Predicting<i>Mycobacterium tuberculosis</i>in patients with community-acquired pneumonia

Cavallazzi, Rodrigo; Wiemken, Timothy; Christensen, Diana; Peyrani, Paula; Blasi, Francesco; Levy, Gur; Aliberti, Stefano; Kelley, Robert; Ramirez, Julio A.

doi:10.1183/09031936.00017813

Cited by 22 publications

(19 citation statements)

References 31 publications

(32 reference statements)

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“…These six questions were derived from a set of 22 questions which are known to provide evidence for the diagnosis of TB [10]. However, while 22 questions are hard to remember and take longer to pose, these few simple questions are, besides being more accurate according to the present study [9], considerably easier to remember; as a result, they can even be applied as a bedside tool for predicting the risk of TB in hospitalised patients with CAP in the setting of a busy emergency department with all its time constraints and distractors. Unsurprisingly, weight loss, night sweats, haemoptysis, exposure to MTB and younger age (,65 years) are among these questions.…”

Section: @Erspublicationsmentioning

confidence: 99%

“…As presented in the large cohort study by CAVALLAZZI et al [9] in this issue of the European Respiratory Journal, there are six simple, though crucial, questions for suspecting active TB in patients admitted to the hospital with CAP. These six questions were derived from a set of 22 questions which are known to provide evidence for the diagnosis of TB [10].…”

Section: @Erspublicationsmentioning

confidence: 99%

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Six simple questions contra the delay

2013

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@ERSpublications Six simple questions could quickly identify active TB in patients with community-acquired pneumonia admitted to hospital http://ow.ly/r3cqtDuring the past decades, the incidence of tuberculosis (TB) has steadily declined in most west European countries, and many physicians will no longer encounter TB in their patients. Along with the declining practical experience of physicians, the chance for delay in diagnosing TB increases. An delayed diagnosis of TB index cases is the most important risk factor for the nosocomial transmission of Mycobacterium tuberculosis (MTB) [1], as numerous unprotected contacts among healthcare workers and inpatients may result before the diagnosis of TB is established and respiratory isolation is applied [2,3]. The clean-up after such a mishap can be complicated and time-consuming, as the individuals concerned need to be identified and contacted. Patients might have been already discharged, or healthcare workers may not be aware of exposure to a TB index case for days or even weeks [4]. However, the difficulty is not over, even when the respective contacts have been identified. As there is no perfect test for the diagnosis of TB infection, the question arises of which test should be used and who should be tested with this assay in order to obtain optimal results. Only close contacts should be tested in order to improve the positive predictive value of the contact screening regardless of the test used. But what is a close contact in a hospital setting? Cumulative exposure to a smear-positive index case for 8 h or more is proposed as an orientation. However, this is merely an inspired guess. In comparison to the tuberculin skin test, the emergence of interferon-c release assays (IGRAs) has facilitated screening after unprotected TB exposure, as there is no booster phenomenon after repeat testing, no need for a second appointment for test reading and no influence of bacillus Calmette-Guérin vaccination on subsequent test results. However, even with IGRAs, many questions remain unanswered. IGRAs are not able to distinguish remote from recent infection and their ability to predict progression to active disease appears to be limited so far. While progression rates of up to 14% have been reported for close contacts with a positive IGRA result [5,6], two recent systematic reviews and metaanalyses indicate considerably lower progression risks [7,8]. Therefore, even after a positive IGRA is observed, the question remains regarding what to do next. Of course, active TB needs to be excluded by chest radiograph. But should we propose preventive chemotherapy to all contacts with a positive IGRA result, well knowing that most of these subjects will never develop active TB anyway?When a patient with community-acquired pneumonia (CAP) is admitted to the hospital, MTB could almost always be the causative pathogen. However, administering an IGRA for all CAP patients would be a waste of time and money, as current IGRAs are not able to distinguish active TB from latent TB infection. Moreove...

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Section: @Erspublicationsmentioning

confidence: 99%

Section: @Erspublicationsmentioning

confidence: 99%

Six simple questions contra the delay

2013

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From the authors:We thank Aggarwal and colleagues for their comments on our article [1]. They raise four important points for discussion.

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Risk factors for pulmonary tuberculosis in community-acquired pneumonia

2014

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From the authors:We thank Aggarwal and colleagues for their comments on our article [1]. They raise four important points for discussion. First, that tuberculosis (TB) is a chronic disease, and duration of symptoms is an important factor differentiating tuberculous from non-tuberculous pneumonia. Secondly, that in India a large proportion of the population is infected with TB, thus making prior exposure to TB of questionable relevance as a risk factor. Thirdly, that absence of risk factors should not mean exclusion of TB. They suggest that patients with pneumonia should have a sputum test for acid-fast bacilli, even in the absence of risk factors, in areas of high burden of TB. Fourthly, that more prospective research is needed from TB endemic countries.

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We read with interest the study by CAVALLAZZI et al [1] in which authors have devised a subset of risk factors that can efficiently predict pulmonary tuberculosis (TB) in patients of community-acquired pneumonia (CAP). Although they have improvised upon existing Centers for Disease Control and Prevention (CDC) list of risk factors, the study requires discussion regarding its practical value.

TB is a chronic disease with symptoms ranging from a few weeks to several months, while CAP is generally an acute process.

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confidence: 99%

“…Only 85 (1.2%) out of 6976 patients were from Asia, Africa and Australia [1], the regions that harbour an estimated 80% of incident cases of TB [2]. Mantoux positivity and recent exposure to TB were found to be significant risk factors for predicting TB in their study [1]. However, with 40% of the Indian population infected with Mycobacterium tuberculosis [3], its relevance seems questionable.…”

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confidence: 99%

Risk factors for pulmonary tuberculosis in community-acquired pneumonia

Aggarwal¹,

Mohapatra

Chikkahonnaiah³

2014

Eur Respir J

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We read with interest the study by CAVALLAZZI et al. [1] in which authors have devised a subset of risk factors that can efficiently predict pulmonary tuberculosis (TB) in patients of community-acquired pneumonia (CAP). Although they have improvised upon existing Centers for Disease Control and Prevention (CDC) list of risk factors, the study requires discussion regarding its practical value.TB is a chronic disease with symptoms ranging from a few weeks to several months, while CAP is generally an acute process. Duration of presenting symptoms seems to be a strong factor differentiating TB from CAP, which has not been evaluated in the study.The results of the study should be interpreted with caution as they may not be universally applicable. Only 85 (1.2%) out of 6976 patients were from Asia, Africa and Australia [1], the regions that harbour an estimated 80% of incident cases of TB [2]. Mantoux positivity and recent exposure to TB were found to be significant risk factors for predicting TB in their study [1]. However, with 40% of the Indian population infected with Mycobacterium tuberculosis [3], its relevance seems questionable.Pulmonary TB presents with a wide spectrum of clinical and radiological features that may affect the sensitivity and specificity of its risk factors. Asymptomatic presentation, normal chest radiographs [4], lower zone disease [5], Mantoux negativity (as in immunocompromised), co-infection with bacteria and fungus, associated comorbidities like COPD are important features that can falsely shift the diagnosis away from TB. Hence, absence of TB risk factors in pneumonia should not mean ''exclusion of tuberculosis'' but should be followed by a screening sputum microscopy for acid fast bacilli, especially in areas of high disease burden.Further research is required, incorporating prospective cases from TB endemic countries, which may add new risk factors or change their hierarchy leading to better TB prediction.

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PredictingMycobacterium tuberculosisin patients with community-acquired pneumonia

Cited by 22 publications

References 31 publications

Six simple questions contra the delay

Six simple questions contra the delay

Risk factors for pulmonary tuberculosis in community-acquired pneumonia

Risk factors for pulmonary tuberculosis in community-acquired pneumonia

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