Disseminated tuberculosis and diagnosis delay during the COVID-19 era in a Western European country: a case series analysis

Abstract

Background: Disseminated tuberculosis is frequently associated with delayed diagnosis and a poorer prognosis.

Objectives: To describe case series of disseminated TB and diagnosis delay in a low TB burden country during the COVID-19 period.

Methodology: We consecutively included all patients with of disseminated TB reported from 2019 to 2021 in the reference hospital of the Northern Crown of the Metropolitan Area of Barcelona. We collected socio-demographic information, clinical, laboratory and radiological findings.

Results: We included all 30 patients reported during the study period-5, 9, and 16 in 2019, 2020, and 2021 respectively-20 (66.7%) of whom were male and whose mean age was 41 years. Twenty-five (83.3%) were of non-EU origin. The most frequent system involvement was central nervous system (N = 8; 26.7%) followed by visceral (N = 7; 23.3%), gastro-intestinal (N = 6, 20.0%), musculoskeletal (N = 5; 16.7%), and pulmonary (N = 4; 13.3%). Hypoalbuminemia and anemia were highly prevalent (72 and 77%). The median of diagnostic delay was 6.5 months (IQR 1.8-30), which was higher among women (36.0 vs. 3.5 months; p = 0.002). Central nervous system involvement and pulmonary involvement were associated with diagnostic delay among women. We recorded 24 cured patients, two deaths, three patients with post-treatment sequelae, and one lost-to-follow up. We observed a clustering effect of patients in low-income neighborhoods (p < 0.001).

Conclusion: There was a substantial delay in the diagnosis of disseminated TB in our study region, which might impacted the prognosis with women affected more negatively. Our results suggest that an increase in the occurrence of disseminated TB set in motion by diagnosis delay may have been a secondary effect of the COVID-19 pandemic.

Keywords: clinical presentation; delayed diagnosis; disseminated tuberculosis; hard-to-reach populations; tuberculosis.

Figure 1

Number of cases by year and initial focus at diagnosis including dTB cases not referred to the HUGTiP (PP, pleuropulmonary; MSK, musculoskeletal; GI, gastrointestinal; and CNS, central nervous system). System involvement refers to the initial TB focus at diagnosis.

Figure 2

Map showing geo-location of TB disseminated cases in the northern crown of the greater Barcelona metropolitan area (N = 23). Patient’s region of origin is indicated by the type of symbol. Symbols have been placed very approximately to protect patient anonymity. Household income map was obtained from (17).

Figure 3

Plot of diagnostic delay (months) stratified by sex (A) and by number of visits prior to diagnosis (B). Horizontal bar indicates the median.

Figure 4

Plot of diagnostic delay (months) stratified by TB initial focus at diagnosis (A) and by number of visits prior to diagnosis (B) (CNS, central nervous system; GI, gastrointestinal; MSK, musculoskeletal; V, visceral; and PP, pleuropulmonary). Horizontal bar indicates the median.