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 TB in adults dying at home in whom there was no apparent CoD by doing limited autopsies. Methods: Mortuaries in Matlosana, South Africa identified eligible adults without an ante-mortem diagnosis and/or no recent hospital admission. A questionnaire was administered to next-of-kin. Bilateral lung core biopsies, and modified broncho-alveolar lavages (BAL) were performed. Biopsies were examined histologically and submitted with BAL aspirates for mycobacterial culture and Xpert® MTB/RIF. HIV testing was not performed. Results: 162 families were approached to participate. 28 Refused; 49 were not eligible for the study and included 29 deceased who were on, or had recently stopped TB treatment; 85 were included. All were Black and 53% were men. The median age was 57 years (IQR: 44-66), and median symptom duration 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 TB. Conclusion: In this high HIV prevalence setting, almost one third of home deaths had evidence of undiagnosed TB, suggesting TB-related mortality is underascertained and under-reported, with grave implications for TB control in high TB burden settings.