What causes smear-negative pulmonary tuberculosis in Malawi, an area of high HIV seroprevalence

SETTING: The Central Hospital and the District Tuberculosis (TB) Registry i n Lilongwe, the capital of Malawi. In this setting smear-negative pulmonary tuberculosis (PTB) is diagnosed using clinical and radiographic criteria f or TB, and mycobacterial cultures are not routinely available. OBJECTIVE: To determine the proportion of patients being registered for sme ar-negative PTB treatment in Lilongwe who have TB that can be confirmed mic robiologically. DESIGN: Prospective cohort study of patients about to start treatment under operational conditions for smear-negative PTB in Lilongwe between October 1997 and June 1998. Patients referred to the study team underwent a detaile d clinical re-assessment, testing for human immunodeficiency virus (HIV), r epeat sputum smear microscopy for acid-fast bacilli and mycobacterial cultu res of sputum and blood. Bronchoscopy and bronchoalveolar lavage (BAL) were performed and BAL fluid was examined for TB, Pneumocystis carinii and othe r fungi. RESULTS: Of 352 smear-negative PTB suspects assessed, the diagnosis of TB w as confirmed in 137 (39%) cases. Eighty-nine per cent of patients assessed were HIV-positive, of whom 81% met the expanded case definition for the acq uired immune-deficiency syndrome (AIDS). CONCLUSION: TB was the most commonly confirmed diagnosis amongst patients a bout to start treatment for smear-negative PTB in an area of high backgroun d HIV seroprevalence.