Treating refugee patients with severe disseminated tuberculosis (TB) who do not have HIV presents unique diagnostic and therapeutic challenges, requiring heightened awareness, comprehensive medical histories despite language barriers, and a multidisciplinary team effort between healthcare providers, social workers, clinical psychologists, and nutritionists, according to a grand rounds report published in The Lancet Infectious Diseases.
As the presentation of TB changes in high-income countries, primarily as a result of migration, it becomes increasingly important to understand the health needs of susceptible populations. Moreover, more research is needed to further the currently limited understanding of the mechanisms leading to disseminated TB in the absence of HIV infection. Disseminated TB is well-described in patients with HIV, but poorly documented and less expected in patients without HIV. Authors of this grand round report examined 8 refugee patients with disseminated TB and discussed mechanisms to identify and overcome the clinical challenges presented in literature on immunosuppression in refugees.
Seven of the 8 patients with extensively disseminated TB had negative results on sputum smear, combined with false negative interferon-γ release assay results, making a diagnosis was notably difficult and less timely, particularly in the absence of pulmonary symptoms. The causes of immunosuppression were multifactorial, including suboptimal access to health care, stress and subsequent post-traumatic stress disorder, social deprivation, and precarious living conditions, all of which contribute to chronic disorders and malnutrition and may lead to a state predisposed to immune deficiency.
Language barriers between healthcare workers and refugees present unique communication difficulties, but researchers highlight that it is crucial to obtain a comprehensive and accurate patient history, because this guides each step through the imaging and other types of diagnostic procedures needed to establish and confirm a diagnosis of TB. Because many patients in this population are at risk for multidrug-resistant TB, treatment plans should be guided by drug susceptibility testing. However, there is an absence of treatment guidelines for cases such as these. Clinicians must therefore determine treatment duration according to guideline recommendations available for extrapulmonary TB and affected organs. Any paradoxical expansion of tuberculous lesions observed during treatment should be addressed with corticosteroid therapy. Overall treatment duration must be individualized to patient need, and in some cases may exceed 12 months.
The study investigators concluded, “The application of appropriate diagnostic procedures will result in the use of efficacious treatment regimens, often to be applied for prolonged periods of time. The mechanisms that lead to disseminated tuberculosis in the absence of HIV infection are not well understood and should be the subject of further research.”
Suárez I, Fünger SM, Jung N, et al. Severe disseminated tuberculosis in HIV-negative refugees [published online June 7, 2019]. Lancet Infect Dis. doi: 10.1016/S1473-3099(19)30162-8