Focused assessment with sonography for HIV/TB.

We were pleased to read Ahmed et al.’s paper supporting the use of ultrasound in pleural tuberculosis (TB). The diagnosis of TB is often difficult, and in resourcepoor settings, advanced techniques such as GeneXpertR might be unavailable. Extrapulmonary TB can be especially hard to diagnose, and there is increasing evidence that point of care ultrasound (POCUS) might be helpful. In the particular case described, although we agree with the authors that TB was probably the correct diagnosis, POCUS appeared to be limited to lung ultrasound, and the findings of pleural effusion and small consolidation were also consistent with an atypical pneumonia. Anti-TB treatment should be avoided in those who don’t have TB, so to increase the diagnostic yield of POCUS in suspected TB where gold standard methods are unavailable, we would strongly recommend the use of a more comprehensive FASH ultrasound protocol: focused assessment with sonography for HIV/TB. FASH is now a well-established tool in low-resource settings, where TB is often associated with HIV. The protocol employs similar probe positions to the eFAST examination in trauma. The right hepatorenal view assesses free peritoneal fluid, as well as microabscesses in the liver; the left splenorenal view for fluid and focal splenic abscesses; in each case the probe is also moved cephalad a few centimetres to assess for pleural effusion. The pelvic view assesses free fluid. The subxiphoid view looks for pericardial effusion, but the probe is then angled down to identify para-aortic lymph node enlargement. Lung ultrasound examines pleural pathology, pneumothorax or consolidation. Sincerely, Giles Cattermole and Gabin Mbanjumucyo ORCID iD