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What causes symptoms suggestive of tuberculosis in HIV-positive people with negative initial investigations?

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To identify the causes of symptoms suggestive of tuberculosis (TB) among people living with the human immunodeficiency virus (PLHIV) in South Africa.


A consecutive sample of HIV clinic attendees with symptoms suggestive of TB (⩾1 of cough, weight loss, fever or night sweats) at enrolment and at 3 months, and negative initial TB investigations, were systematically evaluated with standard protocols and diagnoses assigned using standard criteria. TB was ‘confirmed' if Mycobacterium tuberculosis was identified within 6 months of enrolment, and ‘clinical' if treatment started without microbiological confirmation.


Among 103 participants, 50/103 were pre-antiretroviral therapy (ART) and 53/103 were on ART; respectively 68% vs. 79% were female; the median age was 35 vs. 45 years; the median CD4 count was 311 vs. 508 cells/mm3. Seventy-two (70%) had ⩾5% measured weight loss and 50 (49%) had cough. The most common final diagnoses were weight loss due to severe food insecurity (n = 20, 19%), TB (n = 14, 14%: confirmed n = 7; clinical n = 7), other respiratory tract infection (n = 14, 14%) and post-TB lung disease (n = 9, 9%). The basis for TB diagnosis was imaging (n = 7), bacteriological confirmation from sputum (n = 4), histology, lumbar puncture and other (n = 1 each).


PLHIV with persistent TB symptoms require further evaluation for TB using all available modalities, and for food insecurity in those with weight loss.

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Keywords: South Africa; TB symptoms; Xpert<sup>®</sup> MTB/RIF; human immunodeficiency virus

Affiliations: 1: TB Centre, London School of Hygiene & Tropical Medicine, London, UK 2: Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg 3: University of the Witwatersrand, Johannesburg 4: The Aurum Institute, Johannesburg 5: School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 6: Advancing Care and Treatment for TB-HIV, South African Medical Research Council Collaborating Centre for HIV and TB, Tygerberg 7: Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases, Johannesburg 8: School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 9: Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town 10: National Health Laboratory Service, Johannesburg 11: Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 12: Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa

Appeared or available online: 24 January 2019

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