Strengths of this study include consecutive enrollment of patients who were well characterized. Sputum induction was used to obtain quality samples, and liquid culture was used as the reference gold standard and processed in an accredited laboratory according to standardized protocols and quality assurance procedures. A limitation of this study includes the lack of available red blood cell indices or iron studies. With only hemoglobin levels available, we could only classify patients according to the degree of anemia without being able to further investigate possible underlying mechanisms, such as iron deficiency or chronic inflammation. An additional limitation is that it was not possible to determine whether anemia in patients with TB was directly related to their TB disease, attributable to their HIV infection, or was simply a prevalent comorbidity unrelated to either their TB or HIV disease. Finally, the reference standard was determined by testing paired sputum samples using liquid culture. As extrapulmonary TB is more common in patients with advanced immunodeficiency, this may have underestimated the prevalence of active disease. Sampling multiple sites of disease for extrapulmonary TB may have therefore enhanced the reference standard.
The authors are grateful to the Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland, for providing access to the Xpert MTB/RIFassay cartridges with preferential pricing.
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