title: An algorithm for tuberculosis screening and diagnosis in people with HIV.
abstract: BACKGROUND
  Tuberculosis screening is recommended for people with human immunodeficiency virus (HIV) infection to facilitate early diagnosis and safe initiation of antiretroviral therapy and isoniazid preventive therapy. No internationally accepted, evidence-based guideline addresses the optimal means of conducting such screening, although screening for chronic cough is common.
  
  
  METHODS
  We consecutively enrolled people with HIV infection from eight outpatient clinics in Cambodia, Thailand, and Vietnam. For each patient, three samples of sputum and one each of urine, stool, blood, and lymph-node aspirate (for patients with lymphadenopathy) were obtained for mycobacterial culture. We compared the characteristics of patients who received a diagnosis of tuberculosis (on the basis of having one or more specimens that were culture-positive) with those of patients who did not have tuberculosis to derive an algorithm for screening and diagnosis.
  
  
  RESULTS
  Tuberculosis was diagnosed in 267 (15%) of 1748 patients (median CD4+ T-lymphocyte count, 242 per cubic millimeter; interquartile range, 82 to 396). The presence of a cough for 2 or 3 weeks or more during the preceding 4 weeks had a sensitivity of 22 to 33% for detecting tuberculosis. The presence of cough of any duration, fever of any duration, or night sweats lasting 3 or more weeks in the preceding 4 weeks was 93% sensitive and 36% specific for tuberculosis. In the 1199 patients with any of these symptoms, a combination of two negative sputum smears, a normal chest radiograph, and a CD4+ cell count of 350 or more per cubic millimeter helped to rule out a diagnosis of tuberculosis, whereas a positive diagnosis could be made only for the 113 patients (9%) with one or more positive sputum smears; mycobacterial culture was required for most other patients.
  
  
  CONCLUSIONS
  In persons with HIV infection, screening for tuberculosis should include asking questions about a combination of symptoms rather than only about chronic cough. It is likely that antiretroviral therapy and isoniazid preventive therapy can be started safely in people whose screening for all three symptoms is negative, whereas diagnosis in most others will require mycobacterial culture.
authors.affiliation: U.S. Centers for Disease Control and Prevention, Division of Tuberculosis Elimination, Atlanta, GA 30333, USA. kcain@cdc.gov
authors.forename: Kevin P
authors.initials: KP
authors.lastname: Cain
authors.forename: Kimberly D
authors.initials: KD
authors.lastname: McCarthy
authors.forename: Charles M
authors.initials: CM
authors.lastname: Heilig
authors.forename: Patama
authors.initials: P
authors.lastname: Monkongdee
authors.forename: Theerawit
authors.initials: T
authors.lastname: Tasaneeyapan
authors.forename: Nong
authors.initials: N
authors.lastname: Kanara
authors.forename: Michael E
authors.initials: ME
authors.lastname: Kimerling
authors.forename: Phalkun
authors.initials: P
authors.lastname: Chheng
authors.forename: Sopheak
authors.initials: S
authors.lastname: Thai
authors.forename: Borann
authors.initials: B
authors.lastname: Sar
authors.forename: Praphan
authors.initials: P
authors.lastname: Phanuphak
authors.forename: Nipat
authors.initials: N
authors.lastname: Teeratakulpisarn
authors.forename: Nittaya
authors.initials: N
authors.lastname: Phanuphak
authors.forename: Huy Dung
authors.initials: HD
authors.lastname: Nguyen
authors.forename: Thi Quy
authors.initials: TQ
authors.lastname: Hoang
authors.forename: Hung Thai
authors.initials: HT
authors.lastname: Le
authors.forename: Jay K
authors.initials: JK
authors.lastname: Varma
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000175:diagnosis*; D000293:Adolescent; D000328:Adult; D000368:Aged; D000465:Algorithms; D002648:Child; D003371:Cough / Q000209:etiology; D005260:Female; D015658:HIV Infections / Q000150:complications*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D014397:Tuberculosis, Pulmonary / Q000150:complications / Q000175:diagnosis*; D055815:Young Adult