Clinical features of tuberculous lymphadenitis in a low-incidence country

Study on the Association Network of Tuberculosis Lesions in Adult Extrapulmonary Tuberculosis in China: A Large-Scale Multicenter Observational Study

Background: Extrapulmonary tuberculosis (EPTB) is a significant health problem which can lead to severe morbidity and mortality. In clinical practice, EPTB can have a variety of nonspecific clinical manifestations and can be concurrent with other types of EPTB. As information pertaining to concurrent EPTB is scarce, research efforts are needed to find concurrent EPTB types and to explore the association networks and rules of concurrent EPTB. Materials and Methods: An observational multicenter study was carried out at 21 hospitals from 15 provinces in China from Jan 1, 2011, to Dec 31, 2017. All the adult EPTB inpatients (≥ 15 years) were included. Multivariable logistic regression analysis was used to examine the associations of gender and age group for concurrent EPTB. The association network and rules for concurrent EPTB were analyzed by the Apriori algorithm. Results: A total of 75,993 adult EPTB inpatients (not including EPTB concurrent with PTB) were included. The ratio of male:female was 1.32. The most common types of EPTB lesions were tuberculous pleurisy (46.47%). In the fully adjusted multivariable logistic regression models, it was found that female EPTB patients (aOR = 1.129, 95% CI: 1.081-1.178) were more likely to have concurrent EPTB. As age increased, the risk of concurrent EPTB decreased (aOR < 1, p value for trend < 0.001). The association network graph showed that almost all the EPTB diseases may be concurrent with other types of EPTB. Ureteric tuberculosis and sacral tuberculosis diseases existed mainly in concurrence with other types of EPTB (about 80%). Tuberculous pleurisy and tuberculous lymphadenitis of the neck could be concurrent with more than 60 other types of EPTB disease. The most common concurrent EPTB types were tuberculous peritonitis concurrent with tuberculous pleurisy (1.64%). Sacral tuberculosis concurrentwith lumbar vertebra tuberculosis had the highest confidence value (68.56%). The strongest association rule was found for vesical tuberculosis concurrent with ureteric tuberculosis (lift = 166.18) and ureteric tuberculosis concurrent with vesical tuberculosis (lift = 166.18). Conclusion: The present study revealed the occurrence of concurrent EPTB types and analyzed the association network and rules among adult EPTB for the first time in a large sample population. Clinicians should be alert to the incidence of concurrent EPTB and that these patients require administration of customized treatment regimens in order to achieve the best outcomes.

Clinical characteristics and diagnostic practices in nontuberculous mycobacterial pulmonary disease: Insights from Denmark

BACKGROUND

Clinical characteristics of patients with nontuberculous mycobacterial pulmonary disease (NTM-PD) in Denmark are undescribed. This study investigated clinical characteristics and diagnostic practices in patients with pulmonary NTM isolates.

METHODS

Patients in Central Region Denmark from 2016 to 2021 were identified using mycobacterial reference laboratory data, and hospital records were reviewed for demographics, comorbidities, risk factors, and diagnostic details. Diagnostic guideline criteria for NTM-PD were assessed, and clinical characteristics were compared between those who met the criteria and those who did not.

RESULTS

Among 193 patients, M. avium complex (56 %), M. gordonae (15 %), and M. xenopi (11 %) were most common. Symptoms included cough (62 %), expectoration (51 %), dyspnea (43 %), and systemic symptoms (42 %), with 36 % experiencing symptoms for over 6 months. The median time from first hospital contact to receipt of the first sample yielding NTM was 14 days (IQR: 42). Forty-five percent (n = 87) of patients were initially seen in a fast-track pulmonary cancer referral pathway. Fifty-three percent (n = 103) met the diagnostic criteria for NTM-PD. This was associated with older age, lower BMI and FEV1, a higher comorbidity burden, longer time to diagnostic sampling, and higher bacterial loads.

CONCLUSIONS

In Denmark, a high percentage of patients met the NTM-PD criteria compared to other studies, which may be attributed to a high prevalence of structural lung disease and delayed disease presentation and diagnosis. Many patients were initially seen in a fast-track pulmonary cancer pathway, which could be leveraged to improve the diagnostic pathway of NTM-PD.

Factors associated with hospitalization and mortality in adult and pediatric extrapulmonary tuberculosis at a tertiary care hospital in Central India

BACKGROUND

Comorbidities complicate the management of tuberculosis (TB) and have become an essential part of the end TB strategy to eradicate TB. However, pulmonary TB has received the most attention, and little is known about the impact of comorbidities and other factors on outcomes in patients with extrapulmonary tuberculosis (EPTB).

OBJECTIVES

Our aim was to analyze the factors associated with hospitalization and mortality in EPTB at a hospital in Central India, using non-TB patients with similar clinical presentations as a comparison.

METHODS

Patients with presumptive EPTB were prospectively enrolled and followed up until the end of treatment or for at least 6 months. Detailed demographic and clinical information was collected for all participants, and patients were categorized as TB or non-TB using a composite reference standard. Multivariate logistic regression was used to analyze the impact of various clinical findings and risk factors on hospitalization and mortality.

RESULTS

A total of 276 patients were categorized as TB cases and 175 as non-TB cases. Factors associated with hospitalization in children were younger age and non-adenitis site of disease. In adults, factors associated with mortality were older age, non-adenitis site of disease and HIV infection regardless of TB diagnosis, while diabetes mellitus increased the odds of mortality in EPTB patients.

CONCLUSION

Our results show that comorbidities increase the odds of death in both TB and non-TB patients in low-resource settings. This argues for a shift away from the traditional vertical management of diseases in these areas and supports a continued focus on building robust healthcare systems.

The Performance of GeneXpert in the Diagnosis of Lymph Node Tuberculosis: A Prospective Study Comparing GeneXpert and Culture Findings

Background and objective Lymph node tuberculosis (LNTB) is a common manifestation of extrapulmonary tuberculosis (EPTB). GeneXpert is a rapid diagnostic molecular test that simultaneously detects tuberculosis and rifampicin (RIF) resistance. In this study, we aimed to assess the epidemiology of LNTB and diagnostic performance parameters of the GeneXpert in routine ENT practice. Methods We conducted a cross-sectional prospective study from January to July 2019, in the Department of Otorhinolaryngology and Head Neck Surgery at the Hassan II University Hospital Center of Fez, Morocco. The samples were collected using lymph node biopsy and subjected to GeneXpert assay, culture, and histopathology. Diagnostic performance parameters of the GeneXpert were calculated and compared with culture. Results All patients with cervical adenopathy were included. Lymph node biopsies were performed for all patients. The performance of the GeneXpert was assessed according to culture findings. Among the 75 cases, the mean age was 21.6 ± 12.7 years with a female predominance (60%). GeneXpert was positive in 66.7% of specimens. The sensitivity and specificity of the GeneXpert assay were 78.6% and 40.4% respectively. GeneXpert accuracy was 54.6%. The positive predictive value (PPV) and negative predictive value (NPV) were found to be 44% (95% CI: 30.2-57.8) and 76% (95% CI: 59.3-92.7) respectively. Mycobacterium bovis was isolated in all samples, with no case of resistance to RIF found. Conclusions The performance of GeneXpert was found to be superior in terms of establishing the diagnosis of LNTB. It offers speedy and prompt results and clinicians should adopt it in routine clinical practice.

Tuberculosis immune reconstitution syndrome (TB-IRIS) followed by recurring lymphadenitis up to 8 years post-antituberculous treatment

We present the case of a patient with HIV and tuberculosis (TB) coinfection who initially developed paradoxical TB immune reconstitution inflammatory syndrome (TB-IRIS) post-antituberculous treatment and post-antiretroviral therapy initiation. Despite being managed effectively, lymphadenitis recurred as many as three times over the course of several years. Due to consistent culture-negative lymph node biopsies, the recurring lymphadenitis was eventually deemed inflammatory rather than microbiological recurrences. Cessation of anti-TB treatment led to symptom remission followed by a long asymptomatic period, corroborating the immunological nature of the episodes. However, 5 and 6 years after cessation of anti-TB treatment, respectively, lymphadenitis returned. In both instances, her symptoms regressed without treatment with anti-TB drugs. This case underscores the complexities of managing TB-IRIS and the necessity of differentiating between paradoxical TB-IRIS and other paradoxical reactions for appropriate treatment decisions. Recognition of such distinctions is crucial in guiding effective therapeutic interventions in TB-HIV coinfection scenarios.

Colliding Challenges: An Analysis of SARS-CoV-2 Infection in Patients with Pulmonary Tuberculosis versus SARS-CoV-2 Infection Alone

Background and Objectives: The concurrent occurrence of tuberculosis and COVID-19 coinfection poses significant clinical complexities, warranting a nuanced approach to diagnosis, management, and patient care. Materials and Methods: A retrospective, cross-sectional study was conducted on two groups: one comprising 32 patients with pulmonary TB (PTB) and COVID-19 co-infection, and one including 100 patients with COVID-19 alone. Data was collected from medical records, including patient history, clinical parameters, laboratory, imaging results, and patient outcome. Results: A lower BMI emerges as a significant marker suggesting underlying PTB in patients with SARS-CoV-2 co-infection. Type 2 diabetes mellitus increases the risk of death in PTB-SARS-CoV-2 co-infection. Co-infected patients show lymphocytopenia and higher neutrophil levels, CRP, transaminases, and D-dimer levels. Elevated CRP and ALT levels are linked to increased co-infection likelihood. Certain parameters like SpO2, CRP, ALT, AST, and D-dimer effectively differentiate between co-infected and COVID-19 patients. Platelet-to-lymphocyte ratio is notably higher in co-infected individuals. Lesion severity on imaging is significantly associated with co-infection, highlighting imaging's diagnostic importance. Longer hospital stays are linked to co-infection but not significantly to death risk. Conclusions: Certain clinical and biological factors may serve as potential indicators of PTB co-infection in patients with SARS-CoV-2.

Pulmonary tuberculosis in an adult presenting with severe hyponatremia: A case report and review of literature

Key Clinical Message

Identifying pulmonary pathology while evaluating electrolyte disorders is crucial for optimal patient management. Physicians working in endemic regions of tuberculosis should consider this pathology as a differential for electrolyte imbalances.

Abstract

Hyponatremia, a common electrolyte imbalance, can arise from various underlying etiologies such as diuretics, diarrhea, vomiting, congestive heart failure, and liver and renal disease. We present a case report of a 74-year-old man highlighting the association between pulmonary tuberculosis (TB) and the development of hyponatremia. GeneXpert assay of the patient's sputum sample led to the identification of underlying active pulmonary TB as the cause of hyponatremia. The patient was started on anti-TB therapy, and concurrent fluid restriction and sodium supplementation were initiated to correct the electrolyte imbalance. Over the next 3 days, the patient demonstrated clinical improvement with the resolution of hyponatremia. This case also highlights the importance of considering TB as a potential etiology in patients presenting with hyponatremia, especially in endemic areas. Further research is warranted to explore the mechanistic pathways linking pulmonary TB and hyponatremia, aiding in the development of targeted therapeutic interventions.

Clinical characteristics and outcome of Tuberculosis lymphadenitis in a tertiary center from Saudi Arabia

Introduction

Tuberculosis is among the deadliest infectious diseases. Lymphadenitis is an inflammation of the lymph nodes which is the most common extrapulmonary manifestation of tuberculosis. Saudi Arabia is rated as a country with a low incidence of tuberculosis. The study's objective is to describe the clinical characteristics and outcome of TB lymphadenitis (TBL) at a large tertiary care center in Riyadh, Saudi Arabia.

Method

All patients 18 years and older diagnosed with TB lymphadenitis between 2010 and 2021 at a single tertiary center in Riyadh, Saudi Arabia, were reviewed retrospectively for their clinical presentation, diagnostic yield, therapy, and outcome.

Result

107 patients were included in the final analysis. The distribution of males and females were nearly equal, at 50.5 % and 49.5 %, respectively. The average age was 45. During the ten-year period of our investigation, the number of confirmed TBL ranged from 19 (the highest in 2010) to as little as one patient in 2021. 72.8 percent of patients presented with TBL affecting the neck. The most commonly used diagnostic method was histopathological examination of the tissue sample, granulomatous inflammations were found in 89.2 % of cases of theses necrotizing granuloma. 10.7 % of our isolates had resistance. The average duration of anti-TB treatment was 6.8 months with a cure rate of 72.9 %.

Conclusion

The majority of patients in this study had cervical lymphadenopathy, with histopathology being the mainstay of diagnosis. 90 % of TBL cultures were susceptible to first-line anti-TB therapy.

Comparative Diagnostic of Cervical Tuberculous Lymphadenitis: PCR is a Fast, Efficient, and Improved Diagnostic Approach

METHODS

The study included 100 clinically suspected cases of TBLN. Fine needle aspirate (FNA) samples were processed for cytology staining and cultured on LJ & BACTEC 12B media. The biochemical tests were performed to identify the isolates at the species level. Additionally, for PCR, DNA was extracted and used for the diagnosis and identification of mycobacterial species.

RESULTS

Patients ranged from 2 to 45 years with a mean age of 24.96 ± 9.10 years. Out of 100 patients, 73% had clinical symptoms of weight loss, followed by fever (72%), anorexia (66%), and night sweats (58%). 24% of patients were found to be smear-positive after Ziehl-Neelsen (ZN) staining and statistically highly significant with PCR. On LJ medium 34% and on BACTEC radiometric 45% of samples were smearing positive. Overall, 48% of cases were PCR-positive for TBLN. When compared with culture, the sensitivity and specificity of PCR were 93.75% and 100%, respectively, which are higher than cytology. The true positive predictive value (PPV) and negative predictive value (NPV) were 83.3% and 61.5%, respectively.

CONCLUSION

This study suggests that PCR is a rapid, sensitive, and specific tool for correct diagnosis of TBLN cases as compared to staining and culture which lead to the early and proper management of mycobacterial diseases.

Clinico-epidemiologic Considerations in the Diagnosis of Tuberculous Lymphadenitis: Evidence from a high burden country

Tuberculosis is the biggest global health issue, tuberculous lymphadenopathy (TBL) being its commonest extra-pulmonary manifestation. Clinical diagnoses of TBL often pose challenges,thus this study aimed to analyze the clinical, epidemiologic and laboratory aspects of TBL in Debre Markos Specialized Comprehensive Hospital (DMSCH), North-west Ethiopia.

METHODS

The study was conducted at DMSCH, from October 2019 to March 2021. Patients with lymphadenopathy displaying cytomorphologic features of TB were enrolled. Checklist was used to collect clinico-demographic data.

RESULTS

Among a total of 294 TBL patients, majority 237 (80.61%) were adults aged 15-45 years. A fluctuant consistency 177 (60.20%; n=294) with predominant involvement of cervical lymph nodes 229 (77.8%) was the most frequent presentation. Most patients did not have either HIV infection 235 (94.37%; n=261) or known chronic medical illnesses 250(95.8%). Constitutional symptoms 113 (41.85%; n=270) and chronic cough 56 (20.74%; n=270) were infrequent. Erythrocyte Sedimentation Rate (ESR) raised in majority 133 (80%; n=165), of whom, extreme elevation (≥ 100mm/hr) seen in 63 (38.18 %).

CONCLUSION

TBL typically present as a fluctuant neck mass, predominantly in adults. Majority patients have no constitutional symptoms or cough. HIV infection or chronic medical illnesses are uncommon. Raised ESR is a fairly consistent finding.

Parotid Gland Tuberculosis: A Case Report and Literature Review

Tuberculosis (TB) is an infection caused by Mycobacterium tuberculosis that primarily affects the lungs. Although TB can affect many organs, involvement of the head and neck is extremely rare and involvement of the salivary glands is even rarer. Clinical diagnosis is challenging and may be misdiagnosed, as it mimics neoplasms on physical exams and imaging. In this paper, we present a case of parotid tuberculosis in a 28-year-old man who presented with a painful left parotid mass, loss of appetite, fever, and weight loss for six months. Suspicion of infection arose, and treatment began with intravenous antibiotics, followed by oral antibiotics, with no improvement. A biopsy of the patient's left parotid gland was performed, and a diagnosis of parotid TB with jaw osteomyelitis due to Mycobacterium tuberculosis infection was made. The patient was started on isoniazid for one week, followed by isoniazid, ethambutol, and rifampicin for six months. Follow-up after six months showed full resolution of the swelling.

Delayed Tuberculosis Treatment and Cost of Care in a Low-Incidence Country

Background

Tuberculosis (TB) elimination requires high-quality, timely care. In countries with a low incidence of TB, such as Ireland, delayed diagnosis is common. This evaluation aimed to determine the factors that predict patient-related and health care provider–related delays in TB management and to establish how TB care cost is affected by care delays.

Methods

Health care records of patients with signs and symptoms of TB evaluated by a tertiary service in Ireland between July 1, 2018, and December 31, 2019, were reviewed to measure and determine predictors of patient-related delays, health care provider–related delays, and the cost of TB care. Outcomes were compared against benchmarks derived from the literature.

Results

Thirty-seven patients were diagnosed with TB, and 51% (19/37) had pulmonary TB (PTB). The median patient-related delay was 60 days among those with PTB, greater than the benchmark derived from the literature (38 days). The median health care provider–related delay among patients with PTB was 16 days and, although similar to the benchmark (median, 22 days; minimum, 11 days; maximum, 36 days), could be improved. The health care provider–related delay among patients with EPTB was 66 days, greater than the benchmark (42 days). The cost of care was €8298 and, while similar to that reported in the literature (median, €9319; minimum, €6486; maximum, €14 750), could be improved. Patient-related delays among those with PTB predicted care costs.

Conclusions

Patient-related and health care provider–related delays in TB diagnosis in Ireland must be reduced. Initiatives to do so should be resourced.

Mycobacterium tuberculosis and SARS-CoV-2 Coinfections: A Review

BACKGROUND

Tuberculosis (TB) is still one of the most important causes of death worldwide. The lack of timely attention on TB diagnosis and treatment during the coronavirus disease 2019 (COVID-19) pandemic is a potential threat to health issues and may have severe consequences for patients and health systems. There is not much information on the management of TB during this period. Here, we reviewed the current literature to evaluate the rate of Mycobacterium tuberculosis and severe acute respiratory syndrome coronavirus 2 coinfections and interactions between these infectious agents.

METHODS

Several databases, including Web of Science, Scopus, and MEDLINE (via PubMed), were searched for original articles addressing TB and COVID-19 diseases published from December 2019 to April 2021.

RESULTS

Of 3,879 articles, 57 articles were included in this study, and among 106,033 patients affected by COVID-19, 891 also had TB. Overall, investigators found a consistent increase in C-reactive protein, D-dimer (especially in patients with severe clinical manifestation), erythrocyte sedimentation rate, lactate dehydrogenase, alanine aminotransferase, and a reduction of lymphocytes. The respiratory symptoms of TB/COVID-19 patients were similar to those of TB patients, but the risk of developing pulmonary TB increased in COVID-19 patients. Also, the mortality rate in TB/COVID-19 patients was higher than that in patients affected only by COVID-19 or TB.

CONCLUSION

Some reports indicated worsening respiratory symptoms and even activation of latent TB after COVID-19 or vice versa. It seems that both active and previously treated TB constituted a risk factor for COVID-19 in terms of severity and mortality, regardless of other underlying diseases and patient status. Health systems should not neglect TB during this era of the ongoing COVID-19 pandemic by setting up appropriate diagnostic and clinical management algorithms.

TB Antigen-Stimulated CXCR3 Ligand Assay for Diagnosis of Tuberculous Lymphadenitis

The diagnosis of tuberculous lymphadenitis (TB-LAP) is challenging. We evaluated the role of blood CXC chemokine receptor 3 (CXCR3) ligands in its diagnosis. A total of 65 lymphadenopathy patients were enrolled and lymph node sampling was performed. We also recruited 113 control subjects, consisting of 27 with positive results and 86 with negative results, in the interferon (IFN)-γ release assay (IGRA). In all study subjects, whole-blood samples were collected using the IGRA methodology. After incubation, plasma levels of IFN-γ and two CXCR3 ligands, IFN-inducible T-cell a chemoattractant (I-TAC) and monokine induced by IFN-γ (MIG), were measured using immunoassay. Fifty-three TB-LAP patients were enrolled. TB antigen-stimulated IFN-γ, I-TAC, and MIG levels were all significantly higher in the TB-LAP patients than in the controls and non-TB-LAP patients. The levels of I-TAC and MIG, but not IFN-γ, showed significant differences between the TB-LAP patients and IGRA-positive controls. Area under the receiver operating characteristic curves (AUROCs) of IFN-γ, I-TAC, and MIG were 0.955, 0.958, and 0.959, respectively, for differentiating TB-LAP from control group, and were 0.912, 0.956, and 0.936, respectively, for differentiating TB-LAP from non-TB-LAP. In conclusion, the TB antigen-stimulated MIG and I-TAC could be useful biomarkers in the diagnosis of TB-LAP.