TB or not TB? Diagnostic difficulties in HIV-positive versus HIV-negative tuberculosis patients with an immigration background in Germany

Abstract

Patients immigrated or born to immigrated parents constitute an increasing proportion of TB in Germany. This study aimed to assess the clinical presentation and outcome of immigrated TB-monoinfected (TB/HIV-) patients versus TB patients with an HIV coinfection (TB/HIV+). Ninety-three patients (36 boys/men, 57 girls/women; age range, 2-59 years) were investigated of whom 47 were TB/HIV+ and 46 TB/HIV-. TB/HIV+ patients more frequently had an African background (76.6% [36/47], P <0.001), TB/HIV- patients (63.0% [29/46]) more often had an East-European or Asian background (P <0.001). Most common symptoms included lymphadenopathy (37.6% [35/93]) and weight loss (35.5% [33/93]). In TB/HIV+ patients acute presentation was more frequent including fever (57.4% [27/47]), gastrointestinal (44.7% [21/47]), and respiratory symptoms (36.2% [17/47]). TB skin test was highly positive in all performed cases (20/20), IGRA was positive in 98.2% (55/56) cases applied. Pulmonary involvement was relatively rare (51/93 [54.8%]), especially in TB/HIV- patients (36.10% [17/46]) vs. TB/HIV+ (70.23% [36/47]; P <0.001). An infectious etiology was suspected in only 43.5% (20/46) TB/HIV- vs. 72.3% (34/47) TB/HIV+ patients (P ≤0.005); a malignancy was suspected in (21/46 [45.7%] TB/HIV- patients vs. 12/47 [25.5%] TB/HIV+; P ≤0.043). The diagnostic delay between first presentation to a doctor and TB diagnosis was long in all cases, especially in TB/HIV- patients (range, 0-336 weeks; median, 8 weeks vs. TB/HIV+ patients; range, 0-288 weeks; median, 0 weeks; P <0.05). TB, especially in young immigrated HIV- patients frequently presents as an atypic extrapulmonary disease, which may end up in a delayed diagnosis of up to several years.