Diagnosing asymptomatic tuberculosis: current approaches, emerging tools, and persistent challenges

Asymptomatic tuberculosis is a major but incompletely defined manifestation of the tuberculosis disease spectrum and an important challenge for active case finding. It is best understood as a symptom-defined and method-dependent phenotype rather than a uniform biological stage. Individuals classified as asymptomatic may have minimal or extensive radiographic abnormalities, low or intermittent bacillary shedding, or clinically inapparent disease that remains stable, regresses, fluctuates, or progresses. Differences in terminology, symptom ascertainment, population risk and diagnostic intensity have therefore led to substantial variation in how asymptomatic or subclinical tuberculosis is recognized and interpreted across studies and programmes. This Review examines current and emerging approaches for diagnosing asymptomatic tuberculosis, with emphasis on the interaction between epidemiological risk, radiological detectability, microbiological confirmation and longitudinal follow-up. Symptom-based screening and passive case finding miss a substantial proportion of bacteriologically or radiographically evident tuberculosis. Conventional sputum-based testing is constrained by difficulty obtaining specimens, paucibacillary disease, intermittent shedding and imperfect sensitivity. Chest radiography and computer-aided detection can expand screening capacity and standardize triage, but they cannot independently establish disease activity or exclude tuberculosis. Computed tomography and positron emission tomography/computed tomography provide more sensitive characterization in selected settings, although their cost, accessibility and limited specificity preclude routine use. Non-sputum pathogen assays and host biomarkers are promising because they may reduce dependence on spontaneous sputum, but most remain insufficiently validated, and their incremental clinical or programmatic value over imaging-based triage and conventional confirmation remains uncertain. The diagnostic challenge of asymptomatic tuberculosis lies not simply in the absence of symptoms, but in the unstable boundary between infection, early disease, radiological abnormality, microbiological detectability and future risk. Clinical and public health practice should therefore move beyond single-test strategies toward staged, risk-stratified diagnostic pathways that integrate symptom ascertainment, exposure risk, imaging, confirmatory microbiology, enhanced specimen collection and longitudinal reassessment. Such pathways should be viewed as flexible clinical-programmatic frameworks for organizing diagnostic uncertainty, guiding multidisciplinary decisions and generating testable hypotheses, rather than as validated treatment algorithms.