Extrapulmonary tuberculosis at King Edward hospital : a descriptive retrospective study.

Abstract

Background Globally, South Africa remains one of the top twenty high tuberculosis(TB) burden countries. In addition, South Africa has the highest burden of tuberculosis/Human Immunodeficiency virus (TB/HIV) coinfection in the world, with the province of KwaZulu-Natal representing the global epicenter of TB/HIV. With the scaling up of one of the world’s largest antiretroviral therapy programs, it was envisioned that the burden of tuberculosis would be reduced. While significant progress has been made to improve the diagnosis of pulmonary tuberculosis, the diagnosis of extrapulmonary TB(EPTB) remains a significant challenge in resource constrained settings. This study describes the profile of patients with EPTB at a tertiary hospital in a TB/HIV hyperendemic setting in Durban, South Africa. Methods A retrospective chart review was conducted, and included all adult patients diagnosed with EPTB at a tertiary hospital in Durban, South Africa, between 1 January 2016 and 31 March 2016. Data was extracted from the facility TB register, as well as patient clinical records. All data was analysed using SPSS software (SPSS 23.0, Armonk NY: IBM Corp). For all statistical comparisons, a 5% level of significance was used; correspondingly 95% confidence intervals were used to describe effect size. All data was assessed for normality, and non-parametric tests were used where necessary. Medians and interquartile ranges were used for data not amenable to parametric description. Pearson’s Chi-square test was utilised for comparison between subgroups. All p values were 2-tailed and considered significant below 0.05. Significant findings were analysed for association using Phi and Kramers V test for symmetric measures. Results There were 188 new cases of TB during the study period, with 80 patients diagnosed with EPTB. The mean age of patients was 34.73 years (SD ±9.44). Forty two (52.5%) patients were female, while 76(96%) were black African. The most common risk factor for EPTB was HIV co-infection (88.8%). The median CD4 cell count was 68 (IQR 32-165) cells/mm3. Pleural (36.3%), lymph node (28.7%) and abdominal(27.5%) involvement were the most common sites of extrapulmonary disease Eleven of the 80 patients (13.8%) presented with EPTB involving more than one anatomical system. Weight loss, fever, night sweats and cough were amongst the most common symptoms reported. Signs varied according to the site of infection. Non-specific symptoms were common. In the majority of cases, more than one diagnostic method was used to confirm the presence of TB in distant organs. Conclusion A high index of suspicion is required when assessing a patient with known risk factors for EPTB. Immunosuppression remains the most significant risk factor for the development of EPTB. In our setting, HIV co-infection remains the most common risk factor. Advancements in Xpert MTB/Rif and computer tomography have greatly assisted in rapidly diagnosing EPTB. Despite improved access to antiretroviral therapy over the past years, advanced HIV disease remains a significant challenge to eradicating TB.