Protocol for clinical diagnosis and empiric treatment of pulmonary tuberculosis in severely burned patients: observations and literature review

Abstract

Introduction Reactivation of pulmonary tuberculosis is a prevalent concomitant infection and cause for mortality in burns patients in Sub-Saharan Africa. First line laboratory diagnostic studies for pulmonary tuberculosis are often negative in these patients and if relied on, result in high mortality. The purpose of this report is to share our experience with a novel protocol of empiric treatment of clinically suspected pulmonary tuberculosis in severely burned patients with negative GeneXpert tests in a tertiary burns centre and to present a brief literature review on the topic. Methods A retrospective chart review of all patients, who sustained thermal injury with an inhalation component, with negative GeneXpert tests who were treated empirically for pulmonary tuberculosis over a five-year period (2015–2020) was performed. Additionally, a literature search was performed on Medline (PubMed), Cochrane and Google Scholar databases. Results Over the five-year period, 20 patients with suspected pulmonary tuberculosis and severe burns requiring ventilation were managed according to the protocol and all survived to discharge. The literature search identified six factors that explain the consequence of pulmonary tuberculosis in severely burned patients and provide a hypothesis for the negative laboratory studies encountered. Conclusion There was an improved outcome for patients with the clinical diagnosis of reactivation of pulmonary tuberculosis when they were started on empirical pulmonary tuberculosis treatment. There are several potential mechanisms that can contribute to reactivation of pulmonary tuberculosis in susceptible severely burned patients. The GeneXpert test should not be relied upon in these patients for a diagnosis, but rather all other clinical evidence should inform management. Lay Summary From the current literature evidence most patients who have severe burns complicated by a secondary infection known as pulmonary (lung) tuberculosis, die as a result. The purpose of this report is to share our experience with treatment of pulmonary tuberculosis during a five-year period, from 2015 to 2020, in a specialized adult tertiary burn center. Severely burned patients who were suspected of having pulmonary tuberculosis and received treatment despite having negative laboratory tests for pulmonary tuberculosis, had a better survival rate than expected. A brief literature review on the topic of pulmonary tuberculosis and severe burns was done to investigate causes for reactivation of pulmonary tuberculosis and negative laboratory studies in these patients. The literature search identified the following factors that can potentially affect the reactivation of pulmonary tuberculosis in severely burned patients: decreased immune system; secondary infections; low blood albumin(protein) levels; decreased clearance of bacteria from the airways, the development of pulmonary tuberculosis biofilms (capsules that protect the bacteria from chemicals and antibiotics) and the role of a fat molecule called phosphatidylinositol mannoside in pulmonary tuberculosis. In conclusion, the pulmonary tuberculosis test should not be relied upon in these patients, but rather all the clinical evidence such X-ray changes in association with difficulty to wean the patient off the ventilator should be used to inform treatment choice.