How can gastro-intestinal tuberculosis diagnosis be improved? A prospective cohort study

Christopher Lowbridge, Soraya A. M. Fadhi, Gayathri D. Krishnan, Emma Schimann, Raman Muthu Karuppan, Nagaraj Sriram, Giri Shan Rajahram, Jayaram Menon, Aatish Patel, William Timothy, Dawn Carmel Paul, Anna Ralph

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    Abstract

    Background: Gastrointestinal tuberculosis (TB) is diagnostically challenging; therefore, many cases are treated presumptively. We aimed to describe features and outcomes of gastrointestinal TB, determine whether a clinical algorithm could distinguish TB from non-TB diagnoses, and calculate accuracy of diagnostic tests.

    Methods: We conducted a prospective cohort study of hospitalized patients in Kota Kinabalu, Malaysia, with suspected gastrointestinal TB. We recorded clinical and laboratory characteristics and outcomes. Tissue samples were submitted for histology, microscopy, culture and GeneXpert MTB/RIF®. Patients were followed for up to two years.

    Results: Among 88 patients with suspected gastrointestinal TB, 69 were included in analyses; 52 (75%) had a final diagnosis of gastrointestinal TB; 17 had a non-TB diagnosis. People with TB were younger (42.7 versus 61.5 years, p=0.01) and more likely to have weight loss (91% versus 64%, p=0.03). An algorithm using age <44, weight loss, cough, fever, no vomiting, albumin >26 g/L, platelets >340 x109/L and immunocompromise had good specificity (96.2%) in predicting TB, but very poor sensitivity (16.0%). GeneXpert® performed very well on gastrointestinal biopsies (sensitivity 95.7% versus 35.0% for culture against a gold standard composite case definition of confirmed TB). Most patients (79%) successfully completed treatment and no treatment failure occurred, however adverse events (21%) and mortality (13%) among TB cases were high. We found no evidence that six months of treatment was inferior to longer courses.

    Conclusions: The prospective design provides important insights for clinicians managing gastrointestinal TB. We recommend wider implementation of high-performing diagnostic tests such as GeneXpert® on extra-pulmonary samples.
    Original languageEnglish
    Article number255
    JournalBMC Infectious Diseases
    Volume20
    DOIs
    Publication statusPublished - 30 Mar 2020

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    Lowbridge, C., Fadhi, S. A. M., Krishnan, G. D., Schimann, E., Karuppan, R. M., Sriram, N., Rajahram, G. S., Menon, J., Patel, A., Timothy, W., Paul, D. C., & Ralph, A. (2020). How can gastro-intestinal tuberculosis diagnosis be improved? A prospective cohort study. BMC Infectious Diseases, 20, [255]. https://doi.org/10.1186/s12879-020-04983-y