Challenges in diagnosing extrapulmonary tuberculosis in the European Union, 2011

Abstract

In the European Union (EU) 72,334 tuberculosis (TB) cases were notified in 2011, of which 16,116 (22%) had extrapulmonary tuberculosis (EPTB). The percentage of TB cases with EPTB ranged from 4% to 48% in the reporting countries. This difference might be explained by differences in risk factors for EPTB or challenges in diagnosis. To assess the practices in diagnosis of EPTB we asked European Union/European Economic Area (EU/EEA) countries to participate in a report describing the diagnostic procedures and challenges in diagnosing EPTB. Eleven EU Member States participated and reports showed that in the majority EPTB is diagnosed by a pulmonologist, sometimes in collaboration with the doctor who is specialised in the organ where the symptoms presented. In most countries a medical history and examination is followed by invasive procedures, puncture or biopsy, to collect material for confirmation of the disease (by culture/histology/cytology). Some countries also use the tuberculin skin test or an interferon-gamma-release-assay. A wide variety of radiological tests may be used. Countries that reported challenges in the diagnosis of EPTB reported that EPTB is often not considered because it is a rare disease and most medical professionals will not have experience in diagnosing EPTB. The fact that EPTB can present with a variety of symptoms that may mimic symptoms of other pathologies does pose a further challenge in diagnosis. In addition, obtaining an appropriate sample for confirmation of EPTB was frequently mentioned as a challenge. In summary, diagnosis of EPTB poses challenges due to the diversity of symptoms with which EPTB may present, the low level of suspicion of clinicians, and due to the difficulty in obtaining an adequate sample for confirmation.

The epidemiology of extrapulmonary tuberculosis in China: A large-scale multi-center observational study

“…The most common of EPTB (0.4% or about �800cases) was tuberculous pleurisy (50.15%, 95%CI:49.93%-50.37%), followed by bronchial tuberculosis (14.96%, 95%CI: 14.80% -15.12%), tuberculous lymphadenitis of the neck (7.24%, 95%CI:7.13%-7.36%), tuberculous meningitis (7.23%, 95%CI:7.12%-7.35%), etc. Other studies have also found that pleural TB is the most common EPTB in sub Saharan Africa(63.2%, 144/228), Poland (36%, 214/599) and Romania (58%, 1606/2781) [21,28,33]. However, other studies found that lymph node tuberculosis is the most common sites of extrapulmonary tuberculosis in the Netherlands (39%, 1963 / 504239%), the United States (40%, 19107 / 47293), the United Kingdom (37%, 10358 / 27762), Saudi Arabia (44.6%, 170 / 381), Turkey (21%, 29 / 141) and Afghanistan (37.3%, 44 / 118) [6,7,23,[51][52][53].…”

“…In fact, EPTB can present a variety of symptoms, which may be similar to the symptoms of other diseases, which poses a further challenge for diagnosis. In addition, getting the right samples to confirm EPTB is often seen as a challenge [21]. The ratio of PTB to EPTB varies with geographical, social, ethnic and economic parameters [22].…”

“…The proportion of extrapulmonary tuberculosis in the population aged 0-19 in Poland is higher than that in other age groups [28]. Extrapulmonary tuberculosis is more common in Saudi Arabia at a young age (20)(21)(22)(23)(24)(25)(26)(27)(28)(29) [19]. Sreeramareddy et al, also confirmed that youth may be an independent risk factor for EPTB in high burden countries [29].…”

Sequential 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) scan findings in patients with extrapulmonary tuberculosis during the course of treatment—a prospective observational study

“…In mouse, rabbit and primate models, 18 F-FDG PET/CT has been used to display progression of disease after exposure to M. tuberculosis and the response to treatment [1][2][3][4]. Previous human studies using 18 F-FDG PET/CT scanning to monitor ATT response have shown that there is decreased metabolic activity after 1 month treatment of pulmonary (n=10) and extra-pulmonary (n=10) TB [5], a steady decline in uptake after 6, 12 and 18 months of treatment of skeletal TB (n=18) [6] and no significant uptake in PTB (n=8) after a year of treatment [7]. PET and CT have shown complementary results in the detection and response monitoring of pulmonary and extra-pulmonary TB [8].…”

Tuberculosis: a medical evergreen

“…The radiologist must also have “peripheral vision” and knowledge about extrapulmonary manifestations like tubercular lymph glands, disease in bone, brain, pleura or pericardium, and abdomen (7). The frequency of extrapulmonary tuberculosis was 22% in 2011 within the European Union (12). Furthermore, radiology can be important in diagnosing certain forms of pulmonary atypical or non-tuberculous mycobacterial infections which in turn are recognized in increasing frequency (13).…”