Diagnostic value of bronchoscopy in diagnosis of pulmonary tuberculosis: bronchial aspirate, bronchial washing and transbronchial lung biopsy

The diagnosis of pulmonary tuberculosis is confirmed by the detection of Mycobacterium tuberculosis in sputum. Bronchoscopy has been used for diagnosis of various pulmonary diseases. The value of bronchoscopy such as bronchial aspirate, bronchial washing and transbronchial lung biopsy in diagnosis of pulmonary tuberculosis was evaluated, and the results were as follows: 1) One hundred ninety cases were investigated bronchoscopically due to suspicion of pulmonary tuberculosis with sputum negative smear and 92 cases were confirmed to be pulmonary tuberculosis. 2) Out of 91 cases examined by bronchial aspirate and 46 cases by bronchial washing, smear positivity was 20.9% and 23.9% and culture positivity was 58.2% and 84.8%, respectively. Transbronchial lung biopsy showed positive findings of tuberculosis in 75.8% out of 33 specimens. 3) Out of 88 sputa taken before bronchoscopy and 50 sputa after bronchoscopy, smear positivity was 0% and 12%, and culture positivity was 54.5% and 40% respectively. Gastric lavage culture positivity was 29.4% in 17 cases examined. 4) Diagnosis of tuberculosis was made rapidly in 28 cases (30.4%) by smear positive results of bronchial aspirate, bronchial washing and sputa after bronchoscopy, and relatively rapidly in 20 cases (21.7%) by transbronchial lung biopsy.     

Fiberbronchoscopy in smear-negative miliary tuberculosis

Twenty-two patients with smear-negative miliary tuberculosis underwent fiberbronchoscopy and brush smears; bronchial aspirates and transbronchial lung biopsy specimens were obtained. A definite diagnosis of tuberculosis was made in 16 (73 percent) patients. A rapid diagnosis was established in 14 of these 16 patients either from brush smears alone (three) or bronchial aspirate smear alone (one) or exclusively by histopathologic study of biopsy specimens (seven). Both brush smears and biopsy histopathology results provided the diagnosis in three patients. Bronchial aspirate culture was the only positive specimen in two patients. No serious complication resulted from the procedure. Our experience substantiates previous reports of the value and safety of fiberbronchoscopy in the rapid diagnosis of smear-negative miliary tuberculosis.     

Fibreoptic bronchoscopy in smear-negative pulmonary tuberculosis

Fifty smear-negative pulmonary tuberculosis patients underwent fibreoptic bronchoscopy. Bronchial aspirate smears of twelve patients and post-bronchoscopic sputum smears of fourteen patients were positive for acid-fast bacilli (AFB). Bronchial biopsy provided the diagnosis in 9 out of 30 patients. Brush smears were positive in 28 patients, being the only positive sample in ten cases. A high yield from brush smears was obtained due to their preparation from caseous material wherever visible in the bronchi. With these results a rapid diagnosis was established in 36 of the 50 patients. When culture results were available, a definite diagnosis of tuberculosis was made in 45 of the patients. The yield from brush smears was found to be significantly better when compared to bronchial aspirate smears (p less than 0.01) and post-bronchoscopic sputum smears (p less than 0.01).     

Clinical utility of a commercial ligase chain reaction kit for the diagnosis of smear-negative pulmonary tuberculosis.

SETTING: In paucibacillary forms of smear-negative tuberculosis it is very difficult to establish a correct and rapid diagnosis, as several weeks are usually required to obtain positive results from culture. In the last few years new rapid techniques based on molecular biology for the detection of Mycobacterium tuberculosis have been introduced. OBJECTIVE: The aim of this study was to evaluate the utility of the ligase chain reaction method (LCx, Abbott) for the diagnosis of smear-negative pulmonary tuberculosis. DESIGN: Thirty smear-negative patients with radiographic changes and clinical signs consistent with TB participated in the study. Sputum and bronchial aspirate were assessed according to traditional methods on L?wenstein-Jensen medium, and bronchoalveolar lavage (BAL) was assessed by the LCx test and the Bactec 460 system. Another 30 patients with non-tuberculous infections were included in the study as controls. RESULTS: Of the 30 patients suspected of tuberculosis, 19 had active disease on clinical, bacteriological and radiographic grounds, nine inactive tuberculosis and two had lung cancer. Bacteriological confirmation was obtained in 12 of the 19 (63.2%) patients with active tuberculosis. The sensitivity of sputum culture was 42.1% and bronchial aspirate culture 47.4%. BAL fluid revealed positive results in 57.9% using both LCx and Bactec. The results of the LCx assay can be obtained in 5 hours as opposed to several weeks using other methods. CONCLUSION: The LCx test may be useful in the diagnosis of smear-negative pulmonary tuberculosis and may be recommended in these clinical situations.     

Diagnostic role of fiberoptic bronchoscopy for mycobacterial diseases]

From 1981 to 1991, 5,572 patients underwent bronchoscopic examination, in this series 3,754 patient's samples were sent for determination of mycobacterial isolation. In the 506 samples, mycobacterial bacilli were detected with smear or culture. In the low tuberculous incidence area like northern part of America, many reporters supported the opinion that routine bronchial aspirate detection for tuberculosis was not cost-effective. Inversely, in the high tuberculous incidence area like Hong Kong, M. lp et al. claimed the usefulness of routine bronchial aspirate examination for mycobacterial bacilli. Japan was regarded as moderate tuberculous incidence area. We review a ten-year experience with fiberoptic bronchoscopy for mycobacterial isolation. Our results suggest that in an area with a moderate prevalence of tuberculosis, bronchoscopic examination for mycobacterial disease is useful in the selected hospitals for the selected cases. In Japan, the smear positive prevalence has been on the increase from 1982. We estimate that the Japanese popularization of fiberoptic bronchoscopy may influence a part of the Japanese epidemic statistical analysis of mycobacteriosis.     

A tuberculostearic acid assay in the diagnosis of sputum smear-negative pulmonary tuberculosis. A prospective study of bronchoscopic aspirate and lavage specimens

OBJECTIVE: To determine whether the detection of tuberculostearic acid (TBSA) in bronchial aspirate and bronchoalveolar lavage specimens is useful for the rapid diagnosis of active pulmonary tuberculosis in patients suspected of having the disease. SETTING: A pulmonary clinic in a teaching hospital. PATIENTS: Forty patients suspected of active pulmonary tuberculosis but who failed to produce sputum or whose sputum smears were negative for acid-fast bacilli on at least 3 occasions, 29 of whom were subsequently confirmed to have tuberculosis. A group of 13 patients who were having fiberoptic bronchoscopy for other reasons served as controls. INTERVENTION: All patients had fiberoptic bronchoscopy; bronchial aspirate, bronchoalveolar lavage, and sputum specimens were obtained when possible. MEASUREMENTS AND MAIN RESULTS: All specimens were examined microscopically for acid-fast bacilli, cultured for mycobacteria, and assayed for TBSA by gas chromatography and mass spectrometry with selected ion monitoring. Only 4 of the 29 patients with tuberculosis were diagnosed by direct microscopy compared with 26 by TBSA assay. In 2 patients who required surgical biopsy for conventional diagnosis, the TBSA test was positive. There were no false-positive TBSA results in the 13 controls, but 2 of 5 sputum specimens from the 11 test patients in whom tuberculosis was excluded were falsely positive, probably because of contamination with mouth flora. Because sputum can rarely be obtained from these patients and may give false-positive results, it is not a good specimen for TBSA assay. Sensitivities and specificities of the test for the other specimens were as follows: aspirate, 0.52 (CI, 0.32 to 0.71) and 1.00 (CI, 0.75 to 1.00); lavage, 0.68 (CI, 0.46 to 0.85) and 1.00 (CI, 0.84 to 1.00); aspirate and lavage combined, 0.79 (CI, 0.60 to 0.92) and 1.00 (CI, 0.86 to 1.00). CONCLUSIONS: The TBSA assay for bronchial aspirate and bronchoalveolar lavage fluid is useful for rapidly diagnosing "smear-negative" pulmonary tuberculosis. In these specimens it is highly specific and more sensitive than microscopy. This assay could be used to diagnose other mycobacterial infections, however, it cannot distinguish among species.     

纤支镜灌洗液的结核分支杆菌快速培养对不典型肺结核的诊断价值

目的　评价纤维支气管镜(以下简称纤支镜)支气管肺泡灌洗液(BALF)的结核分支杆菌快速培养对不典型肺结核的诊断价值。方法 选无痰或痰菌阴性的不典型肺结核患者49例行纤支镜检查,进行活检、刷检、BALF经BBLMGIT分支杆菌快速培养查结核杆菌。结果 49例经纤支镜刷检、BALF快速培养结核分支杆菌检出率分别是67.4%、83.7%,其中15例经纤支镜肺活检,10例病理证实为结核肉芽肿,检出率为66.7%。结论 纤支镜对无痰或痰菌阴性下BALF行结核分支杆菌快培对不典型肺结核具有较高的诊断价值,快速,阳性率较高。根据镜下所见采用不同的取材方法可望提高诊断率。     

The value of bronchial lavage in patients with radiologically suggestive pulmonary tuberculosis with no sputum production and gastric lavage smear negativity

We assessed whether acid-fast bacilli (AFB) investigation in bronchial lavage (BL) contributes to diagnosis in patients with gastric lavage smear negative and radiologically suggestive of pulmonary tuberculosis. Eighty-three patients were recruited for the study, five cases were excluded due to diagnosis of inactive disease or non-tuberculosis disease. The remaining 78 patients were evaluated. All patients were unable to expectorate sputum and their gastric lavages were negative for AFB. BL was performed for the detection of Mycobacterium tuberculosis in all patients. Bronchial lavage smear were positive in 15.4%(12 patients). BL culture positivity was 58.3%(42 patients) and gastric lavage culture positivity was 33.3%(26 patients). Eighteen cases had both gastric lavage and BL culture positivity. BL culture was positive in 24 cases who had gastric lavage culture negativity. We suggest that in cases who do not produce sputum and whose gastric lavage smears are negative; BL should be performed for diagnosis of pulmonary tuberculosis.     

Primary tuberculosis of the thyroid gland: report of three cases.

We report on three cases with rapidly increasing thyroid masses who were referred with the provisional diagnosis of thyroid carcinoma. In the two cases, the diagnosis of tuberculosis was established after thyroidectomy, but in the third case diagnosis was made pre-operatively with acid fast bacilli (AFB) staining and culture from fine needle aspiration (FNA) material. Although rare, tuberculosis of the thyroid gland should be included in the differential diagnosis of thyroid masses. FNA, AFB staining and culture of the aspirate are important diagnostic tools in these cases.     

Diagnosis of pulmonary tuberculosis in general hospital "a study of 114 cases"]

We conducted a study on the diagnosis of pulmonary tuberculosis at Chiba Kaihin Municipal Hospital. Examinations were performed to determine the presence of active Mycobacterium tuberculosis in sputum and gastric aspirate. For the sputum smear-negative cases, fiberoptic bronchoscopy was further used as a means for detecting the tuberculosis. The results obtained were as follows: 1. A total of 114 cases in the past six years diagnosed as active pulmonary tuberculosis (including 88 primary treatment cases) were analysed. 2. The 114 cases consisted of 74 males and 40 females, the mean age was 49.3 years old. Categorically, the main age groups were: 60s, 24 cases; 30s, 21 cases; and 40s, 20 cases. 3. Chest X-ray findings: Cavitary cases were 28.9% GAKKAI classification of the sizes of the affected areas being Type 1 (mostly limited cases), 58.9% of all total cases, and 68.4% in the cases under the age of 50 years old. The number of cases having infection in a solitary nodule was 19, and the ages of 15 out of the 19 patients were under 50 years old. 4. Sputum or gastric aspirate smear-positive cases totalled 37 (32.5%), and culture-positive cases totalled 77 (67.5%). Sputum or gastric aspirate cultures were positive in 52 out of 56 cases (92.9%) with extended shadows, GAKKAI classification Types 2 and 3, but were positive in 25 out of 58 cases (43.1%) with Type 1. 5. Fiberoptic bronchoscopy was performed on 49 out of the 77 smear-negative cases. 6. Definite diagnosis was obtained in 90 (78.8%) out of total 114 cases. The results of this study suggest that examination for active mycobacterium in sputum and gastric aspirate are very useful for the diagnosis of active pulmonary tuberculosis, especially in extended cases.     

Adequately washed bronchoscope does not induce false-positive amplification tests on bronchial aspirates in the diagnosis of pulmonary tuberculosis

STUDY OBJECTIVES: To investigate the clinical usefulness of amplification (COBAS AMPLICOR; Roche Diagnostics Systems; Branchburg, NJ) on bronchoscopic aspirate specimens in the diagnosis of pulmonary tuberculosis, with particular regard to the possibility of false-positive results in subsequent specimens due to residual Mycobacterium tuberculosis DNA. DESIGN AND SETTING: A prospective clinical study at a tertiary referral medical center. PARTICIPANTS AND METHODS: Four hundred fiberoptic bronchoscopic procedures were performed, using seven bronchoscopes on 335 consecutive patients, for therapeutic or diagnostic purposes. Serial bronchial aspirates were collected and tested for M tuberculosis, using COBAS AMPLICOR (CA). Bronchoscopes were cleaned and disinfected automatically, between patient use, by the same endoscope washer. The name of each bronchoscope and the sequence of its use were recorded, together with the sequence of washing. The CA results were compared with the bacteriologic and histologic results for M tuberculosis infection. When there was a suspicion of contamination, outward polymerase chain reaction analysis was performed. RESULTS: Of 392 specimens (332 subjects), excluding the 8 specimens (4 subjects) in which bacteriologic and histologic analyses were omitted, a smear-positive result for acid-fast bacilli (AFB), culture-positive or biopsy-positive results, and CA-positive results were obtained in 16, 49, and 32 specimens, respectively. In AFB smear-positive subjects, the sensitivity, specificity, positive predictive values (PPVs), and negative predictive values (NPVs) were 92%, 67%, 92%, and 67%, respectively. In AFB smear-negative subjects, the sensitivity, specificity, PPV, and NPV values were 38%, 99%, 74%, and 94%, respectively. The CA test was more sensitive than the AFB smears for the diagnosis of pulmonary tuberculosis (53% vs 27%, respectively; p < 0.05). False-positive CA results were seen in only six specimens. Three of these six subjects received a diagnosis of pulmonary tuberculosis on clinical and radiologic grounds, and none of the six results seemed to be associated with bronchoscopic cross-contamination. CONCLUSIONS: Adequately cleaned and disinfected bronchoscopes did not cause false-positive amplification test results for M tuberculosis on bronchial aspirates by cross-contamination. Furthermore, sensitivity was greater with the CA tests. Therefore, CA tests on bronchial aspirates seem to be useful in the diagnosis of pulmonary tuberculosis.     

Diagnostic usefulness of transbronchial aspiration and bronchial lavage for pulmonary tuberculosis

Fiberoptic bronchoscopy is a well established methods as a useful tool in the diagnosis of pulmonary tuberculosis with smear negative cases. In order to get the early and definite diagnosis of pulmonary tuberculosis, we performed transbronchial aspiration and bronchial lavage by a fiberoptic bronchoscope in 97 patients. All patients (1) were clinically suspected of having active tuberculosis; (2) showed abnormal chest roentgenogram suggesting tuberculosis; (3) showed negative sputum smears of acid-fast bacilli, or had no sputum. The results of the study were summarized as follows: 1) Final diagnosis of study subjects were 90 patients of active pulmonary tuberculosis, and 7 patients of pulmonary atypical mycobacteriosis. 2) Sputum culture of acid-fast bacilli was positive in 22 out of 90 patients with active pulmonary tuberculosis. 3) Smear and culture examination of acid-fast bacilli of transbronchial aspirates were positive in 9 and 28, respectively out of 90 patients. 4) Smear and culture examination of acid-fast bacilli of bronchial lavage were positive in 12 and 39, respectively out of 90 patients. 5) A rapid and definite diagnosis was made in 16 out of 90 patients by transbronchial aspirates or bronchial lavage. 6) Atypical mycobacteria were detected in 7 out of 97 patients by transbronchial aspirates or bronchial lavage. 7) There were no serious complications such as pneumonia and exacerbation of pulmonary tuberculosis. These results suggested that transbronchial aspiration and bronchial lavage were useful procedures for rapid and definite diagnosis of pulmonary tuberculosis.     

Utility of polymerase chain reaction in diagnosis of tuberculosis from samples of bone marrow aspirate

Fever of unknown origin (FUO) poses a diagnostic challenge to the clinicians, with a differential diagnosis as varied as neoplastic and infectious diseases. In developing countries, the infectious causes are responsible for more cases of FUO, with tuberculosis as one of the main causes of classic FUO. Disseminated tuberculosis with negative pulmonary findings is a diagnostic problem. This study examines the diagnostic utility of the polymerase chain reaction (PCR) in samples of bone marrow aspirate in 85 patients presenting with diverse clinical symptoms. Using primers specific for Mycobacterium tuberculosis, tubercular etiology was detected in 33% of patients clinically suspected of tuberculosis while culture on Lowenstein-Jensen medium grew M. tuberculosis in only one patient (2.5%). None of these patients had been diagnosed by microscopy. Clinical improvement with ATT was observed in 85% of the patients with positive PCR. PCR demonstrated much higher sensitivity and specificity, thereby facilitating early therapeutic decisions for suspected extrapulmonary tuberculosis.     

Utility of stool CBNAAT in the diagnosis of pediatric pulmonary tuberculosis in India

BackgroundIndia houses 27% of the tuberculosis cases worldwide. Pediatric tuberculosis accounts for 11% cases worldwide. Microbiological confirmation of diagnosis is difficult in children. We aimed to study the proportion of Stool CBNAAT (Cartridge Based Nucleic Acid Amplification Test) and GA CBNAAT positive cases among the presumptive cases of tuberculosis in children and assess diagnostic utility of the Stool CBNAAT in comparison to GA CBNAAT and culture.MethodsOurs was a cross sectional study. 75 children, aged 6 months to 12 years who were presumptive cases of pulmonary tuberculosis and who were unable to expectorate, were enrolled. Gastric aspirate and stool samples were obtained and CBNAAT and culture was done. Results of stool CBNAAT were compared with GA CBNAAT and culture.ResultsOf the 75 children enrolled, 28 were started on antitubercular therapy, 12 of whom were microbiologically confirmed and 16 were started on clinical grounds. Overall, 10 (13.3%) and 11 (14.6%) were positive by Stool CBNAAT and GA CBNAAT respectively. GA CBNAAT and Stool CBNAAT were found to have near perfect agreement (Cohen's kappa 0.834). Stool CBNAAT had sensitivity and specificity of 73% and 97% as compared to culture.ConclusionsStool CBNAAT may be used for bacteriological confirmation of pediatric pulmonary tuberculosis. It was found to have a high degree of concordance with the conventionally used GA CBNAAT. This test would be helpful in endemic countries where there is a dearth of trained staff, especially in the periphery, to obtain gastric aspirate. Discomfort associated with sampling would be avoided.     

Diagnosis of tuberculosis: routine cultures of bronchial washings are not indicated.

During a five-year period, cultures of bronchial washings for Mycobacterium tuberculosis were obtained almost routinely (859 of 1,012 bronchoscopic examinations.). This practice proved costly, and the diagnostic yield was extremely low. Only three cases were diagnosed solely by this method (0.35 percent). Five other cases were false-positive. Additionally, 39 patients with known active pulmonary tuberculosis had false-negative cultures of bronchial washings; 13 of these 39 patients were receiving antituberculosis drugs at the time of their bronchoscopic examinations. The inhibitory effect of local anesthetics upon the growth of M tuberculosis is the possible cause for the remaining 26 false-negative cultures. We conclude that bronchoscopic examination and culture of bronchial washings are not the best sources for diagnosis of pulmonary tuberculosis and that cultures of sputum and/or gastric washings are usually sufficient. The practice of obtaining routine cultures of bronchial washings in known pulmonary tuberculosis is of questionable value, when nearly two-thirds may be false-negative.     

Features of bronchial tuberculosis--an analysis of 103 cases

OBJECTIVES: The aim of this study is to clarify the features of bronchial tuberculosis. MATERIALS AND METHODS: We analyzed the clinicopathological data from 103 out of 4467 (2.3%) cases of culture positive tuberculosis admitted to the National Hospital Organization Tokyo National Hospital in the period from 1993 to 2004 in which bronchial tuberculosis was confirmed by bronchofiberscopy. RESULTS: There were 62 women and 41 men, and 53 cases were less than 50 years old. The most common symptom, namely cough was observed in 70 cases, while 79 cases showed III1 to III2 on roentgenographic examination, and 81 cases were smear-positive for acid-fast bacilli in the sputum. Regarding the bronchofiberscopic findings, ulcers were detected in 60 cases, and the major site of bronchial tuberculosis was in the left main bronchus (35 cases). The number of the cases in which the time span from the onset of symptoms to diagnosis took over 3 months was 29, and 26 of them were "doctor's delay" cases which had a history of medical consultation resulting in diagnosis and treatment of other diseases, such as bronchial asthma (7 cases). There were 41 cases in which the second bronchofiberscopic findings have been reviewed, and regardless of the length of the span from the onset to diagnosis, the first bronchofiberscopy mostly revealed ulcer within 1 month after the start of treatment for tuberculosis, and 3 months after the start of treatment, many patients developed fibrous scars. Between 1999 to 2004, the first bronchofiberscopies were usually performed within 2 weeks to 1 month after the start of the treatment in contrast to the cases admitted between 1993 to 1998 in which bronchofribroscopy was mainly performed before the start of the treatment. However, there were no differences in the findings due to the timing of bronchofiberscopy. CONCLUSION: The clinical characteristics of bronchial tuberculosis have not changed, and the delay of diagnosis of bronchial tuberculosis due to doctor's delay also continues to be an important issue today. In patients showing positive sputum smear for mycobacteria, the timing of bronchofiberscopy, although required upon medical examination, is considered to be more appropriately performed from 2 weeks to 1 month after the start of treatment from the view point of nosocomial tuberculosis infection control strategy.     

纤支镜灌洗液经变色液体培养基快速培养结核分枝杆菌对涂阴肺结核诊断价值的研究

目的评价纤维支气管镜小量肺泡灌洗液经变色液体培养基快速培养结核分枝杆菌对涂阴肺结核的诊断价值。方法对40例涂阴肺结核患者分别行纤支镜小量肺泡灌洗、刷检或活检,将灌洗液经变色液体培养基快速培养结核分枝杆菌。结果纤支镜肺泡灌洗40例,灌洗液培养出结核分枝杆菌17例,阳性率42．5％,刷检32例,阳性5例,活检8例,阳性3例,刷检＋活检阳性率20％,P〈0．05有统计学意义。快速培养检出时间平均13．5天。结论纤支镜灌洗液经变色液体培养基快速培养结核支杆菌,可提高涂阴肺结核中结核分枝杆菌的检出率,缩短了细菌培养检出时间,值得应用     

纤支镜在菌阴肺结核中的应用评估

目的 观察纤支镜在菌阴肺结核诊断中的价值.方法 分析190例入院时痰涂片和PCR分析均为阴性疑诊为肺结核患者的病例资料,从经纤支镜抗酸杆菌涂片的阳性率、PCR检测结核分枝杆菌阳性率、上皮性肉芽肿支气管活检、结核分枝杆菌的培养阳性率等四个方面进行分析.结果 190例病例中,经纤支镜取样的阳性率:42.6％(痰涂片),63.6％(PCR分析),31.2％(肉芽肿支气管活检),54.2％(痰培养),将各种检查手段联合起来,诊断率可以达到85.2％.结论 经纤支镜取样有较高阳性率,可以提供快速明确的结核诊断.     

经支气管针吸活检对支气管结核的诊断价值

目的　探讨经支气管针吸活检术 (TBNA)对支气管结核的诊断价值。方法 对36例支气管结核患者进行TBNA检查,同时与刷检、活检的病理学及细菌学结果对比分析。结果 36例患者中TBNA的确诊率为83.3% (30/36),刷检为44.4% (16/36),活检为55.6% (10/18)。TBNA与刷检比较,经统计学处理,有显著性差异 (P＜0.005)。其中21例早期支气管结核病人的TBNA确诊率为90.5%(19/21),刷检为28.6% (6/21),两者经统计学处理,具有显著性差异 (P＜0.005)。结论 该技术能够显著提高支气管结核的诊断率,特别是老年患者,值得推广应用。     

Impact of HIV-1 co-infection on presentation and hospital-related mortality in children with culture proven pulmonary tuberculosis in Durban, South Africa.

BACKGROUND: Diagnosis of tuberculosis (TB) in childhood is difficult and is compounded by HIV-1, as both diseases often co-exist and have many similar features. Most studies from developing countries have included subjects in whom the diagnosis of TB is suspected but not proven. We therefore compare the findings in HIV-infected and non-HIV-infected children with culture-proven TB. METHODS: Records were obtained from the laboratory at King Edward VIII Hospital, Durban, South Africa, between January 1998 and December 1999. Children aged 0-12 years with proven pulmonary tuberculosis (sputum, gastric washing or endotracheal aspirate culture for Mycobacterium tuberculosis) from the paediatric medical wards and intensive care unit were included in the study. A retrospective chart review of demographic data, clinical presentation, diagnostic modalities for TB, HIV-1 result, management and outcome were evaluated. RESULTS: Of 138 culture-proven cases of TB identified during the study period, the medical records of 118 (86%) could be traced. Of these, 57 (48%) were HIV-1 infected, 44 (37%) non-HIV-1-infected, and in 17 (14%) HIV-1 status was not determined. In contrast to previous studies, this study has shown that TB-HIV co-infection in children is common (48% of all culture-proven cases), the presentation of tuberculosis may be acute (43%), and supportive tests are individually only reliable in confirming a diagnosis in a third of cases. All culture evaluations for M. tuberculosis were positive by 8 weeks. Where other diseases often co-exist with TB and HIV infection and the pressure for hospital in-patient admissions are excessive, the diagnosis of tuberculosis could easily be missed (21.2%). Clubbing and age over 2 years were the most reliable indicators of underlying HIV-1 disease in a child with tuberculosis, while clinical features, radiology and supportive tests were found to be similar between HIV-infected and non-HIV-infected TB cases. Hospital-related mortality, all causes, was higher (17.5%) in the HIV-1-infected than the non-infected group (11.4%). CONCLUSION: The changing pattern of presentation of childhood tuberculosis and the high prevalence of TB in HIV endemic areas has made it imperative to maintain a high index of suspicion, with culture evaluation being an important part of clinical practice.