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

Bibliographical note

Queen Elizabeth Hospital supported this study through provision of
additional laboratory and radiological testing of study participants.
Investigator time to conduct this study was supported by the National
Health and Medical Research Council (NHMRC) of Australia (grants 605806
and 1131932). APR is supported by NHMRC fellowship 1142011. The funders
had no role in study design, data collection and analysis, decision to publish,
or preparation of the manuscript.

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