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Site matters: Extrapulmonary tuberculosis localization patterns and clinical outcomes in the Netherlands, 1993-2022

Frouke A Procee¹, Sabine M Hermans², Frank G J Cobelens³

¹Department of Global Health, Amsterdam University Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands; Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, The Netherlands; Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands; Amsterdam Institute for Immunology and Infectious Diseases, Amsterdam University Medical Center, Amsterdam, The Netherlands.

International Journal of Infectious Diseases : IJID : Official Publication of the International Society for Infectious Diseases

|July 5, 2026

Abstract

Objectives:

Extrapulmonary tuberculosis (EPTB) accounts for a substantial proportion of tuberculosis (TB) diagnoses in low-incidence countries. Comprehensive data on disease localization, associated determinants, and clinical outcomes remain limited. This study aimed to explore anatomical localization, demographic determinants, and clinical outcomes of EPTB in the Netherlands.

Methods:

Using national TB surveillance data (1993-2022), individuals were categorized as having pulmonary TB (PTB), EPTB-only, or combined EPTB+PTB. Determinants of localization, hospitalization, and TB-related mortality were assessed using multinomial and multivariate regression analyses with PTB as the reference category.

Results:

Among 34,048 individuals diagnosed with TB, 14,186 (41.7%) had EPTB-only, 16,382 (48.1%) had PTB, and 3480 (10.2%) had combined EPTB+PTB. The most frequent EPTB localizations were peripheral lymph nodes (30.8%) and pleura (25.8%). Secondary extrapulmonary localizations occurred particularly in the combined EPTB+PTB group. Miliary and meningeal/central nervous system (CNS) TB had the poorest outcomes. Female sex and birth in South Asia or the Horn of Africa were associated with lymph node and intestinal TB. Younger age was associated with primary complex and meningeal/CNS TB, and older age with miliary TB. Hospitalization and mortality risks were highest for meningeal/CNS and miliary TB, and were positively associated with older age, HIV, diabetes, and immunosuppressive medications. Across most EPTB localizations, treatment success remained below the World Health Organization End TB Strategy targets.

Conclusion:

EPTB localization and treatment outcomes in the Netherlands vary by age, sex, and country of birth. Severe and disseminated forms continue to contribute substantially to morbidity and mortality. Recognizing localization-specific patterns can support earlier diagnosis and tailored management to improve EPTB outcomes in low-incidence settings.

Keywords:

Disease localization Extrapulmonary tuberculosis (EPTB)Low-incidence countries Migration and health Treatment outcomes Tuberculosis epidemiology

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