BMJ  2006;332:1392 (10 June), doi:10.1136/bmj.332.7554.1392-a

Letter

Pulmonary tuberculosis

Chest radiograph can appear normal in immunocompromised patients

EDITOR—Campbell and Bah-Sow describe the varied patterns of abnormality in chest radiographs in patients with pulmonary tuberculosis, appearances often being less specific in immunocompromised patients.¹ We agree that a high index of suspicion is necessary in such patients and highlight the inadequacy of a chest radiograph in excluding pulmonary tuberculosis.

Our hospital is in a major suburban town in Greater London and has an ethnically diverse and unusually mobile population. In the past 12 months, 16% of cases of pulmonary tuberculosis (excluding mediastinal lymphadenitis and pleural disease) had co-infection with HIV. In one such case the chest radiograph was completely normal while sputum was smear positive.

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This occurs more often than we expected: in 2004 a paper from Addis Ababa showed that 9.2% of patients with HIV and culture proved pulmonary tuberculosis had a normal chest radiograph.² An earlier paper from Rome showed that 9% of patients who were HIV positive and sputum culture positive had a normal chest radiograph and were sputum smear negative. Although these patients were no different in demographic characteristics, degree of immunosuppression, or Mycobacterium tuberculosis drug susceptibility pattern, they had an increased risk of death and shorter median survival.³ In a series from New York, 14% of patients with coinfection (HIV or culture positive for tuberculosis) had a normal chest radiograph, and this rose to 21% when patients with low CD4 counts were considered (< 200).⁴

Mayday University Hospital, Thornton Heath, Surrey CR7 7YE drbencb{at}gmail.com

Mayday University Hospital, Thornton Heath, Surrey CR7 7YE

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Competing interests: None declared.

References

1. Campbell IA, Bah-Sow O. Pulmonary tuberculosis: diagnosis and treatment. BMJ 2006;332: 1194-7. (20 May.)[Free Full Text]
2. Aderaye G, Bruchfeld J, Assefa G, Feleke D, Kallenius G, Baat M, et al. The relationship between disease pattern and disease burden by chest radiography, M. tuberculosis load, and HIV status in patients with pulmonary tuberculosis in Addis Ababa. Infection 2004;32: 333-8.[Medline]
3. Palmieri F, Girardi E, Pellicelli AM, Rianda A, Bordi E, Rizzi EB, et al. Pulmonary tuberculosis in HIV-infected patients presenting with normal chest radiograph and negative sputum smear. Infection 2002;30: 68-74.[CrossRef][Medline]
4. Greenberg SD, Frager D, Suster B, Walker S, Stavropoulos C, Rothpearl A. Active pulmonary tuberculosis in patients with AIDS: spectrum of radiographic findings (including a normal appearance). Radiology 1994;193: 115-9.[Abstract/Free Full Text]

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Relevant Article

Pulmonary tuberculosis: diagnosis and treatment

Ian A Campbell and Oumou Bah-Sow
BMJ 2006 332: 1194-1197. [Extract] [Full Text] [PDF]