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Focused ultrasound to diagnose HIV-associated tuberculosis (FASH) in the extremely resource-limited setting of South Sudan: a cross-sectional study
  1. Flavio Bobbio1,
  2. Francesco Di Gennaro2,
  3. Claudia Marotta3,
  4. John Kok4,
  5. Gabriel Akec4,
  6. Luca Norbis5,
  7. Laura Monno2,
  8. Annalisa Saracino2,
  9. Walter Mazzucco6,
  10. Marta Lunardi7
  1. 1Doctors With Africa CUAMM, Yirol, South Sudan
  2. 2Infectious Diseases, University of Bari, Bari, Italy
  3. 3Department of Sciences for Health Promotion and Mother to Child Care G.D Alessandro, University of Palermo, Palermo, Italy
  4. 4Yirol Hospital, Yirol, South Sudan
  5. 5Ospedale San Raffaele, Milano, Lombardia, Italy
  6. 6Department of Sciences for Health Promotion and Mother to Child Care G.D Alessandro, University of Palermo, Palermo, Italy
  7. 7Doctors With Africa CUAMM, Yirol, South Sudan
  1. Correspondence to Dr Flavio Bobbio; flavio.bobbio{at}


Objective Our cross-sectional study aimed at evaluating the diagnostic performance of Focused Assessment with Sonography for HIV-associated tuberculosis (FASH) to detect extrapulmonary tuberculosis in extremely resource-limited settings, with visceral leishmaniasis as a differential diagnosis with overlapping sonographic feature.

Design Cross-sectional study.

Setting Voluntary Counselling and Testing Centre (VCT) of Yirol Hospital, South Sudan.

Participants From May to November 2017, 252 HIV-positive patients out of 624 newly admitted to VCT Centre were registered for antiretroviral treatment. According to the number of trained doctors available to practise ultrasound (US) scan, a sample of 100 patients were screened using the FASH protocol.

Interventions Following a full clinical examination, each patient was scanned with a portable US scanner in six different positions for pleural, pericardial, ascitic effusion, abdominal lymphadenopathy and hepatic/splenic microabscesses, according to the FASH protocol. A k39 antigen test for visceral leishmaniasis was also performed on patients with lymphadenopathy and/or splenomegaly. All demographic, clinical and HIV data, as well as FASH results and therapy adjustments, were recorded following the examination.

Results The FASH protocol allowed the detection of pathological US findings suggestive of tuberculosis in 27 out of the 100 patients tested. Overall, FASH results supported tuberculosis treatment indication for 16 of 21 patients, with the treatment being based exclusively on FASH findings in half of them (8 patients). The group of FASH-positive patients had a significantly higher proportion of patients with CD4 count below 0.2 x109/L (n=22, 81%) as compared with FASH-negative patients (n=35, 48%) (p=0.003). Moreover, 48% (n=13) of FASH-positive patients had CD4 below 100 cells/mm3. All patients tested had a negative result on k39 antigen test.

Conclusion FASH was found to be a relevant diagnostic tool to detect signs of tuberculosis. Further research is needed to better define a patient profile suitable for investigation and also considering diagnostic accuracy.

  • ultrasound
  • south sudan
  • fash
  • extra-pulmonary tuberculosis
  • infectious diseases

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  • Contributors All individuals listed as authors have contributed substantially to designing, performing or reporting the study, and every specific contribution is indicated as follows: conception and design of the study: CM, FB, FDG, WM; data collection: FB, LN, GA, JK, ML; statistical analysis: CM, LM, AS, WM; interpretation of data: CM, FDG, WM; manuscript writing and drafting: CM, FDG, FB; revision of the manuscript: CM, FDG, FB, LM, GA, JK, LN, AS, WM. All authors read and approved the final manuscript.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Ethics approval The study protocol was submitted to the State Ministry of Health in Juba and to the Local Ministry of Health in Yirol and was approved by the ethical committee of the State Ministry of Health of South Sudan in April 2017 (Authorisation MOH/ERB33/2018). Informed consent was obtained from all participants together with consent for HIV testing.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The data that support the findings of this study are available on demand from the authors upon reasonable request and with permission from Doctors with Africa Cuamm.

  • Patient consent for publication Not required.

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