The DOTS strategy rests mainly on rapid identification and proper treatment of active pulmonary TB. Ensuring that sputum samples are taken from anyone who has a persistent cough continues to be essential to prevent onward transmission. However, people with HIV are more likely to suffer TB outside the lung than people without HIV. Diagnosing and treating these other forms of TB is a vital part of healthcare for people living with HIV. TB diagnosis can therefore be enhanced by routinely screening HIV-positive clients for TB symptoms at every visit
At Chris Hani Bharagwanath Hospital, Soweto, HIV positive mothers were offered tuberculin skin tests - half of them were positive and 3% had active TB that had not been diagnosed.
In Cambodia, routine sputum collection on monthly home visits to people diagnosed with HIV revealed that 8% were sputum positive and half of these were confirmed, previously unsuspected cases of TB.
HAUSLER: In 1999, the South African Department of Health established four TB/HIV Pilot Districts that implemented and evaluated a comprehensive package of TB/HIV/STI prevention, care and support. The package included strengthening TB/HIV public/private collaboration, voluntary counselling and rapid HIV testing, active TB case finding among HIV-positives, isoniazid TB preventive therapy for HIV-positives with no TB symptoms, co-trimoxazole prophylaxis and better management of opportunistic infections. People living with HIV were screened for TB symptoms at baseline and symptomatics were investigated for TB. The proportion found to have active TB as a result of active case finding was 3% in Bohlabela (Limpopo), 7.4% and 9.8% in East London (Eastern Cape). Active case finding therefore detects a large number of TB cases which allows earlier initiation of TB treatment and decreases TB transmission.
MARTIN: It is absolutely essential that no opportunity be lost to diagnose TB. A high index of suspicion is necessary and any persistent cough must be vigorously investigated. In addition TB contacts and inmates of prisons, hostels, crowded slums should be under active surveillance.
Early diagnosis is important and as it is our commonest OI this should be aggressively pursued especially in the case of smear negative disease. Blood and bone marrow examinations should be carried out and fine needle aspirates of lymph nodes should be performed. There are many practitioners in our region who carry out a trial of therapy when they have been unable to establish a diagnosis. This is particularly done when there are abnormal syndromes associated with a smear negative picture. I still feel aggressive pursuit of a diagnosis is a better pathway.
PRABHU: Since HIV patients are prone to respiratory infections, questions and physical examination need to be thorough. A good clinical history and proper physical examination have no subsitutes. They provide an invaluable insight into the patients body and guide clinical and lab investigations. Sometimes they are all we have at our resources, since the patients may be extremely poor and unable to afford even a basic sputum test and radiographs.
The most important point is to approach with an open mind. We must not think of TB even before we put our stethoscopes on, in which case, anything the patient says or we find, will fit in with TB. It may well be a deadly trap which we can get our patients into. Bacterial pneumonias of varying etiology are exceedingly common, and treatment must be based on local epidemiological data. An empirical trial of a good powerful antibiotic is given and the clinical response judged. If the patient feels better, then good. If not, we are both in trouble. What organisms are we dealing with, are they resistant, how do we further work up the case keeping in mind the financial constraints?
Detection of extrapulmonary TB is challenging, since in these instances routine sputum microscopy is negative. The expenses incurred in the diagnosis burn a huge hole in the patients pockets -special investigations need to be ordered, biopsies have to be done to get a tissue diagnosis. The patience and resilience of the physicians are tested. Patients have to be cajoled into undergoing these tests, which may still come back as negative - in which case, the patient wonders why he went through it all. Radiology, pathology, microbiology and surgical departments have to work together to perform a battery of tests in order to detect and diagnose extrapulmonary TB. It is very much the physician's prerogative to investigate, the more he probes the more he may uncover and herein lies the difficulty... how much is enough? There are no guidelines in the diagnosis of extrapulmonary TB... individuals vary in the thoroughness of their investigations and accordingly case detection rates vary.