Chest
Volume 102, Issue 1, July 1992, Pages 143-146
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The Role of Bronchoscopy in the Diagnosis of Pulmonary Tuberculosis in Patients at Risk for HIV Infection

https://doi.org/10.1378/chest.102.1.143Get rights and content

The present study was undertaken to clarify the role of bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB) in the diagnosis of pulmonary tuberculosis in patients at risk for human immunodeficiency virus (HIV) infection. We retrospectively identified 31 patients at risk for HIV who proved to have Mycobacterium tuberculosis on culture of at least one pulmonary specimen. All had pulmonary symptoms but initial sputum smears negative for acid-fast bacilli (AFB). All underwent fiberoptic bronchoscopy (FOB), including BAL and TBB; postbronchoscopy sputum was also collected in 19 patients. A specimen was considered to yield an immediate diagnosis when positive for AFB either on smear or histologic study; granulomas alone were considered positive when no other causes were identified. Overall, an immediate diagnosis was made by bronchoscopic specimens in 15 (48 percent) of 31 cases. TBB was the sole positive specimen in seven patients (23 percent). For comparison, similar specimens from 40 patients in whom M avium complex (MAC) grew on culture were also evaluated. An immediate identification of AFB was made in only four patients (10 percent). We conclude that the finding of AFB on staining of any pulmonary specimen is highly suggestive of tuberculosis, rather than MAC, and warrants institution of antituberculosis therapy. Of all bronchoscopic specimens, TBB provides the highest yield for an immediate diagnosis of tuberculosis.

(Chest 1992; 102:143–46)

Section snippets

MATERIALS AND METHODS

Criteria for inclusion in the study were as follows: (1) Mycobacterium tuberculosis (MTb) or MAC was isolated from a specimen of sputum, BAL fluid, or TBB; (2) diagnosis of AIDS or HIV infection was established, or the patient was a member of a group at risk for HIV infection; (3) a diagnostic bronchoscopy, which included both BAL and TBB, was performed; (4) when obtained prior to bronchoscopy, sputum stain was negative for AFB.

The medical records of patients hospitalized between April 1984 and

RESULTS

All 31 patients with MTb infection were male; mean age was 38.3 years (range, 25 to 56 years). Risk factor for HIV infection was intravenous drug use in 24 patients, homosexuality in six, and blood transfusion in one. HIV infection was established by serologic tests in 18 patients who consented to testing. An additional three patients, who were not tested, met Centers for Disease Control (CDC) criteria for AIDS. In total, 12 patients met the CDC criteria for AIDS. The diagnosis of AIDS preceded

DISCUSSION

The diagnosis of tuberculosis is often unsuspected in HIV-infected patients. Symptoms are nonspecific, upper lobe cavitary infiltrates are usually not present, and the PPD skin test is often nonreactive.4 A previous study from our institution found that 5 (31 percent) of 16 HIV-infected patients with positive sputum cultures had AFB seen on smear.2 A more recent study found 19 (83 percent) of 23 patients with HIV infection and pulmonary tuberculosis had positive sputum smears.3 The role of FOB

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Manuscript received April 25; revision accepted July 3.

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