A comparison of chest radiographic findings in HIV-infected and HIV-uninfected children with pulmonary tuberculosis

Abstract

The incidence of pulmonary tuberculosis (PTB) has increased globally with the HIV epidemic. Chest X-ray (CXR) plays a primary role in the diagnosis of PTB in children; however, co-infection with HIV may pose additional diagnostic complexity. AIM: To compare CXR findings in HIV-infected and HIV-uninfected children who had laboratory-proven PTB. A secondary aim was to investigate the impact of nutritional status on these CXR findings and within the study population.METHOD: Retrospective analysis of CXRs from children with known HIV status and proven PTB (culture and GeneXpert® Xpert® MTB/RIF positive), who were hospitalised at Red Cross War Memorial Children’s Hospital or seen at Nolungile Primary Health Care Centre from Feb 2009 to April 2014. Children underwent anteroposterior (AP) and lateral CXR as part of a routine initial assessment. These CXRs were interpreted for this study by two independent readers. A third independent reader was used as a tie-breaker if there was no consensus. A standardised reporting form was used, and all readers were blinded to HIV-status, clinical data and other laboratory results of all the patients. Radiological findings were subsequently compared according to HIV and nutritional status. RESULTS: A total of 130 CXRs were analysed from 35 (27 %) HIV-infected and 95 (73 %) HIV-uninfected children, median age 45.7 months, interquartile range 18.0 - 81.3 months. CXR changes consistent with PTB were reported in 21/35 (60%) of HIV-infected and 58/95 (61%) of HIV-uninfected patients. Normal CXR was identified in 3/35 (8.6%) of HIV-infected and 5/95 (5.3%) of HIV-uninfected patients. Airway compression was present in 3/35 (8.6%) of HIV-infected and 7/95 (7.4%) of HIV-uninfected patients. Hilar lymphadenopathy was present in 8/35 (23%) of HIV-infected and 25/95 (26%) of HIV-uninfected patients, while mediastinal lymphadenopathy occurred in 8/35 (23%) of HIV-infected and 20/95 (21.1%) of HIV-uninfected children. Airspace consolidation was present in 60% of both HIV-infected (21/35) and HIV-uninfected patients (57/95). Only 1/35 (3%) of the HIV-infected cases compared with 12/95(13%) of the HIV-uninfected cases had lung cavities; similarly, 1/35 (3%) of HIV-infected and 11/95 (11.6%) of HIV-uninfected patients had interstitial nodular infiltrates. Pleural effusion was present in 2/35 (5.7 %) of HIV-infected and 9/95 (9.5 %) of HIV-uninfected patients. However, p-values for all of these results indicated no significant difference between the CXR findings according to HIV status. Thirty-nine (30.0%) patients were underweight-for-age, 74 (56.9%) adequately nourished and 17 (13.1%) had unknown nutritional status. Pleural effusion was present in 9/74 (12.2%)of the adequately nourished patients, while none of the malnourished patients had this feature, p = 0.025. Most underweight-for age patients (38/39 patients, 97.4%) were hospitalised, p = 0.004, and were male (28/39 patients, 72%), p = 0.046. Underweight-for-age occurred more commonly in HIV-infected patients (17/31, 48.6%) versus HIV-uninfected patients (22/95, 23.3%), p = 0.008. CONCLUSIONS: More than 90% of chest radiographs in both HIV-infected and HIV-uninfected children with confirmed PTB were abnormal but there were no significant differences in the CXR findings between the groups. Concerning nutritional status, pleural effusion was found only in adequately nourished patients and underweight-for-age occurred more commonly in the children who were HIV-infected, hospitalised or male.