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Diagnostic workup of HIV‐positive individuals with suspected abdominal tuberculosis or disseminated tuberculosis with abdominal involvement
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Figure 1

Diagnostic workup of HIV‐positive individuals with suspected abdominal tuberculosis or disseminated tuberculosis with abdominal involvement

Study flow diagram.
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Figure 2

Study flow diagram.

Risk of bias and applicability concerns summary: review authors' judgements about each domain for each included study. Suffix (h) indicates higher quality reference standard; suffix (l) indicates lower quality reference standard.
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Figure 3

Risk of bias and applicability concerns summary: review authors' judgements about each domain for each included study. Suffix (h) indicates higher quality reference standard; suffix (l) indicates lower quality reference standard.

Forest plot of abdominal ultrasound for detecting abdominal TB or disseminated TB with abdominal involvement. TP = true positive; FP = false positive; FN = false negative; TN = true negative. Suffix (h) indicates higher quality reference standard; suffix (l) indicates lower quality reference standard.
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Figure 4

Forest plot of abdominal ultrasound for detecting abdominal TB or disseminated TB with abdominal involvement. TP = true positive; FP = false positive; FN = false negative; TN = true negative. Suffix (h) indicates higher quality reference standard; suffix (l) indicates lower quality reference standard.

Forest plot of individual findings on ultrasound for detecting abdominal TB or disseminated TB with abdominal involvement. TP = true positive; FP = false positive; FN = false negative; TN = true negative. Suffix (h) indicates higher quality reference standard; suffix (l) indicates lower quality reference standard.
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Figure 5

Forest plot of individual findings on ultrasound for detecting abdominal TB or disseminated TB with abdominal involvement. TP = true positive; FP = false positive; FN = false negative; TN = true negative. Suffix (h) indicates higher quality reference standard; suffix (l) indicates lower quality reference standard.

Flow diagram summarizing the main results in hypothetical cohort with TB prevalence 20%
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Figure 6

Flow diagram summarizing the main results in hypothetical cohort with TB prevalence 20%

Abnormal abdominal ultrasound (higher quality).
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Test 1

Abnormal abdominal ultrasound (higher quality).

Abnormal abdominal ultrasound (lower quality).
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Test 2

Abnormal abdominal ultrasound (lower quality).

Ascites.
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Test 3

Ascites.

Splenic lesions.
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Test 4

Splenic lesions.

Abdominal lymph nodes.
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Test 5

Abdominal lymph nodes.

Splenomegaly.
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Test 6

Splenomegaly.

Hepatomegaly.
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Test 7

Hepatomegaly.

Summary of findings Summary of findings for abdominal ultrasound (any abnormality)

Review question: Should abdominal ultrasound be used to diagnose abdominal tuberculosis or disseminated tuberculosis with abdominal involvement in HIV‐positive individuals?

Patient or population: HIV‐positive individuals

Setting: Healthcare facility

Index test: Abdominal ultrasound

Reference standard: We considered two reference standards. The higher‐quality reference standard was bacteriological confirmation of M tuberculosis (any clinical specimen including (i) at least one specimen culture positive for M tuberculosis, (ii) microscopic identification of acid‐fast bacilli on stained sputum smears, lymph node aspirate, or any other specimen; or iii) Xpert MTB/RIF positive). The lower‐quality reference standard was clinical diagnosis of TB without microbiological confirmation (including cases diagnosed on the basis of: i) suggestive histology (necrotizing granulomatous inflammation), ii) x‐ray abnormalities, iii) extrapulmonary cases without laboratory confirmation, and iv) anti‐tuberculosis therapy initiated by a healthcare practitioner for cases with a high suspicion of tuberculosis).

Threshold: Any abnormality found on abdominal ultrasound

Study design: Cross‐sectional and cohort

Limitations: A small number of studies and participants were included in the analyses. Risks of bias were generally high in the patient selection domain

Test result

Number of results per 1000 HIV‐positive individuals tested (95% CI)

Number of studies

Number of participants

Certainty of the evidence (GRADE)

Prevalence 10%

Prevalence 20%

Prevalence 40%

Bacteriological confirmation as reference standard: pooled sensitivity = 63% (95% CI 43% to 79%) and pooled specificity = 68% (95% CI 42% to 87%)

True positives (participants correctly classified as having tuberculosis)

63 (43 to 79)

126 (86 to 158)

252 (172 to 316)

5

368

⊕⊝⊝⊝
VERY LOWa,b,c,d

False negatives (participants incorrectly classified as not having tuberculosis)

37 (21 to 57)

74 (42 to 114)

148 (84 to 228)

True negatives (participants correctly classified as not having tuberculosis)

612 (378 to 783)

544 (336 to 696)

408 (252 to 522)

5

511

⊕⊝⊝⊝
VERY LOWb,c,e,f

False positives (participants incorrectly classified as having tuberculosis)

288 (117 to 522)

256 (104 to 464)

192 (78 to 348)

Abbreviations: CI: confidence interval

GRADE certainty of evidence (GRADEpro GDT 2015; Schünemann 2016)
High certainty: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

The table displays normalized frequencies within a hypothetical cohort of 1000 people at three different tuberculosis prevalences (pre‐test probabilities): 10%, 20% and 40%. We selected prevalence values based on the range of prevalence observed across the included studies. We estimated confidence intervals based on those around the point estimates for pooled sensitivity and specificity.

Explanations

aRisk of bias: We rated one study at high risk for participant selection since it excluded people unable to produce sputum (Griesel 2019‐h). We downgraded the certainty of the evidence by one level.
bIndirectness: We deemed three studies to be of high concern for applicability for receiving ultrasound in a tertiary care (referral) centre (Ndege 2019‐h;Sculier 2010‐hWeber 2018‐h). Two studies only included asymptomatic HIV‐positive participants (Bobbio 2019‐l; Sculier 2010‐h). We downgraded the certainty of the evidence by two levels.
cInconsistency: Point estimates were substantially different between studies. We could not explain this variability and we downgraded the certainty of the evidence by one level.
dImprecision:Three studies had a wide 95% CI for true positives and false negatives (Dominguez‐Castellano 1998‐h; Sculier 2010‐h; Weber 2018‐h). We downgraded the certainty of the evidence by one level.
eRisk of bias: All studies used a higher‐quality reference standard. We did not downgrade the certainty of the evidence.
fImprecision: Two studies had a wide 95% CI for true negatives and false positives (Dominguez‐Castellano 1998‐h; Weber 2018‐h). We downgraded the certainty of the evidence by one level.

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Summary of findings Summary of findings for abdominal ultrasound (any abnormality)
Table 1. Key findings of included studies

Author (publication year)

Study design

Country

Clinical setting

Target condition definition

Qualification of person performing index test

Sample size

Tuberculosisproportion in study

Barreiros 2008‐h

Case‐control

Germany

Not reported

Gastro‐intestinal tuberculosis

Not reported

25a (7 cases, 18 pulmonary tuberculosis controls)

Bobbio 2019‐l

Cross‐sectional

South Sudan

Referral hospital

Extra‐pulmonary tuberculosis

Trained non‐radiologist

100

24%

Dominguez‐Castellano 1998‐h; Dominguez‐Castellano 1998‐l

Cross‐sectional

Spain

Not reported

Extra‐pulmonary tuberculosis

Sonographer

116

55% (higher)

58% (lower)

Griesel 2019‐h

Cross‐sectional

South Africa

Non‐tertiary hospital

Culture‐positive tuberculosis

Sonographer

377

53%

Kaneria 2009‐l

Case‐control

India

Not reported

Pulmonary tuberculosis, extra‐pulmonary tuberculosis, disseminated tuberculosis

Not reported

90 (45 cases, 45 HIV‐positive controls without any pathology)

Monill‐Serra 1997‐l

Case‐control

Spain

Not reported

Disseminated tuberculosis

Not reported

152 (76 cases, 76 HIV‐positive controls without any pathology)

Ndege 2019‐h; Ndege 2019‐l

Cohort

Tanzania

Referral hospital

Pulmonary tuberculosis, extra‐pulmonary tuberculosis, disseminated tuberculosis

Board‐certified sonographers

100 (191 original study sample)

46% (higher)

64% (lower)

O'Keefe 1998‐h

Cross‐sectional

South Africa

Non‐tertiary hospital

Disseminated tuberculosis

Radiologist

35 (44 original study sample)

34%

Sculier 2010‐h

Cross‐sectional

Cambodia

Referral hospital

Disseminated tuberculosis

Radiologist

212

18%

Sinkala 2009‐l

Cross‐sectional

Zambia

Tertiary hospital

Abdominal tuberculosis

Not reported

31

71%

Weber 2018‐h; Weber 2018‐l

Cohort

India

Tertiary hospital

Disseminated tuberculosis

Trained non‐radiologist

81 (425 original study sample)

30% (higher)

49% (lower)

aIncludes five HIV‐negative participants.

Suffix (h) indicates higher‐quality reference standard; suffix (l) indicates lower‐quality reference standard.

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Table 1. Key findings of included studies
Table 2. Indext test threshold and reference standard of included studies

Author (publication year)

Index test variable included (threshold)

Reference standard quality and definition

Barreiros 2008‐h

Ascites (any)

Lymphadenopathy (abdominal and perihepatic nodes with longitudinal diameter > 20 mm)

Splenomegaly (> 135 mm)

Lower: Clinical, endoscopic, histologic, radiologic and operative findings including microbiology and polymerase chain reaction of biopsies taken during endoscopy

Bobbio 2019‐l

Any abnormality (Presence of ≥ 1: i) pericardial effusion, ii) periportal/para‐aortic lymph nodes (> 15 mm diameter), iii) focal splenic lesions, iv) pleural effusion or consolidation of the lung, v) ascites without alternative explanation)

Lower: Sputum microscopy OR clinical reasons OR Focused Assessment with Sonography in HIV‐associated tuberculosis (FASH)

Dominguez‐Castellano 1998‐h; Dominguez‐Castellano 1998‐l

Any abnormality (presence of ≥ 1: i) multiple hypoechoic splenic lesions (< 10 mm), ii) any abdominal adenopathy, iii) hypo‐ or hyperechoic liver lesions)

Higher: Microscopy OR culture
Lower: Microscopy OR culture OR clinical or radiographic indications and response to treatment

Griesel 2019‐h

Any abnormality (presence of ≥ 1: i) abdominal lymph nodes (any size), ii) splenic hypoechoic lesions, iii) splenomegaly (≥ 110 mm), iv) any one of abdominal, pleural, or pericardial effusions)

Ascites (any)

Lymphadenopathy (any size)

Splenic lesions (hypoechoic)

Splenomegaly (≥ 110 mm)

Higher: Positive culture for M tuberculosis from any site

Kaneria 2009‐l

Ascites (any)

Hepatomegaly (not defined)

Lymphadenopathy (diameter > 15 mm)

Splenic lesions (multiple, hypoechoic, 5 mm to 10 mm diameter)

Splenomegaly (not defined)

Lower: Lymphocytic predominance and elevated adenosine deaminase (ADA) levels in pleural or ascitic fluid OR granulomatous lymphadenitis and acid‐fast bacilli in lymph node OR sputum microscopy

Monill‐Serra 1997‐l

Ascites (any)

Hepatomegaly (not defined)

Lymphadenopathy (> 15 mm diameter)

Splenic lesions (hypoechoic nodes)

Splenomegaly (long axis > 120 mm or subjective impression)

Lower: Blood culture positive for M tuberculosis OR medullary bone or liver biopsy with granulomatous inflammation or culture positive for M tuberculosis OR microbiological or histopathological confirmation in ≥ 2 non‐contiguous extra‐pulmonary sites

Ndege 2019‐h; Ndege 2019‐l

Any abnormality (presence of ≥ 1: i) pleural or pericardial effusion, ii) ascites, iii) abdominal lymph nodes > 15 mm, iv) hypoechogenic lesions in the liver or spleen, v) ileum wall thickening > 4 mm or destructed ileum wall architecture)

Ascites (any)

Hepatomegaly (not defined)

Lymphadenopathy (> 15 mm diameter)

Splenomegaly (not defined)

Higher: Xpert MTB/RIF assay and/or bacteriologic culture (growth of M tuberculosis)
Lower: Positive Xpert MTB/RIF assay and/or bacteriologic culture (growth of M tuberculosis) OR acid‐fast bacilli in sputum OR raised adenosine deaminase (ADA) levels in pleural, pericardial or ascitic fluid OR negative microbiological tests and improvement 2 months after start of anti‐tuberculosis treatment

O'Keefe 1998‐h

Ascites (any)

Lymphadenopathy (not defined)

Higher: Positive mycobacterial blood or bone marrow cultures OR positive mycobacterial cultures from 2 or more other sites OR post mortem evidence

Sculier 2010‐h

Any abnormality (presence of ≥ 1: i) any lymph nodes ≥ 12 mm, ii) ascites, iii) hepatomegaly, iv) splenomegaly, v) hepatic or splenic hypoechoic lesions with or without organ enlargement)

Higher: Positive culture for M tuberculosis from any site

Sinkala 2009‐l

Ascites (any)

Hepatomegaly (not defined)

Lymphadenopathy (not defined)

Splenomegaly (not defined)

Lower: Positive bacteriological culture OR granulomatous inflammation with positive Ziehl‐Neelsen (ZN) staining on microscopy OR granulomatous inflammation on microscopy OR visual inspection on laparoscopy consistent with tuberculosis (presence of tubercles, fibro‐adhesive peritonitis, or caseating lymphadenopathy) and favourable response to anti‐tuberculous treatment

Weber 2018‐h; Weber 2018‐l

Any abnormality (presence of ≥ 1: i) pericardial or pleural effusion, ii) focal liver or splenic lesions, iii) abdominal lymphadenopathy)

Ascites (any)

Hepatomegaly (not defined)

Lymphadenopathy (≥ 15 mm diameter)

Splenic lesions (multiple, hypoechoic, 2 mm to 5 mm diameter)

Higher: Positive fluorescent microscopy, polymerase chain reaction, or tuberculosis culture
Lower: Microbiological confirmation (fluorescent microscopy, polymerase chain reaction, culture) OR clinical diagnosis and anti‐tuberculous treatment initiated

Suffix (h) indicates higher quality reference standard; suffix (l) indicates lower quality reference standard

Figuras y tablas -
Table 2. Indext test threshold and reference standard of included studies
Table 3. Summary estimates of sensitivity and specificity for any abnormality and individual abdominal ultrasound findings

Abdominal ultrasound finding

Number of studies

Number of participants (tuberculosiscases)

Pooled sensitivity (95% CI) %

Pooled specificity (95% CI) %

Range of sensitivity %

Range of specificity %

Any abnormality (higher‐quality reference standard)

5

879 (368)

63 (43 to 79)

68 (72 to 87)

35 to 82

20 to 92

Any abnormality (lower‐quality reference standard)

4

397 (149)

68 (45 to 85)

73 (41 to 91)

37 to 88

22 to 92

Splenic lesions

6

916 (477)

Not calculated

Not calculated

13 to 62

86 to 100

Intra‐abdominal lymph nodes

8

917 (455)

Not calculated

Not calculated

22 to 86

56 to 100

Ascites

8

891 (433)

Not calculated

Not calculated

4 to 73

33 to 100

Splenomegaly

6

775 (397

Not calculated

Not calculated

5 to 62

45 to 89

Hepatomegaly

4

373 (189)

Not calculated

Not calculated

24 to 76

20 to 78

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Table 3. Summary estimates of sensitivity and specificity for any abnormality and individual abdominal ultrasound findings
Table Tests. Data tables by test

Test

No. of studies

No. of participants

1 Abnormal abdominal ultrasound (higher quality) Show forest plot

5

879

2 Abnormal abdominal ultrasound (lower quality) Show forest plot

4

397

3 Ascites Show forest plot

8

891

4 Splenic lesions Show forest plot

6

916

5 Abdominal lymph nodes Show forest plot

8

917

6 Splenomegaly Show forest plot

6

775

7 Hepatomegaly Show forest plot

4

373

Figuras y tablas -
Table Tests. Data tables by test