Delayed diagnosis of extrapulmonary tuberculosis presenting as fever of unknown origin in an intermediate-burden country

Abstract

BackgroundTuberculosis (TB), especially extrapulmonary tuberculosis (EPTB), is an important cause of fever of unknown origin (FUO) in TB-burdened areas. Little information is known about patients with EPTB with clinical features presenting as FUO and about the factor of delaying the diagnosis.MethodsWe retrospectively analyzed EPTB patients who were referred with FUO at 3 university-affiliated hospitals over 8 years (2010–2017). The subjects were assigned to groups of early diagnosis and delayed diagnosis within 3 days of an initial comprehensive evaluation from the referral. Clinical and laboratory variables were compared between the groups.ResultsA total of 95 patients with febrile EPTB were included. Localizing symptoms and/or signs suggestive of anatomy were identified in 62.1% of the patients. Concurrent lung involvement by TB was presented by 49.5% (47/95) of the patients, and only 23.4% of them showed typical findings of pulmonary TB on simple chest X-ray. Most of the patients showed abnormal lesions on cross-sectional CT (98.9%) and MRI (100%). The clinical variables and blood test results of patients were not significantly different between the two groups. The less typical imaging finding of EPTB on CT (38.5% vs. 79.0%) and MRI (37.5% vs. 79.0%) in the delayed diagnosis group was a risk factor for delayed diagnosis.ConclusionFebrile EPTB referred as FUO showed nonspecific clinical manifestations. The active application of cross-sectional imaging tests according to clinical clues or randomly in the absence of local manifestations, combined with invasive diagnostic approaches even for atypical presentations may lead to an earlier diagnosis of febrile EPTB.

Extrapulmonary tuberculosis in Pakistan- A nation-wide multicenter retrospective study

“…[3,5,23] EPTB disease site was not recorded in 8.5% of patients included in the study. In TB-burdened countries EPTB is one of the important causes of fever of unknown origin [34]. In TB registers where disease site was recorded for majority of the notified EPTB cases, one plausible explanation for missing details is, that these patients were most likely initiated on empiric TB treatment for fever of unknown origin without further investigations either due to lack of diagnostic facilities or resources.…”

Diagnostic utility of clinical and epidemiologic features in fever of unknown origin

“…Tuberculosis presenting as FUO can be difficult to diagnose due to commonly nonspecific signs and symptoms [25,32,33]. This study found high positive predictive value and high likelihood ratio of a positive test for previous tuberculosis or tuberculosis exposure in the infectious category.…”

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“…Despite the existence of guidelines for the diagnosis and treatment of TB [ 10 ], there tend to be cases of EPTB that present with atypical manifestations such as local pain, weight loss, night sweat and fever, which make the diagnosis difficult [ 11 ]. In addition, the anatomical sites frequently involves in EPTB are not easily accessible and require invasive procedures for diagnostic confirmation.…”