• Advanced
• pulmonary
• tuberculosis
• low
• risk
• tuberculosis

Over and above the recommendation that ‘Clinicians should have a higher index of clinical suspicion of extrapulmonary tuberculosis in non-UK born cases’,1 due to an increasing proportion of non-UK-born cases during 1999–2006,1 we also need to be vigilant for the possibility that UK-born individuals who have escaped early detection of pulmonary tuberculosis might subsequently present with advanced pulmonary tuberculosis (APT), as was the case in the USA during the period 1993–2006. During that period 160 661 notified cases of pulmonary tuberculosis were subdivided into those with APT (35 584 cases), characterised by cavitation on chest radiograph and acid-fast bacilli smear-positive sputum, and those without advanced disease, the latter amounting to 125 077 cases. Further analysis revealed that, during that period, the proportion of patients with APT ‘increased greatest among whites (65.4%), the employed (63.3%), and US born (59.2%)’.2 Accordingly, a recommendation, which also has relevance to the UK, was made that ‘Additional efforts should concentrate on reducing time to treatment initiation in low-incidence areas and among groups traditionally seen as being at low risk for tuberculosis disease’.2 Cautionary tales already abound in the tabloid press3 4 of white UK-born young (age range 25–41) professionals (and, in one instance, a law student) in whom the diagnosis of pulmonary tuberculosis was delayed because of under-recognition of the significance of presenting symptoms in primary care and, in one instance, also in secondary care. What also needs to be recognised is that extrapulmonary tuberculosis itself poses a threat of transmission of the disease to other people, given the fact that, in the event of positive sputum culture results despite normal chest x-ray findings,5 ‘transmission of tuberculosis from smear-negative, culture-positive patients has been well documented in other settings’.5