title: Burden of tuberculosis at post mortem in inpatients at a tertiary referral centre in sub-Saharan Africa: a prospective descriptive autopsy study.
abstract: BACKGROUND
  Patients with subclinical tuberculosis, smear-negative tuberculosis, extrapulmonary tuberculosis, multidrug-resistant tuberculosis, and asymptomatic tuberculosis are difficult to diagnose and may be missed at all points of health care. We did an autopsy study to ascertain the burden of tuberculosis at post mortem in medical inpatients at a tertiary care hospital in Lusaka, Zambia.
  
  
  METHODS
  Between April 5, 2012, and May 22, 2013, we did whole-body autopsies on inpatients aged at least 16 years who died in the adult inpatient wards at University Teaching Hospital, Lusaka, Zambia. We did gross pathological and histopathological analysis and processed lung tissues from patients with tuberculosis through the GeneXpert MTB/RIF assay to identify patients with multidrug-resistant tuberculosis. The primary outcome measure was specific disease or diseases stratified by HIV status. Secondary outcomes were missed tuberculosis, multidrug-resistant tuberculosis, and comorbidities with tuberculosis. Data were analysed using Pearson χ(2), the Mann-Whitney U test, and binary logistic regression.
  
  
  RESULTS
  The median age of the 125 included patients was 35 years (IQR 29-43), 80 (64%) were men, and 101 (81%) were HIV positive. 78 (62%) patients had tuberculosis, of whom 66 (85%) were infected with HIV. 35 (45%) of these 78 patients had extrapulmonary tuberculosis. The risk of extrapulmonary tuberculosis was higher among HIV-infected patients than among uninfected patients (adjusted odds ratio 5·14, 95% CI 1·04-24·5; p=0·045). 20 (26%) of 78 patients with tuberculosis were not diagnosed during their life and 13 (17%) had undiagnosed multidrug-resistant tuberculosis. Common comorbidities with tuberculosis were pyogenic pneumonia in 26 patients (33%) and anaemia in 15 (19%).
  
  
  CONCLUSIONS
  Increased clinical awareness and more proactive screening for tuberculosis and multidrug-resistant tuberculosis in inpatient settings is needed. Further autopsy studies are needed to ascertain the generalisability of the findings.
  
  
  BACKGROUND
  UBS Optimus Foundation, EuropeAID, and European Developing Countries Clinical Trials Partnership (EDCTP).
authors.affiliation: Department of Infection, Division of Infection and Immunity, University College London, London, UK; University of Zambia and University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia.
authors.forename: Matthew
authors.initials: M
authors.lastname: Bates
authors.affiliation: Department of Pathology and Microbiology, University Teaching Hospital, Lusaka, Zambia.
authors.forename: Victor
authors.initials: V
authors.lastname: Mudenda
authors.affiliation: Department of Pathology and Microbiology, University Teaching Hospital, Lusaka, Zambia.
authors.forename: Aaron
authors.initials: A
authors.lastname: Shibemba
authors.affiliation: University of Zambia and University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia.
authors.forename: Jonas
authors.initials: J
authors.lastname: Kaluwaji
authors.affiliation: University of Zambia and University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia.
authors.forename: John
authors.initials: J
authors.lastname: Tembo
authors.affiliation: University of Zambia and University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia.
authors.forename: Mwila
authors.initials: M
authors.lastname: Kabwe
authors.affiliation: University of Zambia and University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia.
authors.forename: Charles
authors.initials: C
authors.lastname: Chimoga
authors.affiliation: University of Zambia and University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia.
authors.forename: Lophina
authors.initials: L
authors.lastname: Chilukutu
authors.affiliation: University of Zambia and University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia.
authors.forename: Moses
authors.initials: M
authors.lastname: Chilufya
authors.affiliation: National Tuberculosis Control Programme, Ministry of Community Development, Maternal and Child Health, Lusaka, Zambia.
authors.forename: Nathan
authors.initials: N
authors.lastname: Kapata
authors.affiliation: Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich, Munich, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Hoelscher
authors.affiliation: Therapeutic Immunology, Department of Laboratory Medicine, Department of Microbiology, and Department of Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden.
authors.forename: Markus
authors.initials: M
authors.lastname: Maeurer
authors.affiliation: University of Zambia and University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia.
authors.forename: Peter
authors.initials: P
authors.lastname: Mwaba
authors.affiliation: Department of Infection, Division of Infection and Immunity, University College London, London, UK; University of Zambia and University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia; National Institute for Health Research Biomedical Research Centre, University College London Hospitals, London, UK. Electronic address: a.zumla@ucl.ac.uk.
authors.forename: Alimuddin
authors.initials: A
authors.lastname: Zumla
mesh_terms: D000328:Adult; D017954:Africa South of the Sahara; D058070:Asymptomatic Diseases; D001344:Autopsy; D060085:Coinfection; D003933:Diagnosis; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000473:pathology / Q000821:virology; D015497:HIV-1 / Q000254:growth & development; D006801:Humans; D008297:Male; D009169:Mycobacterium tuberculosis / Q000254:growth & development; D011446:Prospective Studies; D018088:Tuberculosis, Multidrug-Resistant / Q000175:diagnosis* / Q000382:microbiology / Q000473:pathology; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis* / Q000382:microbiology / Q000473:pathology