Volume 99, Issue 2
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Human immunodeficiency virus (HIV) infection is a major risk factor for the development of active tuberculosis (TB), one of the deadliest infectious diseases globally. The high mortality associated with the disease can be reduced by early diagnosis and prompt antituberculous treatment initiation. Facilities in TB-endemic regions are increasing the use of nucleic acid amplification (e.g., GeneXpert), which provides rapid results but may have suboptimal sensitivity in HIV-associated TB. Our objective was to evaluate the current practices for TB diagnosis at Edendale Hospital, a large regional hospital in KwaZulu-Natal, South Africa—a TB-endemic region with high HIV prevalence. In this cross-sectional study, all adult inpatients newly started on TB treatment at Edendale were identified over a 6-week period. Demographics, clinical information, diagnostic test results, and outcomes were documented. Pulmonary TB (PTB), extrapulmonary TB (EXTB), and PTB + EXTB were defined as disease evidence in the lungs, other organs, or both, respectively. Ninety-four cases were identified, of which 83% were HIV-associated. Only 30% of all TB patients were microbiologically confirmed, consisting of 7/16 (44%) HIV-uninfected and 21/78 (27%) HIV-infected TB patients. Smear microscopy and mycobacterial culture were seldom ordered. Ultrasound was performed in about one-third of suspected EXTB cases and was valuable in identifying abdominal TB. In this clinical setting with a high incidence of HIV-associated TB, TB diagnosis was more commonly based on clinical assessment and imaging results than on mycobacterial gold standard test confirmation.


Article metrics loading...

The graphs shown below represent data from March 2017
Loading full text...

Full text loading...



  1. WHO, 2017. Global Tuberculosis Report 2017. Geneva, Switzerland: World Health Organization.
  2. Toossi Z, , 2003. Virological and immunological impact of tuberculosis on human immunodeficiency virus type 1 disease. J Infect Dis 188: 11461155. [Google Scholar]
  3. Perkins MD, Cunningham J, , 2007. Facing the crisis: improving the diagnosis of tuberculosis in the HIV era. J Infect Dis 196 (Suppl 1): S15S27. [Google Scholar]
  4. Corbett EL, Watt CJ, Walker N, Maher D, Williams BG, Raviglione MC, Dye C, , 2003. The growing burden of tuberculosis: global trends and interactions with the HIV epidemic. Arch Intern Med 163: 10091021. [Google Scholar]
  5. WHO WHO Guidelines Approved by the Guidelines Review Committee; , 2013. Automated Real-Time Nucleic Acid Amplification Technology for Rapid and Simultaneous Detection of Tuberculosis and Rifampicin Resistance: Xpert MTB/RIF Assay for the Diagnosis of Pulmonary and Extrapulmonary TB in Adults and Children: Policy Update. Geneva, Switzerland: World Health Organization.
  6. Lawn SD, Butera ST, Shinnick TM, , 2002. Tuberculosis unleashed: the impact of human immunodeficiency virus infection on the host granulomatous response to Mycobacterium tuberculosis. Microbes Infect 4: 635646. [Google Scholar]
  7. Di Perri G, Cazzadori A, Vento S, Bonora S, Malena M, Bontempini L, Lanzafame M, Allegranzi B, Concia E, , 1996. Comparative histopathological study of pulmonary tuberculosis in human immunodeficiency virus-infected and non-infected patients. Tuber Lung Dis 77: 244249. [Google Scholar]
  8. Jones BE, Young SM, Antoniskis D, Davidson PT, Kramer F, Barnes PF, , 1993. Relationship of the manifestations of tuberculosis to CD4 cell counts in patients with human immunodeficiency virus infection. Am Rev Respir Dis 148: 12921297. [Google Scholar]
  9. Poprawski D, Pitisuttitum P, Tansuphasawadikul S, , 2000. Clinical presentations and outcomes of TB among HIV-positive patients. Southeast Asian J Trop Med Public Health 31 (Suppl 1): 140142. [Google Scholar]
  10. Naing C, Mak JW, Maung M, Wong SF, Kassim AIBM, , 2013. Meta-analysis: the association between HIV infection and extrapulmonary tuberculosis. Lung 191: 2734. [Google Scholar]
  11. Denkinger CM, 2015. Defining the needs for next generation assays for tuberculosis. J Infect Dis 211 (Suppl 1): S29S38. [Google Scholar]
  12. Steingart KR, Schiller I, Horne DJ, Pai M, Boehme CC, Dendukuri N, , 2014. Xpert® MTB/RIF assay for pulmonary tuberculosis and rifampicin resistance in adults. Cochrane Database Syst Rev 1: CD009593. [Google Scholar]
  13. Maynard-Smith L, Larke N, Peters JA, Lawn SD, , 2014. Diagnostic accuracy of the Xpert MTB/RIF assay for extrapulmonary and pulmonary tuberculosis when testing non-respiratory samples: a systematic review. BMC Infect Dis 14: 709. [Google Scholar]
  14. Sculier D, Vannarith C, Pe R, Thai S, Kanara N, Borann S, Cain KP, Lynen L, Varma JK, , 2010. Performance of abdominal ultrasound for diagnosis of tuberculosis in HIV-infected persons living in Cambodia. J Acquir Immune Defic Syndr 55: 500502. [Google Scholar]
  15. Heller T, Goblirsch S, Wallrauch C, Lessells R, Brunetti E, , 2010. Abdominal tuberculosis: sonographic diagnosis and treatment response in HIV-positive adults in rural South Africa. Int J Infect Dis 14 (Suppl 1): e108e112. [Google Scholar]
  16. Massyn N, Peer N, English R, Padarath A, Barron P, Day C, , eds, 2016. District Health Barometer 2015/16. Durban, South Africa: Health Systems Trust.
  17. WHO, 2007. Improving the Diagnosis and Treatment of Smear-Negative Pulmonary and Extra-Pulmonary Tuberculosis among Adults and Adolescents: Recommendations for HIV-Prevalent and Resource-Constrained Settings. Geneva, Switzerland: World Health Organization.
  18. Heidebrecht CL, Podewils LJ, Pym AS, Cohen T, Mthiyane T, Wilson D, , 2016. Assessing the utility of Xpert(®) MTB/RIF as a screening tool for patients admitted to medical wards in South Africa. Sci Rep 6: 19391. [Google Scholar]
  19. Chawla KS, Kanyama C, Mbewe A, Matoga M, Hoffman I, Ngoma J, Hosseinipour MC, , 2016. Policy to practice: impact of GeneXpert MTB/RIF implementation on the TB spectrum of care in Lilongwe, Malawi. Trans R Soc Trop Med Hyg 110: 305311. [Google Scholar]
  20. Van Rie A, Page-Shipp L, Hanrahan CF, Schnippel K, Dansey H, Bassett J, Clouse K, Scott L, Stevens W, Sanne I, , 2013. Point-of-care Xpert® MTB/RIF for smear-negative tuberculosis suspects at a primary care clinic in South Africa. Int J Tuberc Lung Dis 17: 368372. [Google Scholar]
  21. Hanrahan CF, Selibas K, Deery CB, Dansey H, Clouse K, Bassett J, Scott L, Stevens W, Sanne I, Van Rie A, , 2013. Time to treatment and patient outcomes among TB suspects screened by a single point-of-care xpert MTB/RIF at a primary care clinic in Johannesburg, South Africa. PLoS One 8: e65421. [Google Scholar]
  22. Scott LE, McCarthy K, Gous N, Nduna M, Van Rie A, Sanne I, Venter WF, Duse A, Stevens W, , 2011. Comparison of Xpert MTB/RIF with other nucleic acid technologies for diagnosing pulmonary tuberculosis in a high HIV prevalence setting: a prospective study. PLoS Med 8: e1001061. [Google Scholar]
  23. Theron G, 2011. Evaluation of the Xpert MTB/RIF assay for the diagnosis of pulmonary tuberculosis in a high HIV prevalence setting. Am J Respir Crit Care Med 184: 132140. [Google Scholar]
  24. Achkar JM, Jenny-Avital ER, , 2011. Incipient and subclinical tuberculosis: defining early disease states in the context of host immune response. J Infect Dis 204 (Suppl 1): S1179S1186. [Google Scholar]
  25. Meyer AJ, 2017. Sputum quality and diagnostic performance of GeneXpert MTB/RIF among smear-negative adults with presumed tuberculosis in Uganda. PLoS One 12: e0180572. [Google Scholar]
  26. Wekesa C, Kirenga BJ, Joloba ML, Bwanga F, Katamba A, Kamya MR, , 2014. Chest X-ray vs. Xpert® MTB/RIF assay for the diagnosis of sputum smear-negative tuberculosis in Uganda. Int J Tuberc Lung Dis 18: 216219. [Google Scholar]
  27. WHO, 2015. The Use of Lateral Flow Urine Lipoarabinomannan Assay (LF-LAM) for the Diagnosis and Screening of Active Tuberculosis in People Living with HIV: Policy Update. Geneva, Switzerland: World Health Organization.
  28. Lawn SD, Kerkhoff AD, Burton R, Schutz C, Boulle A, Vogt M, Gupta-Wright A, Nicol MP, Meintjes G, , 2017. Diagnostic accuracy, incremental yield and prognostic value of Determine TB-LAM for routine diagnostic testing for tuberculosis in HIV-infected patients requiring acute hospital admission in South Africa: a prospective cohort. BMC Med 15: 67. [Google Scholar]
  29. Kerkhoff AD, Barr DA, Schutz C, Burton R, Nicol MP, Lawn SD, Meintjes G, , 2017. Disseminated tuberculosis among hospitalised HIV patients in South Africa: a common condition that can be rapidly diagnosed using urine-based assays. Sci Rep 7: 10931. [Google Scholar]

Data & Media loading...

  • Received : 08 Dec 2017
  • Accepted : 03 Apr 2018
  • Published online : 11 Jun 2018

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error