Sputum induction for the diagnosis of pulmonary tuberculosis in infants and young children in an urban setting in South Africa

H J Zar; E Tannenbaum; P Apolles; P Roux; D Hanslo; G Hussey

doi:10.1136/adc.82.4.305

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Sputum induction for the diagnosis of pulmonary tuberculosis in infants and young children in an urban setting in South Africa

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Re: Sputum induction not more sensitive than gastric lavage
Heather J Zar
Published on: 8 June 2000
Sputum induction not more sensitive than gastric lavage
H E Wiersma
Published on: 2 June 2000

Published on: 8 June 2000
Re: Sputum induction not more sensitive than gastric lavage
- Heather J Zar
Reply to Dr Wiersma and colleagues:
Dr Wiersma and colleagues suggest that the yield from a single sputum induction should be compared only with the results of those children who had 3 consecutive gastric lavages (Arch Dis Child Rapid Response 2 June 2000). Only 26 of our patients had 3 gastric lavages; amongst this subset however, 4 children were culture positive on sputum while only 3 were positive on gastric...
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Reply to Dr Wiersma and colleagues:
Dr Wiersma and colleagues suggest that the yield from a single sputum induction should be compared only with the results of those children who had 3 consecutive gastric lavages (Arch Dis Child Rapid Response 2 June 2000). Only 26 of our patients had 3 gastric lavages; amongst this subset however, 4 children were culture positive on sputum while only 3 were positive on gastric lavage.
Although the yield from gastric lavage is improved with increasing number of specimens, it is frequently not feasible to perform this procedure on 3 consecutive days, particularly in developing countries with limited resources. Moreover, performing 3 repeated gastric lavages may be very unpleasant both to the child and the health worker. In practice, even in tertiary institutions such as those in which our study was performed, obtaining 3 sequential gastric lavages is rarely feasible.
The yield from sputum induction may also be increased with increasing number of specimens.[1] Therefore we would submit that the yield from consecutive gastric lavages should be compared with that of repeated induced sputa. Data from studies of adult patients using paired specimens of induced sputum and gastric aspirates have reported a higher yield from sputa specimens.[2-4] In our study, the findings that a single induced sputum specimen yielded M tuberculosis more frequently than repeated GLs (in the majority of children) further strengthens our conclusion.
Heather J Zar
Esta Tannenbaum
Patti Apolles
David Hanslo
Gregory Hussey
References
1. Finch D, Beaty CD. The utility of a single sputum specimen in the diagnosis of tuberculosis - comparison between HIV-infected and non-HIV- infected patients. Chest 1997;111:1174-9
2. Elliott RC, Reichel J. The efficacy of sputum specimens obtained by nebulization versus gastric aspirates in the bacteriological diagnosis of pulmonary tuberculosis. Am Rev Resp Dis 1963;88:223-7
3. Jones FL. The relative efficacy of spontaneous sputa, aerosol- induced sputa and gastric aspirates in the bacteriologic diagnosis of pulmonary tuberculosis. Dis Chest 1966;50:403-8
4. Lillehei JP. Sputum induction with heated aerosol inhalations for the diagnosis of tuberculosis. Am Rev Resp Dis 1961;84:276-8
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Conflict of Interest:
None declared.
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Published on: 2 June 2000
Sputum induction not more sensitive than gastric lavage
- H E Wiersma, MD
Dear editor:
With interest we read the study of Zar et al¹ on the usefullness of sputum induction in infants and young children for the diagnosis of pulmonary tuberculosis. Bacteriological confirmation of pulmonary tuberculosis in infants and young children remains a problem because it is difficult to obtain sputum. Therefore, in young children, gastric lavage is the recommended method for the collection of res...
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Dear editor:
With interest we read the study of Zar et al¹ on the usefullness of sputum induction in infants and young children for the diagnosis of pulmonary tuberculosis. Bacteriological confirmation of pulmonary tuberculosis in infants and young children remains a problem because it is difficult to obtain sputum. Therefore, in young children, gastric lavage is the recommended method for the collection of respiratory secretions.² Since the number of tubercle bacilli and the frequency of positive cultures in specimens recovered by gastric lavage are usually small, gastric washings are ideally performed on three consecutive mornings to maximize the yield.³
In this prospective study, children with acute pneumonia with a high risk on pulmonary tuberculosis were included. On 142 children both gastric lavage and sputum induction was performed. The yield of M tuberculosis in sputum and gastric lavage was compared, as was the amount of positive cultures in sputum and gastric lavage. The influence of HIV-status on the yield was also determined. The authors found more positive cultures in the induced sputa compared to the gastric lavages. Therefore they conclude that sputum induction was a more sensitive method than gastric lavage for culture of M tuberculosis. However, in order to compare the sensitivity of two diagnostic tests, one should perform both tests in all patients. In this study, 39 patients underwent only one gastric lavage, 77 patients had lavages on two consecutive mornings and only 26 patients underwent all 3 gastric lavages.
We therefore disagree with the authors on one of the conclusions, that induced sputum is better than gastric lavage for the isolation of M tuberculosis in infants and children. In our opinion, in order to answer the question whether sputum induction is as good as or better than gastric lavage, only the results from the patients who underwent gastric lavages on three consecutive days should be used.
H E WIERSMA
W M C VAN AALDEREN
M O HOEKSTRA
Department of Pediatric Pulmonology
Emma Children's Hospital
Academic Medical Centre
PO BOX 22660
1100 DD Amsterdam
The Netherlands
1. Zar HJ, Tannebaum E, Apolles P, Roux P, Hanslo D, Hussey G. Sputum induction fot the diagnosis of pulmonary tuberculosis in infants and young children in an urban setting in South Africa. Arch Dis Child 2000;82:305- 308.
2. Abadco DL, Steiner P. Gastric lavage is better than bronchoalveolar lavage for isolation of Mycobacterium tuberculosis in childhood pulmonary tuberculosis. Pediatr Invect Dis J 1992;11:735-8.
3. Chernick V, Boat TF. Kendig's disorders of the respiratory tract in children. W.B. Saunders Company 1998;893-894.
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Conflict of Interest:
None declared.
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