Setting: Chris Hani Baragwanath Hospital, Soweto, South Africa.
Objectives: To compare post mortem histological, microbiological and biochemical findings with clinical and radiological data generated ante mortem in children infected with HIV dying from clinical lung disease.
Methods: Post mortem lung and liver biopsies were undertaken on 93 consecutive deaths in children with HIV. Specimens were processed for culture, histology and staining for M. tuberculosis, Pneumocystis carinii pneumonia (PCP) and cytomegalovirus (CMV). Post mortem diagnoses were compared with clinical and radiological data generated during the final hospitalisation.
Results: Tuberculosis (TB) was diagnosed post mortem in four (4.3%) cases; a further 17 (18.2%) patients had been treated empirically for TB before death, and the remaining 72 (77.5%) patients had not been treated for TB. TB was more prevalent in children aged 1 year or older (13.4%) than in younger patients (1.4%) (P < 0.025). Patients with PCP, CMV pneumonitis or lymphocytic interstitial pneumonitis (LIP) had the same clinical presentation or radiographic appearances as patients with TB. The only features distinguishing patients with TB were older age and ante mortem gastric aspirate cultures positive for M. tuberculosis.
Conclusion: The diagnosis of TB in children infected with HIV remains difficult. Clinical and radiographic features are shared with other opportunistic diseases. Case identification strategies relying on clinical and radiographic findings lead to overtreatment, particularly in children younger than 1 year of age. Gastric aspirate cultures remain a reliable tool for the identification of infected patients.