title: Undiagnosed TB in adults dying at home from natural causes in a high TB burden setting: a post-mortem study.
abstract: BACKGROUND
  A high proportion of deaths in Africa occur at home, where cause of death (CoD) is often unknown. We ascertained undiagnosed pulmonary tuberculosis (TB) by performing limited autopsies in adults dying at home in whom there was no apparent CoD.
  
  
  METHODS
  Mortuaries in Matlosana, South Africa, identified potentially eligible adults with no ante-mortem diagnosis and/or no recent hospital admission. A questionnaire was administered to family members. Bilateral lung core biopsies and modified bronchoalveolar lavage (BAL) were performed. The biopsies were examined histologically and submitted with BAL aspirates for mycobacterial culture (MGIT(TM)) and Xpert(®) MTB/RIF testing. Human immunodeficiency virus (HIV) testing was not performed.
  
  
  RESULTS
  Of 162 families approached, 28 refused and 29 of the deceased were on or had recently stopped anti-tuberculosis treatment; 85 were included. All were Black and 53% were men. The median age was 57 years (interquartile range [IQR] 44-66) and median symptom duration (mainly cough) was 63 days (IQR 14-112). Laboratory evidence of TB was found in 27 (31.8%); 21 were Xpert-positive, 23 were MGIT-positive and 14 had histological evidence consistent with active TB.
  
  
  CONCLUSIONS
  In this high HIV prevalence setting, a quarter of the home deaths had evidence of undiagnosed, likely infectious TB, suggesting that TB-related mortality is under-ascertained and under-reported, with serious implications for TB control in high TB burden settings.
authors.affiliation: Department of Anatomical Pathology, National Health Laboratory Service and University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: T
authors.initials: T
authors.lastname: Omar
authors.affiliation: Department of Internal Medicine, Klerksdorp Tshepong Hospital Complex and University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: E
authors.initials: E
authors.lastname: Variava
authors.affiliation: Perinatal HIV Research Unit, and Medical Research Council Soweto Matlosana Centre for HIV/AIDS and TB Research, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: E
authors.initials: E
authors.lastname: Moroe
authors.affiliation: Johns Hopkins University Center for TB Research, Baltimore, Maryland, USA.
authors.forename: A
authors.initials: A
authors.lastname: Billioux
authors.affiliation: Johns Hopkins University Center for TB Research, Baltimore, Maryland, USA.
authors.forename: R E
authors.initials: RE
authors.lastname: Chaisson
authors.affiliation: Perinatal HIV Research Unit, and Medical Research Council Soweto Matlosana Centre for HIV/AIDS and TB Research, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: L
authors.initials: L
authors.lastname: Lebina
authors.affiliation: Perinatal HIV Research Unit, and Medical Research Council Soweto Matlosana Centre for HIV/AIDS and TB Research, University of the Witwatersrand, Johannesburg, South Africa; Johns Hopkins University Center for TB Research, Baltimore, Maryland, USA; Department of Science and Technology/National Research Foundation Centre of Excellence for Biomedical TB Research, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: N
authors.initials: N
authors.lastname: Martinson
mesh_terms: D000328:Adult; D000368:Aged; D001344:Autopsy; D018893:Bronchoalveolar Lavage; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000453:epidemiology; D006801:Humans; D008168:Lung / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D025202:Molecular Diagnostic Techniques; D009169:Mycobacterium tuberculosis / Q000302:isolation & purification*; D010342:Patient Acceptance of Health Care; D013019:South Africa; D014376:Tuberculosis / Q000175:diagnosis* / Q000401:mortality*