A Treatment-Decision Score for HIV-Infected Children With Suspected Tuberculosis

Abstract

BACKGROUND: Diagnosis of tuberculosis should be improved in children infected with HIV to reduce mortality. We developed prediction scores to guide antituberculosis treatment decision in HIV-infected children with suspected tuberculosis. METHODS: HIV-infected children with suspected tuberculosis enrolled in Burkina Faso, Cambodia, Cameroon, and Vietnam (ANRS 12229 PAANTHER 01 Study), underwent clinical assessment, chest radiography, Quantiferon Gold In-Tube (QFT), abdominal ultrasonography, and sample collection for microbiology, including Xpert MTB/RIF (Xpert). We developed 4 tuberculosis diagnostic models using logistic regression: (1) all predictors included, (2) QFT excluded, (3) ultrasonography excluded, and (4) QFT and ultrasonography excluded. We internally validated the models using resampling. We built a score on the basis of the model with the best area under the receiver operating characteristic curve and parsimony. RESULTS: A total of 438 children were enrolled in the study; 251 (57.3%) had tuberculosis, including 55 (12.6%) with culture- or Xpert-confirmed tuberculosis. The final 4 models included Xpert, fever lasting >2 weeks, unremitting cough, hemoptysis and weight loss in the past 4 weeks, contact with a patient with smear-positive tuberculosis, tachycardia, miliary tuberculosis, alveolar opacities, and lymph nodes on the chest radiograph, together with abdominal lymph nodes on the ultrasound and QFT results. The areas under the receiver operating characteristic curves were 0.866, 0.861, 0.850, and 0.846, for models 1, 2, 3, and 4, respectively. The score developed on model 2 had a sensitivity of 88.6% and a specificity of 61.2% for a tuberculosis diagnosis. CONCLUSIONS: Our score had a good diagnostic performance. Used in an algorithm, it should enable prompt treatment decision in children with suspected tuberculosis and a high mortality risk, thus contributing to significant public health benefits.

Call for ultrasound in paediatric tuberculosis work‐up: A case report from Germany

“…As pointed out above, evidence on the utility of focused ultrasound for EPTB is reported from settings with moderate and high TB/HIV prevalence. 4,6,7 Recently the utility of lung ultrasound for PTB has also been reported and discussed for children and adults [8][9][10][11][12] ; however, more data are needed to better understand the diagnostic potential of lung ultrasound in discriminating PTB from other respiratory infections. The utility of systematic ultrasound investigation in settings with low TB/HIV-prevalence has not been studied yet.…”

“…Abdominal lymphadenopathy and focal splenic lesions (micro‐abscesses) correlated with HIV/TB co‐infection but were also prevalent in HIV‐negative children with PTB . Previous ultrasound studies in South African children with PTB had also reported that related abdominal lymphadenopathy and focal splenic lesions were frequent and a recent multi‐centre study from Asian and African countries suggested a diagnostic algorithm including ultrasonography for abdominal lymph nodes to guide antituberculosis treatment decision in HIV‐infected children with suspected TB . To date the potential diagnostic yield of systematically investigating children with presumptive TB for (concurrent) EPTB in addition to PTB has, however, not been studied in settings with low HIV/TB prevalence and ultrasound is commonly not systematically performed during TB work‐up.…”

“…4 Previous ultrasound studies in South African children with PTB had also reported that related abdominal lymphadenopathy and focal splenic lesions were frequent 5 and a recent multi-centre study from Asian and African countries suggested a diagnostic algorithm including ultrasonography for abdominal lymph nodes to guide antituberculosis treatment decision in HIV-infected children with suspected TB. 6 To date the potential diagnostic yield of systematically investigating children with presumptive TB for…”

“…4 Previous ultrasound studies in South African children with PTB had also reported that related abdominal lymphadenopathy and focal splenic lesions were frequent 5 and a recent multi-centre study from Asian and African countries suggested a diagnostic algorithm including ultrasonography for abdominal lymph nodes to guide antituberculosis treatment decision in HIV-infected children with suspected TB. 6 To date the potential diagnostic yield of systematically investigating children with presumptive TB for (concurrent) EPTB in addition to PTB has, however, not been Key Points 1 Diagnosing tuberculosis in children is challenging.2 Ultrasound can provide valuable information for timely diagnosis and substantiate therapy monitoring. 3 Point-of-care ultrasound for paediatric tuberculosis is a promising tool warranting further systematic investigation.…”

Paediatric tuberculosis – new advances to close persistent gaps

“…Considering the persistent challenges in laboratory-based diagnosis, it remains critically important to strengthen the capacity of front-line health care workers to clinically suspect and diagnose TB in children (Huynh et al, 2020). Pragmatic approaches providing evidence-based treatment decision support provides a way forward (Marcy et al, 2019). As a global community we will have to accept a degree of over-treatment if we want to close the case detection gap in children.…”