By Tess Wiskel MD, Vizir J.P. Nsengimana MD, Jean Paul Dushime MD, Michael Henry
Case presentation: A 29 year-old female with no known past medical history was transferred from her nearby district hospital to the tertiary referral center in Kigali, Rwanda with shortness of breath and malaise. Her HIV status was unknown. Her vitals were only remarkable for tachycardia.
Workup: A chest x-ray showed no significant findings. An HIV test and CD4 count were sent. GeneXpert tuberculosis testing was sent from a sputum sample. A bedside Focused Assessment using Sonography for HIV-associated tuberculosis (FASH) exam was performed showing a pericardial effusion and bilateral pleural effusions and pelvic ascites.
Case outcome: The patient remained hemodynamically stable in the emergency ward, and was admitted to the medicine service for further evaluation with a plan to treat for tuberculosis and drain the pericardial effusion.
Background: Worldwide 36.7 million people were living with HIV in 2016, with the vast majority in low- and middle- income countries, particularly in Sub-Saharan Africa.1 Tuberculosis (TB) is the leading cause of death among people living with HIV, accounting for over 1 in 3 HIV deaths.1 Extrapulmonary TB (EPTB) accounts for approximately 15% of TB cases in Africa, and about 50% of TB cases in HIV positive patients. 2,3
Diagnosis: The most commonly used modalities for pulmonary TB diagnosis (chest x-ray and sputum testing) are not sensitive for extrapulmonary TB. 4 CT and MRI can provide useful imaging but are difficult to access in developing countries with high burdens of EPTB such as Rwanda. 5 Manifestations of EPTB can include pericardial effusions, ascites, deep abdominal lymphadenopathy, pleural effusions, and hepatic and splenic microabscesses, all rapidly diagnosed with ultrasound.6 Given the utility and access to ultrasound for diagnosis in resource-limited settings, the Focused Assessment using Sonography for HIV-associated tuberculosis (FASH) protocol is commonly used in similar settings to our case in Rwanda.
In this case, the FASH protocol was used to determine manifestations of EPTB.
Figures 1 & 2: Right upper quadrant views with pleural effusion and trace ascites
Figure 3: Right upper quadrant linear view of liver with no hepatic microabscesses
Figures 4 & 5: Left upper quadrant views with pleural effusion and no ascites
Figure 6: Left upper quadrant linear view of spleen with no splenic microabscesses
Figure 7: Supra-pubic view with pelvic ascites
Figure 8: Subxiphoid view with fibrinous pericardial effusion
Figure 9: Aortic view with no periaortic lymphadenopathy
These views demonstrate typical FASH findings consistent with EPTB: ascites, pleural effusions and a pericardial effusion. A prior study from Cape Town showed that TB was associated with FASH findings of ascites and pericardial effusions with odds ratios of 2.24 and 2.83 respectively.7
Treatment: Previously, suspicion of EPTB led to empiric treatment, which can be associated with significant toxicity and expense.8 Conversely, initiating antiretroviral therapy in patients with untreated TB can lead to the immune reconstitution inflammatory syndrome.9 A small study of 21 patients with suspected TB and HIV who had treatment initiated based on positive FASH exams demonstrated clinical improvement after three months.10
The FASH exam can be used in resource limited areas with high EPTB rates to make prompt diagnostic and treatment decisions with greater accuracy than previously possible.