Clinical Scorecard: Atypical Clinical Features, Longer Diagnostic Delays, and Distinct Co-Detection Patterns in Pulmonary Tuberculosis Among People With Non-HIV Immunocompromise

At a Glance

Key Highlights

• Among 578 patients, 71 are immunocompromised and 507 are non-immunocompromised.

• Median health system delay is 90 versus 24 days, respectively (P < .001). Delay exceeding 14 days occurs in 83.1% versus 69.2% (P = .012).

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

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

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

Guideline-Based Recommendations

Diagnosis

• The findings support maintaining suspicion for PTB in non-HIV immunocompromised patients and considering appropriate specimen selection and molecular testing.

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

• Sputum acid-fast bacilli (AFB) smear positivity is numerically lower in immunocompromised patients, but the difference is not statistically significant and only 29 undergo testing. BALF AFB smear positivity is higher.

Management

• The study does not establish treatment recommendations or compare treatment regimens. Its findings concern diagnostic characteristics and delays.

Monitoring & Follow-up

• Health system delay is measured from first medical contact to the earliest positive respiratory Xpert MTB/RIF, AFB smear, or liquid culture result.

• More than 14 days defines long health system delay. This research definition does not establish a routine follow-up schedule.

Risks

• Less typical presentations may complicate recognition of PTB in immunocompromised patients. A negative interferon-γ release assay does not exclude active tuberculosis.

• Respiratory co-detection identifies additional microorganisms; it does not by itself establish clinically significant coinfection.

Patient & Prescribing Data

Participants are adults with liquid culture-confirmed PTB. Immunocompromise criteria include specified immunosuppressive treatment, organ or hematopoietic stem cell transplantation, solid tumor with chemotherapy within 5 years, hematological malignancy, or primary immunodeficiency.

Patients receiving tuberculosis treatment for more than 4 weeks before admission are excluded. Detailed medication exposures and postdischarge tuberculosis treatment initiation are not systematically captured.

Clinical Best Practices

• Consider PTB despite less typical imaging or negative interferon-γ release assay findings.

• Interpret specimen-specific positivity cautiously because diagnostic testing is selected clinically and is not standardized across patients.

• Distinguish respiratory co-detection from confirmed coinfection.

• Consider the retrospective, single-center design, unequal immunocompromised subgroup sizes, and lack of multiple-testing adjustment when interpreting the findings.

Related Resources & Content

Azoulay E, Russell L, Van de Louw A, et al. Diagnosis of severe respiratory infections in immunocompromised patients. Intensive Care Med. 2020;46(2):298–314.

Kiyan E, Kilicaslan Z, Gurgan M, Tunaci A, Yildiz A. Clinical and radiographic features of pulmonary tuberculosis in non-AIDS immunocompromised patients. Int J Tuberc Lung Dis. 2003;7(8):764–770.

Zhang L, Weng TP, Wang HY, et al. Patient pathway analysis of tuberculosis diagnostic delay: a multicentre retrospective cohort study in China. Clin Microbiol Infect. 2021;27(7):1000–1006.

Tueller C, Chhajed PN, Buitrago-Tellez C, Frei R, Frey M, Tamm M. Value of smear and PCR in bronchoalveolar lavage fluid in culture positive pulmonary tuberculosis. Eur Respir J. 2005;26(5):767–772.

World Health Organization. WHO consolidated guidelines on tuberculosis. Module 3: diagnosis—rapid diagnostics for tuberculosis detection. 3rd ed. World Health Organization; 2024.