Burden of tuberculosis at post mortem in inpatients at a tertiary referral centre in sub-Saharan Africa: a prospective descriptive autopsy study

Matthew Bates; Victor Mudenda; Aaron Shibemba; Jonas Kaluwaji; John Tembo; Mwila Kabwe; Charles Chimoga; Lophina Chilukutu; Moses Chilufya; Nathan Kapata; Michael Hoelscher; Markus Maeurer; Peter Mwaba; Alimuddin Zumla

doi:10.1016/S1473-3099(15)70058-7

Burden of tuberculosis at post mortem in inpatients at a tertiary referral centre in sub-Saharan Africa: a prospective descriptive autopsy study

Lancet Infect Dis. 2015 May;15(5):544-51. doi: 10.1016/S1473-3099(15)70058-7. Epub 2015 Mar 10.

Authors

Affiliations

¹ Department of Infection, Division of Infection and Immunity, University College London, London, UK; University of Zambia and University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia.
² Department of Pathology and Microbiology, University Teaching Hospital, Lusaka, Zambia.
³ University of Zambia and University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia.
⁴ National Tuberculosis Control Programme, Ministry of Community Development, Maternal and Child Health, Lusaka, Zambia.
⁵ Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich, Munich, Germany.
⁶ Therapeutic Immunology, Department of Laboratory Medicine, Department of Microbiology, and Department of Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden.
⁷ Department of Infection, Division of Infection and Immunity, University College London, London, UK; University of Zambia and University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia; National Institute for Health Research Biomedical Research Centre, University College London Hospitals, London, UK. Electronic address: [email protected].

PMID: 25765217
DOI: 10.1016/S1473-3099(15)70058-7

Abstract

Background: Patients with subclinical tuberculosis, smear-negative tuberculosis, extrapulmonary tuberculosis, multidrug-resistant tuberculosis, and asymptomatic tuberculosis are difficult to diagnose and may be missed at all points of health care. We did an autopsy study to ascertain the burden of tuberculosis at post mortem in medical inpatients at a tertiary care hospital in Lusaka, Zambia.

Methods: Between April 5, 2012, and May 22, 2013, we did whole-body autopsies on inpatients aged at least 16 years who died in the adult inpatient wards at University Teaching Hospital, Lusaka, Zambia. We did gross pathological and histopathological analysis and processed lung tissues from patients with tuberculosis through the GeneXpert MTB/RIF assay to identify patients with multidrug-resistant tuberculosis. The primary outcome measure was specific disease or diseases stratified by HIV status. Secondary outcomes were missed tuberculosis, multidrug-resistant tuberculosis, and comorbidities with tuberculosis. Data were analysed using Pearson χ(2), the Mann-Whitney U test, and binary logistic regression.

Findings: The median age of the 125 included patients was 35 years (IQR 29-43), 80 (64%) were men, and 101 (81%) were HIV positive. 78 (62%) patients had tuberculosis, of whom 66 (85%) were infected with HIV. 35 (45%) of these 78 patients had extrapulmonary tuberculosis. The risk of extrapulmonary tuberculosis was higher among HIV-infected patients than among uninfected patients (adjusted odds ratio 5·14, 95% CI 1·04-24·5; p=0·045). 20 (26%) of 78 patients with tuberculosis were not diagnosed during their life and 13 (17%) had undiagnosed multidrug-resistant tuberculosis. Common comorbidities with tuberculosis were pyogenic pneumonia in 26 patients (33%) and anaemia in 15 (19%).

Interpretation: Increased clinical awareness and more proactive screening for tuberculosis and multidrug-resistant tuberculosis in inpatient settings is needed. Further autopsy studies are needed to ascertain the generalisability of the findings.

Funding: UBS Optimus Foundation, EuropeAID, and European Developing Countries Clinical Trials Partnership (EDCTP).

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Adult
Africa South of the Sahara
Asymptomatic Diseases
Autopsy
Coinfection
Diagnosis
Female
HIV Infections / diagnosis*
HIV Infections / pathology
HIV Infections / virology
HIV-1 / growth & development
Humans
Male
Mycobacterium tuberculosis / growth & development
Prospective Studies
Tuberculosis, Multidrug-Resistant / diagnosis*
Tuberculosis, Multidrug-Resistant / microbiology
Tuberculosis, Multidrug-Resistant / pathology
Tuberculosis, Pulmonary / diagnosis*
Tuberculosis, Pulmonary / microbiology
Tuberculosis, Pulmonary / pathology