiltrates, with consolidation being the most common abnormality (41%), followed by cavitation (39%). Right upper lobe was the most frequent lung lobe lavaged (31%), while transbronchial lung biopsies (TBLB) were obtained in 21 (43%). BAL mycobacterial culture and MTB PCR were positive in 35 (71%) and 23 (47%) patients, respectively. Combined BAL MTB PCR and TBLB provided rapid diagnosis in 28 (57%) patients. CONCLUSIONS: An overall diagnostic yield of 90% was achieved with combined use of BAL MTB PCR, culture, and histopathology. Upper lobe lavage and presence of cavities on chest imaging had a higher diagnostic yield.
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