Clinical Report: Atypical Features and Diagnostic Delays in Non-HIV Immunocompromised PTB

Overview

This retrospective study compares clinical characteristics, imaging, microbiological test positivity, respiratory co-detection patterns, and health system delay in non-HIV immunocompromised and non-immunocompromised patients with pulmonary tuberculosis (PTB). Immunocompromised patients have longer diagnostic delays, less typical radiological findings, and distinct co-detection patterns.

Background

The article reports an estimated 10.7 million incident tuberculosis cases worldwide in 2024, approximately 87% occurring in 30 WHO high-burden countries. Non-HIV immunocompromised patients face particular diagnostic challenges, but their diagnostic characteristics are less extensively studied than those of patients with HIV. This investigation examines those differences among hospitalized patients with culture-confirmed PTB.

Data Highlights

Key Findings

• Median health system delay is longer in immunocompromised patients (90 vs 24 days; P < .001).

• Immunocompromised status is independently associated with delay exceeding 14 days (adjusted odds ratio, 2.31; 95% CI, 1.03–5.18).

• Immunocompromised patients have more bilateral lesions, pleural effusion, and lymphadenopathy but fewer cavities.

• Sputum acid-fast bacilli smear positivity is numerically lower in immunocompromised patients, without a statistically significant difference; only 29 undergo testing. Bronchoalveolar lavage fluid smear positivity is higher.

• Xpert MTB/RIF positivity exceeds 75% across sputum, bronchoalveolar lavage fluid, and tissue specimens, without significant between-group differences.

• Fungal, viral, and mixed co-detections are more frequent in immunocompromised patients, although the proportion with any co-detection does not differ significantly.

Clinical Implications

The findings support maintaining suspicion for PTB in non-HIV immunocompromised patients despite less typical imaging or negative interferon-γ release assay findings. Appropriate specimen selection and molecular testing may facilitate diagnosis. Respiratory co-detection should be distinguished from confirmed clinically significant coinfection.

Limitations

The retrospective, single-center inpatient design limits generalizability and precludes definitive causal inference. Unequal immunocompromised subgroup sizes prevent detailed comparisons by cause of immunosuppression. Multiple baseline comparisons lack adjustment for multiple testing. Diagnostic selection rationale, detailed medication exposures, and postdischarge tuberculosis treatment initiation are not systematically captured.

Conclusion

Non-HIV immunocompromised patients with PTB experience longer diagnostic delays and show less typical radiological presentations and distinct respiratory co-detection patterns. The findings support continued clinical suspicion and consideration of appropriate specimens and molecular testing.

Related Resources & Content

World Health Organization. Global tuberculosis report 2025. World Health Organization; 2025.

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