Undiagnosed tuberculosis in patients with HIV infection who present with severe anaemia at a district hospital

BACKGROUND: Tuberculosis (TB) is a major cause of severe anaemia in patients with human immunodeficiency virus (HIV) infection in South Africa. However, TB can be difficult to diagnose as it may be extra pulmonary and paucibacillary. AIM: The aim of this study was to investigate undiagnosed TB in patients with HIV infection and severe anaemia and to identify the optimal investigations for diagnosing TB. SETTING: Mthatha General Hospital, a district hospital. METHODS: The study was a case series. RESULTS: Haemoglobin levels ranged from 3.6 g/dL to 7.9 g/dL, the mean CD4 count was 176 cells/μL and 80% of patients had a positive TB symptom screen. Forty-three (86%) patients had either clinical or bacteriologically proven TB of whom 33 had pulmonary TB, 34 had extra pulmonary TB and 24 had both types. The diagnostic yield for TB was: chest X-ray (CXR) 91%; ultrasound (US) abdomen pericardium and lower chest 62%; sputum Xpert MTB/RIF 35%; TB blood culture 21% and TB urine culture 15%. Blood and urine cultures did not identify any additional cases over those identified by CXR and US. The laboratory turnaround times were as follows: sputum Xpert, 1.6 days; blood culture, 20 days and urine culture, 28 days. CXR and US were done within one day of initial patient assessment. CONCLUSIONS: The majority of HIV patients with severe anaemia had TB disease, and extra pulmonary TB was as prevalent as pulmonary TB. CXR, US and sputum Xpert were the optimum tests for rapid diagnosis of TB. South African national TB/HIV guidelines should incorporate these specific tests to diagnose TB in patients with HIV and severe anaemia.