GPs felt more confident diagnosing TB when it presented classically. However, their clinical suspicion of TB was low if there were few traditional symptoms or risk factors and thus, diagnosis was more difficult (Boxes 4, 5 and 6). This was amplified by their reported lack of recent knowledge about TB, due to insufficient training. More recent knowledge arose from the medical press, the internet, the popular press, and television. Many expressed concerns that medical education about TB was lacking:
‘There haven't been any sessions to inform us about TB … TB is not one of those that's on the agenda.’ (GP 1)
Box 4. Presentation with few traditional symptoms.
Patient 3, a white European in his 50s, had had a suspicious chest X-ray as a child, for which he did not undergo any treatment. His aunt had TB of the spine 50 years previously. He presented six times in the year before diagnosis, to both the GP and accident and emergency department. He gave a 10-year history of pain and reduced range of movement of his shoulder. Initially he was diagnosed as having arthritis, and was treated with steroid joint injection, and painkillers. Having failed to respond, he was referred for a shoulder X-ray and was also found to have raised inflammatory markers. He was eventually referred to an orthopaedic surgeon who aspirated the joint, and TB was diagnosed by culture of the aspirate. In retrospect, it was felt by the patient's GP that this diagnosis might still have been missed, due to the unusual presentation.
Box 5. Presentation with few traditional symptoms.
Patient 16, of Asian origin, presented to her GP four times, and to accident and emergency (A&E) three times before a diagnosis of TB meningitis was made. She reported visiting her GP with a 10-day history of headache, neck discomfort, photophobia, and non-specific flu-like symptoms, including a dry cough. She recalled raising her concerns that she might have meningitis. She stated that her GP initially reassured her that these concerns were unfounded and a diagnosis of upper respiratory tract infection was made.
She was seen again the following day by the same GP who ordered a chest X-ray and blood tests. The patient presented on two further occasions in general practice. A different GP prescribed antibiotics and an out-of-hours doctor diagnosed respiratory infection. She failed to improve, and was finally admitted on her third presentation to A&E. TB meningitis was considered, despite a normal CT scan of the head and negative cerebrospinal fluid cultures. TB treatment was commenced and she responded well.
On reflection, the GP interviewed felt they probably would not have acted differently, having considered her concerns about TB, and by arranging preliminary investigation. Blood tests were normal, but the patient was admitted via A&E before the chest X-ray could be followed up.
Box 6. Presentation with few traditional symptoms.
Patient 8, a white European, presented six times to her GP practice over a period of 5 months and saw three different GPs. She was generally in good health, although a smoker. Her initial symptom was a dry, chesty cough, which she first thought was due to a pollen allergy. After some weeks she developed breathlessness and presented to her GP who diagnosed a chest infection and prescribed antibiotics, which provided some relief. She also took paracetamol and a cough mixture.
She presented again when she became more unwell (tiredness, poor sleeping, weight loss) and was prescribed two more courses of antibiotics. When she presented with pleuritic chest pain, a locum GP requested a chest X-ray as he was concerned about a possible diagnosis of lung cancer. The X-ray indicated a pleural effusion and sputum was sent for AFBs (Acid Fast Bacilli) at which point TB was diagnosed and she was admitted to hospital.
The GP reported that on reflection, the patient might have been referred sooner, and suggested that delay could have arisen due to different approaches by different GPs.
Some GPs thought that TB presentation might be changing, with non-pulmonary presentations becoming increasingly common. Although the majority of GPs were aware of local specialist services, detailed knowledge of these services was lacking. Particular confusion surrounded the current status of the Bacille Calmette-Guérin (BCG) immunisation programme.
