Conference Material > Video
Fidelle L, Mahajan R, Gallo J, Biague E, Goncalves R, et al.
MSF Paediatric Days 2024. 3 May 2024
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Conference Material > Abstract
Fidelle L, Mahajan R, Gallo J, Biague E, Goncalves R, et al.
MSF Paediatric Days 2024. 3 May 2024; DOI:10.57740/EGpRP15g
BACKGROUND AND OBJECTIVES
Over half of childhood tuberculosis (TB) remains undiagnosed yearly. TB culture is often unavailable. WHO recommends Xpert-Ultra as first test for diagnosis of paediatric TB, but microbiological confirmation remains low and often requires invasive procedures. We aimed to determine the utility of Xpert-Ultra in stools and urine samples to diagnose TB in children living with HIV (CLWH) in two high-TB burden settings.
METHODS
This cross-sectional multicentric study took place at Simão Mendes hospital, Guinea-Bissau, from July 2019 to April 2020, and in Malakal hospitals, South Sudan, from November 2019 to June 2023. Children 6 months to 15 years with suspected TB underwent clinical and laboratory assessment, with one respiratory or extrapulmonary sample (gold standard (GS)), one stool and one urine specimen per patient analysed with Xpert-Ultra.
RESULTS
A total of 93 HIV-positive children were enrolled from Bissau (n=57) and Malakal (n=36), with 49 (53%) females and median (IQR) age of 3.3 (1.5-10) years. Three-quarters of children had severe acute malnutrition (SAM). A total of 72 (77%) children were on ART at baseline and 26/77 (34%) had CD4 count <200cells/mm3. Confirmation of TB was achieved in 20 (22%); 51 (55%) had unconfirmed TB, and 22 (24%) had unlikely TB. Of 93 children with GS diagnosis, the overall yield of positive TB results was 22% (20/93): 10% (9/90) in pulmonary samples and 20% (1/5) in extrapulmonary samples. A total of 86 and 91 samples were used to evaluate Xpert-Ultra on stools and urine, respectively. Compared to GS, sensitivity and specificity on stools were 87.5% (95%CI:52.9-97.8) and 100% (95%CI: 95.3-100), whereas on urine were 30% (95%CI:10.8-60.3) and 100% (95%CI:95.5-100), respectively. No patients were positive in stools or urine and negative with GS.
CONCLUSIONS
Xpert-Ultra in stools showed high sensitivity and specificity in HIV-infected children when compared to gold standard. Sensitivity of urine was low, but more research is needed to determine its clinical indication.
Over half of childhood tuberculosis (TB) remains undiagnosed yearly. TB culture is often unavailable. WHO recommends Xpert-Ultra as first test for diagnosis of paediatric TB, but microbiological confirmation remains low and often requires invasive procedures. We aimed to determine the utility of Xpert-Ultra in stools and urine samples to diagnose TB in children living with HIV (CLWH) in two high-TB burden settings.
METHODS
This cross-sectional multicentric study took place at Simão Mendes hospital, Guinea-Bissau, from July 2019 to April 2020, and in Malakal hospitals, South Sudan, from November 2019 to June 2023. Children 6 months to 15 years with suspected TB underwent clinical and laboratory assessment, with one respiratory or extrapulmonary sample (gold standard (GS)), one stool and one urine specimen per patient analysed with Xpert-Ultra.
RESULTS
A total of 93 HIV-positive children were enrolled from Bissau (n=57) and Malakal (n=36), with 49 (53%) females and median (IQR) age of 3.3 (1.5-10) years. Three-quarters of children had severe acute malnutrition (SAM). A total of 72 (77%) children were on ART at baseline and 26/77 (34%) had CD4 count <200cells/mm3. Confirmation of TB was achieved in 20 (22%); 51 (55%) had unconfirmed TB, and 22 (24%) had unlikely TB. Of 93 children with GS diagnosis, the overall yield of positive TB results was 22% (20/93): 10% (9/90) in pulmonary samples and 20% (1/5) in extrapulmonary samples. A total of 86 and 91 samples were used to evaluate Xpert-Ultra on stools and urine, respectively. Compared to GS, sensitivity and specificity on stools were 87.5% (95%CI:52.9-97.8) and 100% (95%CI: 95.3-100), whereas on urine were 30% (95%CI:10.8-60.3) and 100% (95%CI:95.5-100), respectively. No patients were positive in stools or urine and negative with GS.
CONCLUSIONS
Xpert-Ultra in stools showed high sensitivity and specificity in HIV-infected children when compared to gold standard. Sensitivity of urine was low, but more research is needed to determine its clinical indication.
Conference Material > Slide Presentation
Fidelle L, Mahajan R, Gallo J, Biague E, Goncalves R, et al.
MSF Paediatric Days 2024. 3 May 2024; DOI:10.57740/rZE9YDiu3
Conference Material > Video
Moreto-Planas L, Sagrado MJ, Mahajan R, Gallo J, Biague E, et al.
MSF Scientific Days International 2022. 7 June 2022; DOI:10.57740/50a1-ba02
Conference Material > Slide Presentation
Moreto-Planas L, Sagrado MJ, Mahajan R, Gallo J, Biague E, et al.
MSF Scientific Days International 2022. 11 May 2022; DOI:10.57740/mpdr-x060
Conference Material > Abstract
Moreto-Planas L, Sagrado MJ, Mahajan R, Gallo J, Biague E, et al.
MSF Scientific Days International 2022. 11 May 2022; DOI:10.57740/b8m1-p572
INTRODUCTION
Tuberculosis (TB) is an important cause of morbidity and mortality in children and over 50% of childhood TB remains undiagnosed every year. As microbiological confirmation is low (<30%), the majority of cases in low and middle-income countries are diagnosed on clinical grounds. Point-of-care ultrasound (POCUS) is a non-invasive bedside tool, and TB-focused POCUS has been validated for diagnosis of TB in adults with HIV. We aimed to describe the performance and findings of TB-focused POCUS for children with presumptive TB at a tertiary care hospital in Guinea- Bissau, a setting with a high burden of HIV, malnutrition and TB.
METHODS
This observational study took place at Simão Mendes hospital in Bissau, from July 2019 to April 2020. Patients aged between 6 months and 15 years with presumptive TB underwent clinical and laboratory assessment, with at least one sample analysed with GeneXpert Ultra, and unblinded clinician-performed POCUS evaluation. POCUS was used to assess for subpleural nodules (SUN’s), lung consolidation, pleural effusion, pericardial effusion, ascites, liver and splenic focal lesions, and abdominal lymph nodes. Presence of any of these signs prompted a POCUS- positive result. Images and clips were evaluated by an expert reviewer and, if discordant, by a second expert reviewer.
ETHICS
This study was approved by the MSF Ethics Review Board (ERB) and by the Guinea-Bissau Ministry of Health ERB.
RESULTS
A total of 139 children were enrolled, with 62 (45%) female and 55 (40%) aged under 5 years. HIV infection and severe acute malnutrition (SAM) were found in 59 (42%) and 83 (60%) of patients, respectively. Confirmation of TB was achieved in 27 (19%); 62 (45%) had unconfirmed TB, and 50 (36%) had unlikely TB. Children with TB were more likely to have a POCUS positive result (83/89; 93%) as compared to children with unlikely TB (17/50; 34%). The most common POCUS signs in TB patients were: lung consolidation (51; 57%), SUN’s (49; 55%), pleural effusion (27; 30%), and focal splenic lesions (25; 28%). In children with confirmed TB (n=27), POCUS sensitivity was 85.2% (95% confidence interval (CI) 67.5-94.1). In those with unlikely TB (n=50), specificity was 66% (95%CI 2.2-77.6). Unlike HIV infection, SAM was associated with higher risk of positive POCUS. Cohen’s kappa coefficient for concordance between field and expert reviewers ranged from 0.6 to 0.9 depending on the POCUS sign, while overall POCUS concordance was 0.8.
CONCLUSION
We found high prevalence of any POCUS sign in children with TB, as compared to children with unlikely TB. POCUS positivity was independent of HIV status, but not of nutritional status. POCUS concordance between field and expert reviewers was moderate to high. TB-focused POCUS could potentially play a supportive role in the diagnosis of TB in children.
CONFLICTS OF INTEREST
None declared.
Tuberculosis (TB) is an important cause of morbidity and mortality in children and over 50% of childhood TB remains undiagnosed every year. As microbiological confirmation is low (<30%), the majority of cases in low and middle-income countries are diagnosed on clinical grounds. Point-of-care ultrasound (POCUS) is a non-invasive bedside tool, and TB-focused POCUS has been validated for diagnosis of TB in adults with HIV. We aimed to describe the performance and findings of TB-focused POCUS for children with presumptive TB at a tertiary care hospital in Guinea- Bissau, a setting with a high burden of HIV, malnutrition and TB.
METHODS
This observational study took place at Simão Mendes hospital in Bissau, from July 2019 to April 2020. Patients aged between 6 months and 15 years with presumptive TB underwent clinical and laboratory assessment, with at least one sample analysed with GeneXpert Ultra, and unblinded clinician-performed POCUS evaluation. POCUS was used to assess for subpleural nodules (SUN’s), lung consolidation, pleural effusion, pericardial effusion, ascites, liver and splenic focal lesions, and abdominal lymph nodes. Presence of any of these signs prompted a POCUS- positive result. Images and clips were evaluated by an expert reviewer and, if discordant, by a second expert reviewer.
ETHICS
This study was approved by the MSF Ethics Review Board (ERB) and by the Guinea-Bissau Ministry of Health ERB.
RESULTS
A total of 139 children were enrolled, with 62 (45%) female and 55 (40%) aged under 5 years. HIV infection and severe acute malnutrition (SAM) were found in 59 (42%) and 83 (60%) of patients, respectively. Confirmation of TB was achieved in 27 (19%); 62 (45%) had unconfirmed TB, and 50 (36%) had unlikely TB. Children with TB were more likely to have a POCUS positive result (83/89; 93%) as compared to children with unlikely TB (17/50; 34%). The most common POCUS signs in TB patients were: lung consolidation (51; 57%), SUN’s (49; 55%), pleural effusion (27; 30%), and focal splenic lesions (25; 28%). In children with confirmed TB (n=27), POCUS sensitivity was 85.2% (95% confidence interval (CI) 67.5-94.1). In those with unlikely TB (n=50), specificity was 66% (95%CI 2.2-77.6). Unlike HIV infection, SAM was associated with higher risk of positive POCUS. Cohen’s kappa coefficient for concordance between field and expert reviewers ranged from 0.6 to 0.9 depending on the POCUS sign, while overall POCUS concordance was 0.8.
CONCLUSION
We found high prevalence of any POCUS sign in children with TB, as compared to children with unlikely TB. POCUS positivity was independent of HIV status, but not of nutritional status. POCUS concordance between field and expert reviewers was moderate to high. TB-focused POCUS could potentially play a supportive role in the diagnosis of TB in children.
CONFLICTS OF INTEREST
None declared.