Management of pulmonary tuberculosis suspects with negative sputum smears and normal or minimally abnormal chest radiographs in resource-poor settings

SETTING: Queen Elizabeth Central Hospital, Blantyre, Malawi. OBJECTIVES: 1) To determine the proportion of pulmonary tuberculosis (PTB) suspects with negative sputum smears and a normal/minimally abnormal chest radiograph (CXR) who are culture-positive for Mycobacterium tuberculosis, a nd 2) to determine how many develop smear or radiographic evidence of PTB ( TB CXR) during follow-up. METHODS: PTB suspects with negative sputum smears and a normal/minimally ab normal CXR were given a second course of antibiotics and followed up at 3-w eek intervals over 3 months with repeat sputum smears and chest radiography . RESULTS: Of 79 patients (38 men and 41 women, mean age 33 years) with negat ive smears and a normal/minimally abnormal CXR, 16 (21%) were culture-posit ive for M. tuberculosis. Of 15 culture-positive patients who were alive and attended follow-up, seven (47%) developed a TB-CXR by 3 months. Of 41 cult ure-negative patients who were alive and attended follow-up, 13 (32%) devel oped a TB-CXR, including one patient who became sputum smear-positive. TB-C XRs were found only in patients with a cough. CONCLUSION: TB suspects with negative smears and normal/minimally abnormal CXRs in high human immunodeficiency virus (HN) prevalent countries should b e given a second course of antibiotics. If cough improves, patients can be advised not to return for further followup. If cough continues, patients sh ould return for further follow-up with sputum smear examination and chest r adiography. Approximately 50% of those who have culture-positive PTB will d evelop a TB-CXR by 3 months and can be identified if radiographic facilitie s are available.