Post-bronchoscopy sputum: Improving the
diagnostic yield in smear negative pulmonary TB
Peter M. Georgea,d, Meera Mehtaa,d, Jaideep Dhariwala,
Aran Singanayagama, Claire E. Raphaela, Mohammad Salmasia,
David W. Connella, Philip Molyneauxa, Melissa Wickremasinghea,
Annette Jepsonb, Onn Min Kona,c,*
aChest and Allergy Department, St Mary’s Hospital, Imperial College Healthcare NHS Trust, Praed Street,
London W2 1NY, UK
bDepartment of Microbiology, St Mary’s Hospital, Imperial College Healthcare NHS Trust, Praed Street, London W2 1NY, UK
cCentre for Respiratory Infection, St Mary’s Hospital, Imperial College, Norfolk Square, London W2 1PG, UK
Received 6 March 2011; accepted 23 July 2011
Available online 15 August 2011
Introduction: Patients with suspected active Pulmonary Tuberculosis (PTB) who are Acid-Fast
Bacilli (AFB) smear negative or non-productive of sputum may undergo bronchoalveolar lavage.
However, post-bronchoscopy sputum (PBS) sampling is not routine. The aim of this study was to
establish the potential diagnostic value of PBS sampling.
Methods: A retrospective study of patients attending a London University hospital with micro-
biologically confirmed PTB between January 2004 and December 2010. Patients who were AFB
smear negative or non-productive of sputum were eligible if sputum sampling was performed
within 7 days of bronchoscopy.
Results: Over the study period, 236 patients had microbiologically confirmed smear negative
PTB of which 57 patients were eligible for the study. 15 patients (26.3%) were infected with
HIV. 19 patients (33.3%) converted to AFB sputum smear positivity post-bronchoscopy and 5
patients (8.8%) were exclusively AFB sputum smear positive on PBS microscopy. Mycobacterium
tuberculosis was cultured from the PBS of 43 patients (75.4%) and of these, 4 (7.0%) were
exclusively PBS culture positive.
Abbreviations: AFB, Acid-fast bacilli; BAL, bronchoalveolar lavage; HIV, human immunodeficiency virus; PBS, post-bronchoscopy sputum;
PTB, pulmonary tuberculosis; TB, tuberculosis.
* Corresponding author. Chest and Allergy Clinic, St Mary’s Hospital, Imperial College Healthcare NHS Trust, Praed Street, London W2 1NY,
UK. Tel.: þ44 (0) 2033121344.
E-mail addresses: email@example.com (P.M. George), firstname.lastname@example.org (M. Mehta), email@example.com.
uk (J. Dhariwal), firstname.lastname@example.org (A. Singanayagam), email@example.com (C.E. Raphael), firstname.lastname@example.org.
uk (M. Salmasi), email@example.com (D.W. Connell), firstname.lastname@example.org (P. Molyneaux), melissa.wickremasinghe@
imperial.nhs.uk (M. Wickremasinghe), email@example.com (A. Jepson), firstname.lastname@example.org (O.M. Kon).
dJoint first authors.
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/rmed
Respiratory Medicine (2011) 105, 1726e1731
0954-6111/$ - see front matter ª 2011 Elsevier Ltd. All rights reserved.
The authors are grateful for support from the National
Institute for Health Research Biomedical Research Centre
funding scheme and the Centre for Respiratory Infection at
Imperial College London, supported by the Wellcome Trust.
1. Warren JR, Bhattacharya M, De Almeida KN, Trakas K,
Peterson LR. A minimum 5.0 ml of sputum improves the
sensitivity of acid-fast smear for Mycobacterium tuberculosis.
Am J Respir Crit Care Med 2000;161(5):1559e62.
2. Colebunders R, Bastian I. A review of the diagnosis and treat-
ment of smear-negative pulmonary tuberculosis. Int J Tuberc
Lung Dis 2000;4:97e107.
3. Getahun H, Harrington M, O’Brien R, Nunn P. Diagnosis of
smear-negative pulmonary tuberculosis in people with HIV
infection or AIDS in resource-constrained settings: informing
urgent policy changes. Lancet 2007;369:2042e9.
4. Mukadi YD, Maher D, Harries A. Tuberculosis case fatality rates
in high HIV prevalence populations in sub-Saharan Africa. AIDS
5. Whitehorn J, Ayles H, Godfrey-Faussett P. Extra-pulmonary and
smear-negative forms of tuberculosis are associated with
treatment delay and hospitalisation. Int J Tuberc Lung Dis 2010
6. National Institute for Health and Clinical Excellence. Clinical
diagnosis and management of tuberculosis, and measures for
its prevention and control, www.nice.org.uk; March 2006.
7. Anderson C, Inhaber N, Menzies D. Comparison of sputum
induction with fiber-optic bronchoscopy in the diagnosis of
tuberculosis. Am J Respir Crit Care Med 1995;52:1570e4.
8. Khan MS, Dar O, Sismanidis C, Shah K, Godfrey-Faussett P.
Improvement of tuberculosis case detection and reduction of
discrepancies between men and women by simple sputum-
submission instructions: a pragmatic randomised controlled
trial. Lancet 2007 Jun 9;369(9577):1955e60.
9. Yajko DM, Nassos PS, Sanders CA, Madej JJ, Hadley WK. High
predictive value of the acid-fast smear for Mycobacterium
tuberculosis despite the high prevalence of Mycobacterium
avium complex in respiratory specimens. Clin Infect Dis
10. Wallace JM, Deutsch AL, Harrell JH, Moser KM. Bronchos-
copy and transbronchial biopsy in evaluation of patients
with suspected active tuberculosis. Am J Med 1981;70:
11. Chawla R, Pant K, Jaggi OP, Chandrashekhar S, Thukral SS. Fiber-
Respir J 1988;1:804e6.
12. Kennedy DJ, Lewis WP, Barnes PF. Yield of bronchoscopy for
the diagnosis of tuberculosis in patients with human immuno-
deficiency virus infection. Chest 1992;102:1040e4.
13. de Gracia J, Curull V, Vidal R, et al. Diagnostic value of bron-
choalveolar lavage in suspected pulmonary tuberculosis. Chest
14. Aderaye G, Egziabher HG, Aseffa A, Worku A, Lindquist L.
Comparison of acid-fast stain and culture for Mycobacterium
tuberculosis in pre- and post-bronchoscopy sputum and bron-
choalveolar lavage in HIV-infected patients with atypical chest
X-ray in Ethiopia. Ann Thorac Med 2007 Oct;2(4):154e7.
15. Diagnostic Standards and Classification of Tuberculosis in
Adults and Children. This official statement of the American
Thoracic Society and the Centers for Disease Control and
Prevention was adopted by the ATS Board of Directors, July
1999. This statement was endorsed by the Council of the
infectious disease Society of America, September 1999. Am J
Respir Crit Care Med 2000 Apr;161(4 Pt 1):1376e95.
16. Anderson SR, Maguire H, Carless J. Tuberculosis in London:
a decade and a half of no decline. Thorax 2007 Feb;62(2):
162e7. Epub 2006 Nov 13.
17. Aziz MA, Wright A. The World health Organization/Interna-
tional Union against tuberculosis and lung disease Global
Project on Surveillance for Anti-tuberculosis drug resistance:
a model for other infectious diseases. Clin Infect Dis 2005 Aug
Post-bronchoscopy sputum in TB M. tuberculosis