This was a large prospective study over a two-and-a-half year timeframe that enrolled all eligible patients whose tuberculosis screening included bronchoscopy to collect two PBS samples in a tertiary referral center in the country that basically represented the national profile. Globally, the immediate need to control TB is hindered by negative initial diagnostic tests on expectorated sputum and BAL samples in presumptive active pulmonary tuberculosis cases; hence, there are major implications regarding treatment delay and infectious control [3].The prevalence of active tuberculosis in the study population is high but is not surprising amongst those who originate from high-prevalence countries and have abnormal chest radiographs [16,17]. Microbiological confirmation of tuberculosis is highly desirable because it allows for diagnostic certainty and susceptibility-guided therapy [1]. This is particularly critical because the management of drug-resistant Mycobacterium tuberculosis is challenging, especially when the patient is co-infected with HIV [18]. Therefore, the American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) suggest performing post-bronchoscopy sputum examination for AFB smears and Mycobacterium tuberculosis culture for presumptive active pulmonary tuberculosis cases who undergo bronchoscopy [9]. However, this is not routinely requested in practice. A likely explanation for this is the limitation of the data in a few studies with considerable uncertainty and variation in the reported estimated diagnostic yields [8,10,11,19]. In this study, PBS testing allowed for additional confirmation and an improved ability to rule out tuberculosis in a high-prevalence population. However, the tuberculosis diagnostic work-up and screening pathway employed in this study require complex logistics and considerable resources. It is utility and cost-effectiveness vary considerably from one setting to another. Notably, we reported that the addition of AFB smears and Mycobacterium tuberculosis culture to any expectorated sputum or BAL-positive results increased the sensitivity to 81.9%. This is higher than those previously reported in the literature [8,20,21,22]. This higher rate may be explained by the fact that our institute is a tertiary referral center for presumptive active pulmonary tuberculosis cases; hence, there is a higher possibility of obtaining positive TB results. In addition, some studies collected only one PBS sample [21]. Furthermore, it is not clear whether the detection of AFB in PBS necessitates the same isolation precautions as for patients with open pulmonary tuberculosis. However, undergoing bronchoscopy may mobilize mycobacteria-laden, deep bronchial secretions, resulting in the conversion of smear-negative pulmonary TB to positive and potentially infectious [8]. This can be detrimental and have significant implications for public health and infection control. Thus, we advocate respiratory isolation until confirmation of at least one negative acid-fast smear sample post-bronchoscopy, especially when the pre-test probability of pulmonary TB is high, and the patient is still expectorating.Notably, symptoms suggestive of tuberculosis were absent in more than 60% of individuals with confirmed tuberculosis in this study. The denial of symptoms could be due to fear of stigmatization or possible denial of residency application [23]. However, a proportion of these patients may have incipient or subclinical tuberculosis [24]. Intensive screening, including PBS testing, can facilitate early detection and treatment initiation for such clinical entities and, hence, avert disease progression and onward transmission. In contrast to our study, other studies have reported higher PBS smear positivity [8,10,11]. However, it is worth mentioning that most of these studies were not designed to investigate the diagnostic yield of BPS samples for TB. Additionally, the small sample size in these studies casts significant doubt on the acceptance of generalization [10,19,20]. Interestingly, the same yield of BAL and PBS cultures has been reported in HIV patients [25,26]. However, only two patients were HIV-positive in our cohort rendering the conclusion invalid. Interestingly, in one of these two patients, the only exclusive confirmation of active pulmonary TB was reported in PBS AFB culture. This could be of importance as multidrug-resistant TB has been reported to be twice as common in HIV-infected patients [27]. Thus, PBS samples can help determine the early diagnosis and drug susceptibility in this group of patients.To the best of our knowledge, this is the largest study to date to examine the diagnostic yield of PBS as part of a tuberculosis diagnostic work-up [8,12,28]. Our data suggest that PBS sampling can provide a simple and affordable method by which pulmonary TB diagnosis can be further optimized. Moreover, our findings may guide tuberculosis screening and diagnostic pathways in settings where bronchoscopy is readily accessible. However, our findings may have limited generalizability to settings with a high prevalence of tuberculosis. In addition, there is the possibility of selection bias given our center is a referral center for presumptive TB cases and the predomination of South-East Asian patients in our cohort could have confounded the results. Furthermore, in a limited resources center, the increasing cost of further isolation pending the negativity of PBS AFB results may limit the generalizability of the findings.