International Journal of Infectious Diseases 59 (2017) 96–102

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International Journal of Infectious Diseases

journal homepage: www.elsevier.com/locate/ijid

Utility of urine lipoarabinomannan (LAM) in diagnosing tuberculosis

and predicting mortality with and without HIV: prospective TB cohort
from the Thailand Big City TB Research Network$
Gompol Suwanpimolkula,1,* , Kamon Kawkitinaronga,1, Weerawat Manosuthib ,
Jiratchaya Sophonphanc, Sivaporn Gatechompolc , Pirapon June Ohatac,
Sasiwimol Ubolyamc , Thatri Iampornsinc, Pairaj Katerattanakuld ,
Anchalee Avihingsanona,c , Kiat Ruxrungthama,c
a
Department of Medicine, Faculty of Medicine, Chulalongkorn University, The King Chulalongkorn Memorial Hospital, Thai Red Cross Society, 1873 Rama 4
Road, Pathumwan, Bangkok 10330, Thailand
b
Department of Medicine, Bamrasnaradura Infectious Diseases Institute (BIDI), 26, Mueang Nonthaburi District, Nonthaburi 11000, Thailand
c
HIV-NAT, The Thai Red Cross AIDS Research Centre (TRC-ARC), 104 Ratchadamri Rd, Pathumwan, Bangkok 10330, Thailand
d
Rajavithi Hospital, 2, Phayathai Road, Ratchathewi District, Bangkok 10400, Thailand

A R T I C L E I N F O S U M M A R Y

Article history: Objectives: To evaluate the applicability and accuracy of the urine lipoarabinomannan (LAM) test in
Received 11 February 2017 tuberculosis (TB)/HIV co-infected patients and HIV-negative patients with disseminated TB.
Received in revised form 6 April 2017 Methods: Frozen urine samples obtained at baseline from patients in the TB research cohort with proven
Accepted 19 April 2017
culture-positive TB were selected for blinded urine LAM testing. One hundred and nine patients were
Corresponding Editor: Eskild Petersen, Aar-
hus, Denmark
categorized into four groups: (1) HIV-positive patients with TB; (2) HIV-negative patients with
disseminated TB; (3) HIV-negative immunocompromised patients with TB; and (4) patients with
diseases other than TB. The sensitivity of urine LAM testing for culture-positive TB, specificity of urine
Keywords:
Urine lipoarabinomannan
LAM testing for patients without TB, positive predictive value (PPV), and negative predictive value (NPV)
Tuberculosis were assessed.
HIV-infected patients Results: The sensitivity of the urine LAM test in group 1 patients with a CD4 T-cell count of >100, 100,
Disseminated tuberculosis and 50 cells/mm3 was 38.5%, 40.6%, and 45%, respectively. The specificity and PPV of the urine LAM test
Acid-fast bacilli (AFB) were >80%. The sensitivity of the test was 20% in group 2 and 12.5% in group 3, and the specificity and PPV
were 100% for both groups. A positive urine LAM test result was significantly associated with death.
Conclusions: This promising diagnostic tool could increase the yield of TB diagnosis and may predict the
mortality rate of TB infection, particularly in TB/HIV co-infected patients.
© 2017 The Author(s). Published by Elsevier Ltd on behalf of International Society for Infectious Diseases.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).

Introduction Xpert MTB/RIF (Cepheid Inc., CA, USA, and Foundation for
Innovative New Diagnostics, Geneva, Switzerland), also known
Tuberculosis (TB) is a major cause of death among HIV-positive as the GeneXpert test.
people in several resource-limited countries. The early diagnosis of The GeneXpert test has high sensitivity (smear-positive TB
TB can reduce TB-associated morbidity and mortality, as well as 98.2% and smear-negative TB 72.5%) and specificity (99.2%)
transmission. Although culture is the gold standard test for the (Boehme et al., 2010) and is recommended by the World Health
diagnosis of TB, results are not available for several weeks. Other Organization (WHO). However, the cost of the machine, reagents,
tools can also be used, such as the automated real-time PCR test and cartridges represents one of the main factors hindering the
scale-up of early TB diagnosis in many resource-limited settings.
Aside from the exorbitant cost, the system requires a reliable
continuous source of electricity, which is not always available in
$
Study registered at Clinicaltrials.gov #NCT03042754.
some rural areas. Many developing countries continue to use
* Corresponding author. Tel: +662-256-4578-9, Fax: +6682-2564000-3419.
E-mail address: [email protected] (G. Suwanpimolkul). conventional methods to diagnose TB, i.e., the acid-fast bacillus
1
Gompol Suwanpimolkul and Kamon Kawkitinarong contributed equally. (AFB) smear. The sputum AFB smear has a 50–75% false-negative

http://dx.doi.org/10.1016/j.ijid.2017.04.017
1201-9712/© 2017 The Author(s). Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 G. Suwanpimolkul et al. / International Journal of Infectious Diseases 59 (2017) 96–102 97

rate compared to mycobacterial culture, and the false-negative rate The study procedures complied with the ethical standards of
is particularly high in patients with advanced HIV infection the Institutional Review Board of the Faculty of Medicine,
(Steingart et al., 2007). Chulalongkorn University, Bangkok, Thailand (IRB approval
As a result of these issues, an alternative test using a specimen number 086/54) and the 1983 revised version of the Declaration
that can be obtained easily would be beneficial. The detection of of Helsinki of 1975. Informed consent was obtained from all
lipoarabinomannan (LAM) levels in the urine represents one such patients prior to the screening process.
possible test. LAM is a heat-stable glycolipid of the outer cell wall of
Mycobacterium spp (Lawn, 2012) and is released by metabolically Laboratory testing
active bacilli, so it can be used to detect TB. Since LAM is filtered by
the kidney, it is detectable in the urine, particularly in patients with The Determine TB LAM Ag test kit (Alere Inc., Waltham, MA,
advanced HIV infection and disseminated TB (Lawn, 2012). For USA) was used in this study. This is a lateral flow, rapid urine LAM
patients with a CD4 T-cell count of less than 50 cells/mm3, the test. Frozen urine samples stored in biobanks were investigated for
sensitivity of the urine LAM test can range from 56% to 85%, and it TB with the urine LAM test. In brief, the frozen urine specimen was
has a specificity of >88% (Nakiyingi et al., 2014; Talbot et al., 2012). brought to room temperature. After the specimen had thawed, it
Thus, the LAM test may be able to improve the detection of TB was centrifuged at 10 000 g for at least 5 min prior to testing. At
among immunocompromised patients with advanced HIV and least two separate, independent readers interpreted the LAM test
could be used as an adjunct diagnostic tool to AFB smear, clinical results after 30 min. Both readers were blinded to the culture
symptoms, and culture. The urine LAM test is an attractive method results. Positive tests were graded on a scale that ranged from 1+ to
because of its ease of use: the test can be done anywhere, including 5+ (Lawn, 2012). All samples were tested by the same trained
at the patient’s bedside, and takes only 20 min to perform. laboratory technician in a blinded manner.
Many studies on the urine LAM test have been performed in the For mycobacterial culture, the sample was processed with N-
African setting, but the findings of these studies may not be acetyl-cysteine and sodium hydroxide, followed by centrifugation
applicable to Asia, which has a different epidemiological situation, and resuspension in phosphate buffer (total volume 1.5 ml) (Kent
geography, and patient population. Unlike the African setting in PT, Kubica GP. Public health mycobacteriology: a guide for the level
which there is more advanced disseminated TB co-infection with III laboratory. Atlanta, GA: US Department of Health and Human
HIV, Thailand has more severely ill, disseminated and pulmonary Services, Public Health Service, Centers for Disease Control, 1985).
TB cases without HIV infection. The urine LAM test has not been The prepped sample was then inoculated onto a solid medium
evaluated in HIV-negative immunocompromised Asian patients (Ogawa medium) and into a liquid medium (BACTEC MGIT
with disseminated TB and non-disseminated TB (TB located in one (mycobacteria growth indicator tube), using the BACTEC MGIT
organ). In addition, it has been shown that the urine LAM test has 960 System; BD Microbiology Systems). The identification of
poor sensitivity and specificity for detecting pulmonary TB in Mycobacterium tuberculosis was confirmed by biochemical test
patients without an HIV infection (Mutetwa et al., 2009). Hence (nitrate reduction) and immunochromatographic test (MPT64
this study was performed to evaluate the applicability and efficacy antigen detection system, SD Bioline Kit; Standard Diagnostics,
of TB diagnosis using the urine from culture-confirmed TB patients Inc., Korea). We had blood cultures for TB performed only in HIV-
with various immune response conditions: TB in HIV-positive infected patients and pushed it into a TB culture bottle (BD BACTEC
patients, disseminated TB in HIV-negative patients, and TB in HIV- Myco/F lytic culture; BACTEC 9240).
negative immunocompromised patients. At the time this study
was designed, there was limited information pertaining to urine Definitions
LAM testing among HIV-negative immunocompromised Asian
subjects with disseminated TB and non-disseminated TB. The patient was considered to have definite TB in the presence
of at least one positive result for M. tuberculosis via liquid or solid
culture (from any clinical sample, including sputum, blood, or
Materials and methods tissue). The patient was considered to have probable TB in the
event of a negative culture result, but clinical symptoms and
Study population and procedures radiology suggesting otherwise. These patients were highly
suspected to have TB; during treatment and follow-up, they had
The study population comprised a prospective TB cohort from good responses to anti-TB regimens. Subjects with a definite
the Thailand Big City TB Research Network, which included HIV- diagnosis for another disease, such as cancer, pneumonia, etc.,
positive and HIV-negative patients attending three large hospitals were categorized as non-TB patients. Results from various TB
in Thailand (King Chulalongkorn Memorial Hospital, Rajavithi diagnostic tests, including culture, were negative for the presence
Hospital, and Bamrasnaradura Hospital) who were enrolled of M. tuberculosis. These patients were treated with anti-TB
between 2010 and 2013. Frozen urine specimens obtained at the medications and no clinical improvement was observed. Patients
time of TB diagnosis were collected as per the study protocol. For were considered to have disseminated TB in the presence of two or
the TB cohort, sputum and other specimens were tested for TB by more non-contiguous sites resulting from the lympho-haematog-
AFB smear, mycobacterial culture, and Xpert MTB/RIF. Stored urine enous dissemination of M. tuberculosis (Diagnostic Standards and
samples were selected for analysis in this study based on Classification of Tuberculosis in Adults and Children, 2000; Wang
confirmation of the TB diagnosis. et al., 2007; Ayaslioglu et al., 2009; Ribeiro et al., 2016).
The participants were divided into two groups based on the HIV-negative immunocompromised patients were those who
presence and absence of HIV infection. The participants were then had documentation to show that they did not have an HIV infection
further classified into four groups in order to evaluate the yet their immune status was compromised due to an underlying
sensitivity, specificity, positive predictive value (PPV), and negative disease (i.e., diabetes mellitus), condition (i.e., humoral immune
predictive value (NPV) of the urine LAM test in HIV-positive deficiency: multiple myeloma, chronic lymphoid leukaemia,
patients co-infected with TB (group 1), HIV-negative patients with multiple haematological malignancy), and/or the effects of
disseminated TB (group 2), HIV-negative immunocompromised treatment, including those affecting T-cells (i.e., marrow and other
patients with TB (non-disseminated TB) (group 3), and those with transplantation, cancer chemotherapy, and glucocorticoid therapy)
diseases other than TB (group 4). and neutrophils (i.e., chemotherapy).
98 G. Suwanpimolkul et al. / International Journal of Infectious Diseases 59 (2017) 96–102

Patients in group 4 had diseases other than TB; these patients infection. Among the HIV-negative patients, diabetes mellitus
did not have TB, but had other diseases such as lung cancer, was the most common underlying disease (32.6%), followed by
lymphoma, etc. chronic steroid use (8.7%) and chronic lung disease (6.5%)
(Table 1).
Statistical analysis
Urine LAM test results in HIV-positive patients (group 1) and HIV-
The data analysis was performed using Stata version 13.1 (Stata negative patients (groups 2 and 3)
Corp., College Station, TX, USA). For the descriptive analysis, the
frequencies of categorical variables were calculated, while the HIV-positive patients (group 1) were younger (mean age
median and interquartile range (IQR) values were calculated for 35 years) and more predominantly male (75.8%) than the HIV-
continuous variables. The non-parametric Wilcoxon rank sum test negative patients (groups 2 and 3) (mean age 48.8 years, 56.5%
was used to compare continuous variables between two groups. male). Thirty of 63 patients in group 1 (47.6%) had a CD4 T-cell
The Chi-square test was used for categorical variables. The count of 50 cells/mm3, all of whom received highly active
sensitivity, specificity, PPV, and NPV, with 95% confidence intervals antiretroviral therapy (HAART) within 2 weeks after being
(CI), were calculated for the urine LAM test using definite TB as the diagnosed with TB. Trimethoprim–sulfamethoxazole prophylaxis
gold standard. p-Values of less than 0.05 were considered was given to the patients if their CD4 T-cell count was 200 cells/
statistically significant. For the primary objective: the gold mm3.
standard was definite TB secondary objective: the gold standard Fifty-one out of 70 patients (72.8%) had pulmonary TB and
was either definite TB (by culture grew TB) or probable TB (clinical 19 patients (27.2%) had disseminated TB with and without
diagnosis). pulmonary involvement. The sensitivity, specificity, PPV, and
NPV of the urine LAM test in HIV-positive subjects were 40%, 85%,
Results 80%, and 48.6%, respectively. Of note, the specificity, PPV, and NPV
of the urine LAM test in HIV-negative patients were all 100% even
Figure 1 shows a flow diagram of the study. One hundred and though the sensitivity was around 20% in HIV-negative patients
nine out of 594 patients from the TB cohort were analyzed. Four with disseminated TB (group 2) and 12.5% in HIV-negative
hundred and eighty-five patients were excluded: 201 refused to immunocompromised patients with TB (group 3) (Tables 2–4 ).
provide a urine sample, 75 HIV-positive patients had a CD4 T-cell However, for HIV-positive patients, the specificity and PPV were
count >200 cells/mm3, and 209 patients had active TB without any around 85%, and the sensitivity as well as the NPV was close to 40%.
underlying disease. In addition, the sensitivity was positively correlated with the CD4
A total of 109 patients were included in this analysis. Sixty- level: the sensitivity of the test was 38.5% for those patients with a
three of the 109 patients enrolled were HIV-positive (group 1). CD4 count >100 cells/mm3, 40.6% for those with CD4 100 cells/
Forty-six of the 109 patients were HIV-negative: 20 of them had mm3, and 45% for those with CD4 50 cells/mm3 (Figure 2).
disseminated TB (group 2) and the other 26 had TB (group 3).
Seventy patients were diagnosed with active TB. Fifty-one (72%)
of the patients had definite TB. Baseline characteristics of the
study population based on the presence or absence of HIV

Figure 1. Classification of the TB patients analyzed in the study.

 G. Suwanpimolkul et al. / International Journal of Infectious Diseases 59 (2017) 96–102 99

Table 1
Baseline characteristics.

Total (N = 109) HIV-positive (n = 63) HIV-negativea (n = 46) p-Value

Age (years) 38.2 (31.8–49.3) 35 (30–41.2) 48.8 (37.3–68.3) <0.001
Sex, male, n (%) 73 (67.0) 47 (75.8) 26 (56.5) 0.03
Prior TB diagnosis, n (%) 31 (28.7) 20 (32.2) 11 (23.9) 0.34

CD4 cell count (cells/mm3), n (%)

50 30/63 (47.6) 30/63 (47.6) – –
51–100 15/63 (23.8) 15/63 (23.8) – –
101–200 11/63 (17.5) 11/63 (17.5) – –
>200 4/63 (6.3) 4/63 (6.3) – –
Missing 3/63 (4.8) 3/63 (4.8) – –
Diabetes mellitus, n (%) 15 (13.8) 0 15 (32.6) –
Steroid use, n (%) 4 (3.7) 0 4 (8.7) –
Chronic renal disease, n (%) 3 (2.8) 1 (1.6) 2 (4.4) 0.57
Chronic liver disease, n (%) 3 (2.8) 1 (1.6) 2 (4.4) 0.57
Chronic lung disease, n (%) 4 (3.7) 1 (1.6) 3 (6.5) 0.31
Cancer, n (%) 3 (2.8) 1 (1.6) 2 (4.4) 0.57

TB type, n (%)
Pulmonary 51 (46.8) 28 (48) 23 (50) 0.56
Disseminated 19 (17.4) 15 (23.8) 4 (8.7) 0.01

TB, tuberculosis.
a
Groups 2 and 3.

Added effect of the urine LAM test result in smear-negative, culture- A positive urine LAM test result is associated with death
positive disseminated TB/HIV co-infected patients with or without
pulmonary involvement Overall, positive urine LAM results were significantly associated
with death when a comparison was made to patients with negative
When the urine LAM test was used for smear-negative and urine LAM results (27.8% and 8.3%, respectively; p = 0.04). Among
culture-positive patients (n = 30), the sensitivity of diagnosing TB HIV-positive patients, positive urine LAM results were also
increased up to 44% in TB/HIV co-infected patients. This significant significantly associated with death when compared to those with
improvement was seen only in TB/HIV co-infected patients negative urine LAM results (25% and 3.7%; p = 0.02). In TB/HIV co-
compared to the HIV-negative patients (44.4% vs. 8.3%; infected patients who had a CD4 count of 50 cells/mm3 and a
p = 0.0049). On the other hand, for patients with smear-positive positive urine LAM result, the mortality rate was as high as 50% (4/
and culture-positive results, there were no significant added 8). In contrast, patients with a CD4 count of 50 cells/mm3 and
effects with the use of the urine LAM test (Figure 3). who had a negative urine LAM result had a mortality rate of only
4.8% (1/21) (p = 0.01). There appeared to be an increasing trend for
positive urine LAM results and death in HIV-negative patients (25%
Table 2 and 13%); however, this was not statistically significant (Figure 4).
Performance of the urine LAM test compared with the gold standard Mycobacterium
tuberculosis culture in HIV-positive patients. The recovery rate on chest radiography at 2 months after anti-TB
All TB Definite TB Probable TB treatment differs significantly among urine LAM-positive and urine
n/N 16/43 12/30 4/13
LAM-negative patients
Sensitivity (95% CI) 37.2 (23–53.3) 40 (22.7–59.4) 30.8 (9.1–61.4)
n/N 17/20 17/20 17/20 Chest radiography was performed for 70 patients before
Specificity (95% CI) 85 (62.1–96.8) 85 (62.1–96.8) 85 (62.1–96.8) treatment was started. Five patients were excluded because they
n/N 16/19 12/15 4/7
died 2 months before initiating anti-TB treatment. The chest
PPV (95% CI) 84.2 (60.4–96.6) 80 (51.9–95.7) 57.1 (18.4–90.1)
n/N 17/44 17/35 17/26 radiographs of 65 patients were evaluated at 2 months after anti-
NPV (95% CI) 38.6 (24.4–54.5) 48.6 (31.4–66) 65.4 (44.3–82.8) TB treatment. The recovery rate was determined by chest
LAM, lipoarabinomannan; TB, tuberculosis; CI, confidence interval; PPV, positive
radiography. Positive urine LAM results were significantly associ-
predictive value; NPV, negative predictive value. ated with a poor response or recovery rate on chest radiography

Table 4
Table 3 Performance of the urine LAM test compared with the gold standard Mycobacterium
Performance of the urine LAM test compared with the gold standard Mycobacterium tuberculosis culture in HIV-negative immunocompromised patients with TB (group
tuberculosis culture in HIV-negative patients with disseminated TB (group 2). 3).

All TB Definite TB Probable TB All TB Definite TB Probable TB

n/N 2/7 1/5 1/2 n/N 2/20 2/16 0/4
Sensitivity (95% CI) 28.6 (3.67–71) 20 (0.51–71.6) 50 (1.26–98.7) Sensitivity (95% CI) 10 (1.23–31.7) 12.5 (1.55–38.3) 0 (0–60.2)
n/N 13/13 13/13 13/13 n/N 6/6 6/6 6/6
Specificity (95% CI) 100 (75.3–100) 100 (75.3–100) 100 (75.3–100) Specificity (95% CI) 100 (54.1–100) 100 (54.1–100) 100 (54.1–100)
n/N 2/2 1/1 1/1 n/N 2/2 2/2 NA
PPV (95% CI) 100 (15.8–100) 100 (2.5–100) 100 (2.5–100) PPV (95% CI) 100 (15.8–100) 100 (15.8–100) NA
n/N 13/18 13/17 13/14 n/N 6/24 6/20 6/10
NPV (95% CI) 72.2 (46.5–90.3) 76.5 (50.1–93.2) 92.9 (66.1–99.8) NPV (95% CI) 25 (9.77–46.7) 30 (11.9–54.3) 60 (26.2–87.8)

LAM, lipoarabinomannan; TB, tuberculosis; CI, confidence interval; PPV, positive LAM, lipoarabinomannan; TB, tuberculosis; CI, confidence interval; PPV, positive
predictive value; NPV, negative predictive value. predictive value; NPV, negative predictive value.
100 G. Suwanpimolkul et al. / International Journal of Infectious Diseases 59 (2017) 96–102

Figure 2. Sensitivity and positive predictive value of the urine LAM test for definite TB with and without HIV..

Figure 3. Sensitivity of the urine LAM test compared to smear (negative/positive) and positive M. tuberculosis culture in patients with and without HIV.

compared to patients with negative urine LAM results (41.2% and LAM test should not be used alone to screen for TB (Seddiki et al.,
8.3%, respectively; p = 0.005) (Supplementary Material, Tables S1a 2014). However, it can be used in conjunction with culture and the
and S1b). For extrapulmonary TB, there appeared to be an AFB smear test for patients co-infected with HIV. The urine LAM
increasing trend of positive urine LAM results associated with test is especially helpful in cases where the smear result is negative
no improvement (40% and 0%) when compared to patients with for patients suspected to have TB, because it is not practical to wait
negative urine LAM results; however, this was not statistically for the results of culture to determine whether the patient should
significant, probably due to the small sample size (Supplementary start anti-TB treatment or not. In this study, the sensitivity for
Material, Table S1c). With regard to smear status, no statistically diagnosing TB increased up to 44% among smear-negative and
significant differences were found between smear status and urine culture-positive patients who were co-infected with HIV. Thus, the
LAM status (smear-positive/urine LAM-positive in 5/21 patients results of the urine LAM test can be used in these circumstances.
(23.81%) and smear-negative/urine LAM-positive in 12/44 patients The LAM test has been proven to be incredibly helpful in probable
(27.27%); p = 0.76). TB patients with negative smear results who are co-infected with
HIV. The data from this study corroborate the diagnostic sensitivity
Discussion of the urine LAM test, which was reported to be between 44% and
63% in hospitalized HIV-positive patients in South Africa and
The urine LAM test was evaluated in TB patients with and Uganda (Fielding et al., 2015; Lawn et al., 2013; Seddiki et al., 2014;
without HIV co-infection in Thailand. In this study, the utility of the Bjerrum et al., 2015; Shah et al., 2014).
urine LAM test was also investigated among patients with Most studies on the urine LAM test have focused on patients co-
disseminated TB with various immune statuses. The sensitivity infected with TB and HIV. In this study, there was the opportunity
and specificity of the urine LAM test were compared between to investigate the performance of the urine LAM test among HIV-
definite and probable TB patients and non-TB patients. The negative patients with disseminated TB. Although the sensitivity of
sensitivity of the urine LAM test in this study was 40% in HIV- the urine LAM test in this study was 40% in HIV-positive patients
positive patients and 20% in HIV-negative patients, which are (group 1), 20% in HIV-negative patients with disseminated TB
similar to values reported previously (Nakiyingi et al., 2014; (group 2), and 12.5% in HIV-negative immunocompromised
Fielding et al., 2015; Lawn et al., 2013). This confirms that the urine patients with TB (group 3), the PPV and specificity were over
 G. Suwanpimolkul et al. / International Journal of Infectious Diseases 59 (2017) 96–102 101

Figure 4. Association of death and the results of the urine LAM test in patients with and without HIV.

80% in those who were HIV-positive and up to 100% in HIV- indicate that aggressive treatment is needed, such as prompt
negative patients (both groups 2 and 3). For physicians, the PPV of treatment with an effective anti-TB regimen and directly observed
the assay is more useful than the sensitivity and specificity, therapy (DOT) to ensure adherence, in conjunction with good
because it will answer the question regarding how likely it is that supportive care and sufficient provision of essential nutrients.
the patient has TB or not. A high PPV can accurately guide the Since the death rate is much higher among TB/HIV-infected
physician to confidently prescribe crucial TB medications, espe- patients with positive LAM results, trimethoprim–sulfamethoxa-
cially for co-infected patients who are severely ill. For this reason, zole prophylaxis and HAART therapy should be initiated as quickly
the urine LAM test seems to be a useful point-of-care test that can as possible.
easily be incorporated with the AFB smear and culture test in the As with all studies, this study has limitations. First, the sample
Asian population. size was relatively small, so caution is required when interpret-
Furthermore, the urine LAM test is particularly helpful in TB/ ing the results. Second, frozen urine specimens from the
HIV co-infected patients with very low CD4 counts (Swaminathan biobanks were used, which may not give the same sensitivity
and Rekha, 2012). In this study, the sensitivity of the urine LAM test results as fresh urine specimens. It is possible that the LAM
was found to be negatively correlated with the CD4 count. This antigen could have degraded over time. This may explain why the
finding confirms that the urine LAM test can be used effectively in sensitivity of the urine LAM test in this study was lower than that
TB/HIV co-infected patients with very low CD4 counts in the Thai found in African studies, which have reported diagnostic
population (World Health Organization (WHO), 2015). sensitivity and specificity as high as 60–66.7% and 94–98.6%,
In reality, it is physically difficult to obtain sputum, and samples respectively, among HIV-infected patients with CD4 counts of
from severely ill patients, both HIV-positive and HIV-negative, are <50 cells/mm3 (Lawn et al., 2012; Peter et al., 2013; Peter et al.,
often paucibacillary. Delayed diagnosis can contribute to a higher 2012). To date, no one has investigated the stability of frozen
mortality rate in disseminated TB. Therefore, an alternative urine samples compared to ‘fresh’ specimens. Other factors that
technique that can be used to diagnose TB is needed. The data may have affected the results are the TB burden in different types
from this study support those of the most recent large multicenter of population, the different storage procedures used, and the
randomized controlled trial from South Africa, which demonstrat- duration of storage in solid form. Finally, the authors agree with
ed that the use of the urine LAM test could guide physicians on the WHO’s new TB policy that additional tests from other
when to start anti-TB treatment in HIV-positive patients and was geographical settings with different epidemiological situations
associated with a reduced 8-week mortality (relative risk and patient populations should be pursued (World Health
reduction of 17%) (Peter et al., 2016). The urine LAM test is Organization (WHO), 2015), because various factors such as
attractive especially in advanced cases in which sputum is difficult genetic susceptibility, host immune responses, and the types of
to obtain, because it is non-invasive and the sample is easy to M. tuberculosis can affect the applicability and accuracy of the
collect and store. Additionally, urine collection reduces the risk of urine LAM test.
spreading TB compared to sputum collection. In conclusion, data from Asia on the use of the urine LAM test
This study also found that a positive urine LAM test result was among TB patients with advanced HIV infections and in HIV-
significantly associated with death, especially in those with an HIV negative patients with disseminated TB are scarce. The findings
infection. The association was much stronger in patients with very from this study suggest the possible use of the urine LAM test
low CD4 counts, despite the fact that all of the patients were with AFB smear and culture in resource-limited countries, in the
prescribed HAART and trimethoprim–sulfamethoxazole prophy- diagnosis of TB in patients with advanced HIV and in HIV-
laxis, even among those with CD4 counts of 50 cells/mm3 and negative patients with disseminated TB. This promising diag-
200 cells/mm3, respectively. A possible explanation for this is nostic tool can increase the yield of TB diagnosis and predict the
that LAM is associated with the bacillary load. Hence, a higher load mortality rate of TB infection, particularly in patients with
of bacilli in the body may signify a greater risk of mortality (Drain advanced HIV.
et al., 2015). In light of this, a positive urine LAM test result should
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Funding This statement was endorsed by the Council of the Infectious Disease Society of
America, September 1999. Am J Respir Crit Care Med 2000;161:1376–95.
Drain PK, Gounder L, Grobler A, Sahid F, Bassett IV, Moosa MY. Urine
This study was mainly supported by a National Research lipoarabinomannan to monitor antituberculosis therapy response and predict
University Grant (Bangkok, Thailand). The LAM test kits were mortality in an HIV-endemic region: a prospective cohort study. BMJ Open
supported by Orgenics Ltd (Israel) and R.X. Co., Ltd (Bangkok, 2015;5:e006833.
Fielding KL, Charalambous S, Hoffmann CJ, Johnson S, Tlali M, Dorman SE, et al.
Thailand). None of the sponsors had any role in the study design, Evaluation of a point-of-care tuberculosis test-and-treat algorithm on early
data collection, data analysis and interpretation, manuscript mortality in people with HIV accessing antiretroviral therapy (TB Fast Track
writing, decision to publish, or preparation of the manuscript. study): study protocol for a cluster randomised controlled trial. Trials
2015;16:125.
Lawn SD, Kerkhoff AD, Vogt M, Wood R. Diagnostic accuracy of a low-cost, urine
Conflict of interest antigen, point-of-care screening assay for HIV-associated pulmonary tubercu-
losis before antiretroviral therapy: a descriptive study. Lancet Infect Dis
2012;12:201–9.
KR has received a Senior Research Scholar grant from the
Lawn SD, Dheda K, Kerkhoff AD, Peter JG, Dorman S, Boehme CC, et al. Determine TB-
Thailand Research Fund(TRF) and honoraria or consultation fees LAM lateral flow urine antigen assay for HIV-associated tuberculosis:
from Merck, Roche, Jensen-Cilag, Tibotec, Mylan, and GPO recommendations on the design and reporting of clinical studies. BMC Infect
(Governmental Pharmaceutical Organization, Thailand). He has Dis 2013;13:407.
Lawn SD. Point-of-care detection of lipoarabinomannan (LAM) in urine for
also participated in a company sponsored speaker’s bureau from diagnosis of HIV-associated tuberculosis: a state of the art review. BMC Infect
Abbott, Gilead, Bristol-Myers Squibb, Merck, Roche, Jensen-Cilag, Dis 2012;12:103.
GlaxoSmithKline, and GPO. All other authors declare no conflicts of Mutetwa R, Boehme C, Dimairo M, Bandason T, Munyati SS, Mangwanya D, et al.
Diagnostic accuracy of commercial urinary lipoarabinomannan detection in
interest. African tuberculosis suspects and patients. Int J Tuberc Lung Dis 2009;13:1253–9.
Nakiyingi L, Moodley VM, Manabe YC, Nicol MP, Holshouser M, Armstrong DT, et al.
Diagnostic accuracy of a rapid urine lipoarabinomannan test for tuberculosis in
Acknowledgements HIV-infected adults. J Acquir Immune Defic Syndr 2014;66:270–9.
Peter JG, Theron G, van Zyl-Smit R, Haripersad A, Mottay L, Kraus S, et al. Diagnostic
accuracy of a urine lipoarabinomannan strip-test for TB detection in HIV-
We would like to thank our patients, because without them we
infected hospitalised patients. Eur Respir J 2012;40:1211–20.
would not have any data to report. We would also like to thank the Peter JG, Theron G, Dheda K. Can point-of-care urine LAM strip testing for
HIV-NAT staff, King Chulalongkorn Memorial Hospital staff, tuberculosis add value to clinical decision making in hospitalised HIV-infected
persons?. PLoS One 2013;8:e54875.
Rajavithi Hospital staff, and Bamrasnaradura Infectious Diseases
Peter JG, Zijenah LS, Chanda D, Clowes P, Lesosky M, Gina P, et al. Effect on mortality
Institute staff for their strong commitment to the study and hard of point-of-care, urine-based lipoarabinomannan testing to guide tuberculosis
work, especially Naphassanant Laopraynak from HIV-NAT, Lavan treatment initiation in HIV-positive hospital inpatients: a pragmatic, parallel-
Sorasitrungsakul and Daorung Silachamroon from King Chula- group, multicountry, open-label, randomised controlled trial. Lancet 2016;
387:1187–97.
longkorn Memorial Hospital, and Supeda Thongyen and Phanasa Ribeiro S, Trabulo D, Cardoso C, Oliveira A, Cremers I. Disseminated Tuberculosis in
Wongsasiripat from Bamrasnaradura Infectious Diseases Institute. an Immunocompetent Patient: The Answer is in the Liver. GE Port J
Gastroenterol 2016;23:208–13.
Seddiki N, Cook L, Hsu DC, Phetsouphanh C, Brown K, Xu Y, et al. Human antigen-
Appendix A. Supplementary data specific CD4(+) CD25(+) CD134(+) CD39(+) T cells are enriched for regulatory T
cells and comprise a substantial proportion of recall responses. Eur J Immunol
Supplementary data associated with this article can be found, in 2014;44:1644–61.
Shah M, Ssengooba W, Armstrong D, Nakiyingi L, Holshouser M, Ellner JJ, et al.
the online version, at http://dx.doi.org/10.1016/j.ijid.2017.04.017. Comparative performance of urinary lipoarabinomannan assays and Xpert
MTB/RIF in HIV-infected individuals. AIDS 2014;28:1307–14.
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