Prevalence of disseminated tuberculosis in human immunodeficiency virus infected persons admitted with sepsis at Moi Teaching and Referral Hospital, Eldoret, Kenya

Abstract

Background: Disseminated Tuberculosis (TB) has been identified as one of most common causes of death in adult HIV-infected persons. It has a non-specific clinical presentation mimicking that of bacterial sepsis requiring a high index of suspicion to make a diagnosis. The gold standard of diagnosis is blood cultures that have a long incubation period hence delay in initiation of treatment thus an associated high mortality rate. The current burden of disseminated TB in adult HIV-infected persons is not known in Western Kenya. Urinary LAM antigen assay detects the presence of lipoarabinomannan (LAM), a lipopolysaccharide on the TB cell wall. Its sensitivity increases with decreasing CD4 counts and in in-patient, PLHIV regardless of their CD4 counts with a pooled sensitivity of 61% and specificity of 89%. Broad Objective: To determine the prevalence of disseminated tuberculosis and describe the clinical characteristics of PLHIV admitted with sepsis at MTRH. Specific objectives: To determine the prevalence of disseminated tuberculosis in PLHIV admitted with sepsis at MTRH. To describe the clinical characteristics of participants with disseminated tuberculosis in PLHIV admitted with sepsis at MTRH. Methods: A cross sectional study of HIV-infected persons admitted with sepsis conducted at the MTRH adult medical wards, 300 participants recruited. Interviewer administered structured questionnaires used to collect data that included demographics (age and sex); admission vital signs (pulse rate, axillary temperature, blood pressure, and respiratory rate); HIV associated variables (use of antiretroviral therapy). Blood samples taken for a full blood count, serum creatinine and urea levels. A urine sample taken for LAM antigen assay. Data entered into EPIDATA version 13 and analyzed using STATA version 15. Independent variables were summarized using frequencies (percent), mean (SD) and median (IQR); dependent variables were analyzed using Student t-test, Chi square and Wilcoxon rank sum test. A significant p value was less than 0.05. Results: Two hundred and ninety-eight (298) participants were analyzed; fifty eight percent (173) were female. Overall mean age was 41.68 (SD 11.72) with no difference in age between the LAM positive and negative. Prevalence of disseminated TB 26% (95% CI 21.2-31.4). All participants had anemia with the LAM positive group having a lower hemoglobin level of 9.71g/dl versus 10.47g/dl in the LAM negative group (p0.04). One hundred and seventy eight (178) participants had lymphopenia. Out of the seventy-seven participants with LAM antigen assay positive, 55 had lymphopenia, only two had lymphocytosis and 20 had a normal lymphocyte count (p 0.04). Out of the seventy-seven participants with LAM antigen assay positive, fifty-eight were not on HAART with only nineteen being on HAART (p0.02).Thirty seven percent in the LAM positive group died 10 days from admission and a further twenty seven percent died within one month (p <0.001). Conclusion: The prevalence of disseminated TB was 26%. Possible factors associated with LAM antigen positivity included anemia, lymphopenia and not on antiretroviral therapy. There was higher mortality seen in the LAM positive group within 1 month of admission. Recommendations: LAM antigen assay should be a routine diagnostic test in HIVinfected persons admitted with sepsis and anti TB medication started promptly due to the high associated mortality.