title: Test characteristics of urinary lipoarabinomannan and predictors of mortality among hospitalized HIV-infected tuberculosis suspects in Tanzania.
abstract: BACKGROUND
  Tuberculosis is the most common cause of death among patients with HIV infection living in tuberculosis endemic countries, but many cases are not diagnosed pre-mortem. We assessed the test characteristics of urinary lipoarabinomannan (LAM) and predictors of mortality among HIV-associated tuberculosis suspects in Tanzania.
  
  
  METHODS
  We prospectively enrolled hospitalized HIV-infected patients in Dar es Salaam, with ≥2 weeks of cough or fever, or weight loss. Subjects gave 2 mLs of urine to test for LAM using a commercially available ELISA, ≥2 sputum specimens for concentrated AFB smear and solid media culture, and 40 mLs of blood for culture.
  
  
  RESULTS
  Among 212 evaluable subjects, 143 (68%) were female; mean age was 36 years; and the median CD4 count 86 cells/mm(3). 69 subjects (33%) had culture confirmation of tuberculosis and 65 (31%) were LAM positive. For 69 cases of sputum or blood culture-confirmed tuberculosis, LAM sensitivity was 65% and specificity 86% compared to 36% and 98% for sputum smear. LAM test characteristics were not different in patients with bacteremia but showed higher sensitivity and lower specificity with decreasing CD4 cell count. Two month mortality was 64 (53%) of 121 with outcomes available. In multivariate analysis there was significant association of mortality with absence of anti-retroviral therapy (p = 0.004) and a trend toward association with a positive urine LAM (p = 0.16). Among culture-negative patients mortality was 9 (75%) of 12 in LAM positive patients and 27 (38%) of 71 in LAM negative patients (p = 0.02).
  
  
  CONCLUSIONS
  Urine LAM is more sensitive than sputum smear and has utility for the rapid diagnosis of culture-confirmed tuberculosis in this high-risk population. Mortality data raise the possibility that urine LAM may also be a marker for culture-negative tuberculosis.
authors.affiliation: Dartmouth Medical School, Hanover, New Hampshire, United States of America. Elizabeth.talbot@dartmouth.edu
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Talbot
authors.forename: Patricia
authors.initials: P
authors.lastname: Munseri
authors.forename: Pedro
authors.initials: P
authors.lastname: Teixeira
authors.forename: Mecky
authors.initials: M
authors.lastname: Matee
authors.forename: Muhammad
authors.initials: M
authors.lastname: Bakari
authors.forename: Timothy
authors.initials: T
authors.lastname: Lahey
authors.forename: Fordham
authors.initials: F
authors.lastname: von Reyn
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D060085:Coinfection / Q000175:diagnosis* / Q000401:mortality*; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000401:mortality*; D006760:Hospitalization; D006801:Humans; D008070:Lipopolysaccharides / Q000652:urine*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012372:ROC Curve; D012307:Risk Factors; D013636:Tanzania; D014376:Tuberculosis / Q000175:diagnosis* / Q000401:mortality*; D055815:Young Adult
chemical_list: D008070:Lipopolysaccharides; C050016:lipoarabinomannan