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Freund O, Hadad Y, Lagziel T, Friedman Regev I, Kleinhendler E, Unterman A, Bar-Shai A, Perluk TM. The Added Value of Bronchoalveolar Lavage for Pulmonary Tuberculosis Diagnosis in High-Risk Hospitalized Patients with Negative Sputum Samples. Adv Respir Med 2023; 92:15-24. [PMID: 38392033 PMCID: PMC10885945 DOI: 10.3390/arm92010003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/30/2023] [Accepted: 12/20/2023] [Indexed: 02/24/2024]
Abstract
Hospitalized patients with a high suspicion of pulmonary tuberculosis (HS-PTB) are isolated until a definite diagnosis can be determined. If doubt remains after negative sputum samples, bronchoscopy with bronchoalveolar lavage (BAL) is often sought. Still, evidence of the added value of BAL in this patient population is scarce. To address this issue, we included consecutive HS-PTB patients with negative sputum samples who underwent BAL between 2017 and 2018. Chest X-rays (CXR) and CT scans were evaluated by a chest radiologist blind to the final diagnosis. Independent predictors for PTB were assessed by multivariate regression, using all positive PTB patients between 2017 and 2019 (by sputum or BAL) as a control group (n = 41). Overall, 42 HS-PTB patients were included (mean age 51 ± 9, 36% female). BAL was a viable diagnostic for PTB in three (7%) cases and for other clinically relevant pathogens in six (14%). Independent predictors for PTB were ≥2 sub-acute symptoms (adjusted OR 3.18, 95% CI 1.04-9.8), CXR upper-lobe consolidation (AOR 8.70, 95% CI 2.5-29), and centrilobular nodules in chest CT (AOR 3.96, 95% CI 1.20-13.0, p = 0.02). In conclusion, bronchoscopy with BAL in hospitalized patients with HS-PTB had a 7% added diagnostic value after negative sputum samples. Our findings highlight specific predictors for PTB diagnosis that could be used in future controlled studies to personalize the diagnostic evaluation.
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Affiliation(s)
- Ophir Freund
- Institute of Pulmonary Medicine, Sourasky Medical Center, Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6423906, Israel; (I.F.R.); (A.B.-S.)
| | - Yitzhac Hadad
- Radiology Department, Sourasky Medical Center, Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6423906, Israel
| | - Tomer Lagziel
- Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Inbal Friedman Regev
- Institute of Pulmonary Medicine, Sourasky Medical Center, Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6423906, Israel; (I.F.R.); (A.B.-S.)
| | - Eyal Kleinhendler
- Institute of Pulmonary Medicine, Sourasky Medical Center, Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6423906, Israel; (I.F.R.); (A.B.-S.)
| | - Avraham Unterman
- Institute of Pulmonary Medicine, Sourasky Medical Center, Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6423906, Israel; (I.F.R.); (A.B.-S.)
| | - Amir Bar-Shai
- Institute of Pulmonary Medicine, Sourasky Medical Center, Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6423906, Israel; (I.F.R.); (A.B.-S.)
| | - Tal Moshe Perluk
- Institute of Pulmonary Medicine, Sourasky Medical Center, Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6423906, Israel; (I.F.R.); (A.B.-S.)
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Sharma M, Broor S, Maheshwari M, Sudan DPS. Comparison of conventional diagnostic methods with molecular method for the diagnosis of pulmonary tuberculosis. Indian J Tuberc 2023; 70:182-189. [PMID: 37100575 DOI: 10.1016/j.ijtb.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 04/24/2022] [Indexed: 04/28/2023]
Abstract
BACKGROUND Tuberculosis remains one of the deadliest communicable diseases. Prompt diagnosis of active tuberculosis cases facilitates timely therapeutic intervention and minimizes the community transmission. Although conventional microscopy has low sensitivity, still it remains the corner stone for the diagnosis of pulmonary tuberculosis in high burden countries like India. On the other hand, Nucleic acid amplification techniques due to their rapidity and sensitivity, not only help in early diagnosis and management of tuberculosis but also curtail the transmission of the disease. This study therefore was aimed at assessing the diagnostic performance of Microscopy by Ziehl Neelsen (ZN) and Auramine Staining (AO) with Gene Xpert/CBNAAT (Cartridge based nucleic acid amplification test) in the diagnosis of Pulmonary Tuberculosis. METHODS A prospective comparative study was done on the sputum samples of 1583 adult patients from November 2018 to May 2020 suspected of having pulmonary tuberculosis as per NTEP criteria visiting the Designated Microscopic Centre of SGT Medical College, Budhera, Gurugram. Each sample was subjected to ZN staining, AO staining, and was run on CBNAAT as per National Tuberculosis Elimination Program (NTEP) guidelines. The sensitivity, specificity, PPV and NPV and Area under the curve of ZN microscopy and Fluorescent Microscopy were calculated taking CBNAAT as reference in absence of culture. RESULTS Out of the 1583 samples studied, 145 (9.15%) and 197 (12.44%) were positive by ZN and AO staining methods respectively. By CBNAAT 246 (15.54%) samples were positive for M. tuberculosis. AO was also able to detect more pauci-bacillary cases than ZN. While CBNAAT detected M. tuberculosis in 49 sputum samples which were missed by both methods of microscopy. On the other hand there were 9 samples which were positive for AFB by both the smear microscopy techniques but M. tuberculosis was not detected by CBNAAT, these were considered as Non-Tuberculous Mycobacteria. Seventeen samples were resistant to rifampicin. CONCLUSION Auramine Staining technique is more sensitive and less time consuming for the diagnosis of pulmonary tuberculosis as compared to the conventional ZN Staining. CBNAAT can be a useful tool for early diagnosis of patients with high clinical suspicion of pulmonary tuberculosis and detecting rifampicin resistance.
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Affiliation(s)
- Monika Sharma
- Department of Microbiology, SGT Medical College, Hospital and Research Institute, SGT University, Budhera, Gurugram, India.
| | | | - Megha Maheshwari
- Department of Microbiology, B Block, Dr Babasaheb Ambedkar Medical College, Rohini, Sector 6, New Delhi, India.
| | - Dharam Pal Singh Sudan
- Department of Pulmonary Medicine, SGT Medical College, Hospital and Research Institute, SGT University, Budhera, Gurugram, India.
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Anandeswari P, Sivaprakasam A, Gangadharan V, Karthiga G. Diagnostic yield of direct smear, concentrated smear, liquid culture, and GeneXpert by sputum induction in smear-negative pulmonary tuberculosis patients. INDIAN JOURNAL OF RESPIRATORY CARE 2022. [DOI: 10.4103/ijrc.ijrc_33_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Das J, Idh N, Sikkeland LIB, Paues J, Lerm M. DNA methylome-based validation of induced sputum as an effective protocol to study lung immunity: construction of a classifier of pulmonary cell types. Epigenetics 2021; 17:882-893. [PMID: 34482796 PMCID: PMC9423833 DOI: 10.1080/15592294.2021.1969499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Flow cytometry is a classical approach used to define cell types in peripheral blood. While DNA methylation signatures have been extensively employed in recent years as an alternative to flow cytometry to define cell populations in peripheral blood, this approach has not been tested in lung-derived samples. Here, we compared bronchoalveolar lavage with a more cost-effective and less invasive technique based on sputum induction and developed a DNA methylome-based algorithm that can be used to deconvolute the cell types in such samples. We analysed the DNA methylome profiles of alveolar macrophages and lymphocytes cells isolated from the pulmonary compartment. The cells were isolated using two different methods, sputum induction and bronchoalveolar lavage. A strong positive correlation between the DNA methylome profiles of cells obtained with the two isolation methods was found. We observed the best correlation of the DNA methylomes when both isolation methods captured cells from the lower parts of the lungs. We also identified unique patterns of CpG methylation in DNA obtained from the two cell populations, which can be used as a signature to discriminate between the alveolar macrophages and lymphocytes by means of open-source algorithms. We validated our findings with external data and obtained results consistent with the previous findings. Our analysis opens up a new possibility to identify different cell populations from lung samples and promotes sputum induction as a tool to study immune cell populations from the lung.
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Affiliation(s)
- Jyotirmoy Das
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences,Linköping University, Linköping, Sweden
| | - Nina Idh
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences,Linköping University, Linköping, Sweden
| | - Liv Ingunn Bjoner Sikkeland
- Department of Respiratory Medicine, Rikshospitalet, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jakob Paues
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences,Linköping University, Linköping, Sweden.,Division of Infectious Diseases, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Maria Lerm
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences,Linköping University, Linköping, Sweden
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Uchiyama S, Ehara J, Hiraoka E. Pulmonary Tuberculosis Coexisting with Lung Adenocarcinoma. Am J Med 2021; 134:e437-e438. [PMID: 33631162 DOI: 10.1016/j.amjmed.2020.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 12/21/2020] [Indexed: 11/26/2022]
Affiliation(s)
| | - Jun Ehara
- Department of Internal Medicine; Department of Pulmonary Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan.
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Brito GMXD, Mafort TT, Ribeiro-Alves M, Reis LVTD, Leung J, Leão RS, Rufino R, Rodrigues LS. Diagnostic performance of the Xpert MTB/RIF assay in BAL fluid samples from patients under clinical suspicion of pulmonary tuberculosis: a tertiary care experience in a high-tuberculosis-burden area. ACTA ACUST UNITED AC 2021; 47:e20200581. [PMID: 34008762 PMCID: PMC8332835 DOI: 10.36416/1806-3756/e20200581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 03/08/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the diagnostic performance of the Xpert MTB/RIF assay, a rapid molecular test for tuberculosis, comparing it with that of AFB staining and culture, in BAL fluid (BALF) samples from patients with clinically suspected pulmonary tuberculosis (PTB) who are sputum smear-negative or produce sputum samples of insufficient quantity. METHODS This was a retrospective study of 140 cases of suspected PTB in patients who were smear-negative or produced insufficient sputum samples and were evaluated at a tertiary teaching hospital in the city of Rio de Janeiro, Brazil. All of the patients underwent fiberoptic bronchoscopy with BAL. The BALF specimens were evaluated by AFB staining, mycobacterial culture, and the Xpert MTB/RIF assay. RESULTS Among the 140 patients, results for all three microbiological examinations were available for 73 (52.1%), of whom 22 tested positive on culture, 17 tested positive on AFB staining, and 20 tested positive on the Xpert MTB/RIF assay. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy for AFB staining were 68.1%, 96.1%, 88.2%, 87.5%, and 87.6%, respectively, compared with 81.8%, 96.1%, 90.0%, 92.4%, and 91.8%, respectively, for the Xpert MTB/RIF assay. The agreement between AFB staining and culture was 82.3% (kappa = 0.46; p < 0.0001), whereas that between the Xpert MTB/RIF assay and culture was 91.8% (kappa = 0.8; p < 0.0001). CONCLUSIONS In BALF samples, the Xpert MTB/RIF assay performs better than do traditional methods, providing a reliable alternative to sputum analysis in suspected cases of PTB. However, the rate of discordant results merits careful consideration.
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Affiliation(s)
- Guilherme Machado Xavier de Brito
- . Laboratório de Imunopatologia, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro - UERJ - Rio de Janeiro (RJ) Brasil
| | - Thiago Thomaz Mafort
- . Disciplina de Pneumologia e Tisiologia, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro - UERJ - Rio de Janeiro (RJ) Brasil
| | - Marcelo Ribeiro-Alves
- . Laboratório de Pesquisas Clínicas em DST/AIDS, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Rio de Janeiro (RJ) Brasil
| | - Larissa Vieira Tavares Dos Reis
- . Disciplina de Pneumologia e Tisiologia, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro - UERJ - Rio de Janeiro (RJ) Brasil
| | - Janaína Leung
- . Disciplina de Pneumologia e Tisiologia, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro - UERJ - Rio de Janeiro (RJ) Brasil
| | - Robson Souza Leão
- . Departamento de Microbiologia, Imunologia e Parasitologia, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro - UERJ - Rio de Janeiro (RJ) Brasil
| | - Rogério Rufino
- . Disciplina de Pneumologia e Tisiologia, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro - UERJ - Rio de Janeiro (RJ) Brasil
| | - Luciana Silva Rodrigues
- . Laboratório de Imunopatologia, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro - UERJ - Rio de Janeiro (RJ) Brasil
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Luo W, Lin Y, Li Z, Wang W, Shi Y. Comparison of sputum induction and bronchoscopy in diagnosis of sputum smear-negative pulmonary tuberculosis: a systemic review and meta-analysis. BMC Pulm Med 2020; 20:146. [PMID: 32450826 PMCID: PMC7249394 DOI: 10.1186/s12890-020-01192-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 05/19/2020] [Indexed: 11/13/2022] Open
Abstract
Background Pulmonary tuberculosis is one of the most common infectious diseases worldwide. Patients with suspected pulmonary tuberculosis with negative smear are recommended to undergo further tests including sputum induction and bronchoscopy. Our study is aimed to compare sputum induction and bronchoscopic specimens in the diagnosis of sputum smear-negative pulmonary tuberculosis. Method PubMed, Web of Science, Cochrane Library and Embase were searched for eligible studies. The pooled sensitivities (SEN), specificities (SPE), positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and 95% confidence intervals (CI) were constructed, and the areas under the curves (AUCs) were calculated. Results Five studies with a total number of 586 cases were included. For mycobacterial culture, the SEN and SPE of sputum induction were 0.72(95% CI, 0.66–0.77) and 1.00(95%CI, 0.99–1.000) respectively, whereas the SEN and SPE of bronchoscopy were 0.70(95%CI, 0.64–0.75) and 1.00(95%CI, 0.99–1.00) respectively. Sputum induction had a similar AUC (0.9564, SE = 0.0749) with bronchoscopy (0.8618, SE = 0.1652) (P = 0.602). For specimen of acid-fast bacilli smear, the SEN and SPE of sputum induction were 0.35(95% CI, 0.29–0.42) and 0.99(95% CI, 0.96–1.00) respectively, whereas the SEN and SPE of bronchoscopy were 0.38(95% CI, 0.32–0.45) and 0.99(95% CI, 0.96–1.00) respectively. There is no statistically significant difference in the AUC for sputum induction (0.6016) compared with bronchoscopy (0.8163) (P = 0.792). Conclusions For the diagnosis of sputum smear-negative pulmonary tuberculosis, the diagnosis yield of sputum induction and bronchoscopy is similar.
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Affiliation(s)
- Wen Luo
- Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Xiamen University, Xiamen, 361001, China
| | - Yihua Lin
- Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Xiamen University, Xiamen, 361001, China
| | - Zhibin Li
- Epidemiology Research Unit, the First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Wanyu Wang
- Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Xiamen University, Xiamen, 361001, China
| | - Yonghong Shi
- Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Xiamen University, Xiamen, 361001, China.
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Patil S, Narwade S, Mirza M. Bronchial Wash Gene Xpert MTB/RIF in Lower Lung Field Tuberculosis: Sensitive, Superior, and Rapid in Comparison with Conventional Diagnostic Techniques. J Transl Int Med 2017; 5:174-181. [PMID: 29085791 PMCID: PMC5655465 DOI: 10.1515/jtim-2017-0030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Lower lung field tuberculosis (LLF TB) is an atypical presentation of tuberculosis (TB). LLF TB is common, and a proportionate number of non-resolving pneumonia cases are diagnosed to have pulmonary TB. MATERIALS AND METHODS The prospective observational study was conducted during June 2013 to December 2015 in the Department of Pulmonary Medicine, MIMSR Medical College, Latur, India; the objective of the study is clinical, microbiological, and radiological presentation of LLF TB and the comparison of yield of conventional diagnostic techniques and bronchoscopy-guided modalities in LLF TB. Additional important objective of the study is to find LLF TB in patients with nonresolving pneumonia (NRP). A total of 2,600 patients with pulmonary TB were included in the study after inclusion and exclusion criteria. Ethical clearance was taken from the ethical committee of the institutional review board. Consent was taken from the patients before inclusion in the study. Statistical analysis was done using chi-square test. RESULTS In the present study, 300 (11.53%) cases of LLF TB of total 2600 pulmonary tuberculosis were included, females constitutes 66.66% (200/300) with mean age of 58.4 ± 11.8 years and males constitutes 33.34% (100/300) with mean age of 56.8 ± 10.6 years. Constitutional symptoms were observed as cough in 93% cases, fever in 83% cases, shortness of breath in 72% cases, anorexia in 91% cases, and weight loss in 84% cases. Radiological assessment of study cases documented the involvement of right lower zone in 84% cases and left lower zone in only 16% cases. In the studied LLF TB cases, 57 cases (20.66%) were diagnosed by routine sputum microscopic examination for acid fast bacilli (AFB) and 80 cases (28%) were diagnosed by induced sputum microscopic examination for AFB. In the study of 170 LLF TB cases, head-to-head comparison between conventional diagnostic techniques (sputum microscopy and Induced sputum microscopy for AFB) made diagnosis in 60 cases, while bronchoscopy-guided sampling techniques (BAL for AFB and BAL for Gene Xpert MTB/RIF) made diagnosis in 155 cases (91.17%) (P < 0.00001). Comorbid conditions such as human immunodeficiency virus (HIV) coinfection in 36 cases (12.00%), Diabetes mellitus in 64 cases (21.33%), and chronic kidney disease (CKD) in 22 cases (7.33%) were observed. Comorbidities were observed in 41.67% of the studied cases and found very significant assessment to have successful treatment outcome (P < 0.00001). In the study of 300 LLF TB cases, 60 cases were having NRP pattern. In LLF TB cases with NRP pattern, bronchoscopy-guided bronchial wash microscopy for AFB made diagnosis in 18 cases (42%), while bronchoscopy-guided BAL for Gene Xpert MTB/RIF made diagnosis in 58 cases (96.66%) (P < 0.00001). CONCLUSION LLF TB is usually underdiagnosed because of diverse clinical and radiological presentation, less diagnostic yield of conventional diagnostic modalities, and these modalities used routinely and universally. Bronchoscopy-guided diagnostic techniques are superior, sensitive, and reliable to confirm LLF TB. Gene Xpert MTB/RIF in bronchial wash samples is found to be best diagnostic modality in evaluating LLF TB and should be used routinely to have successful treatment outcome. A proportionate number of NRP cases are having LLF TB and a high index of suspicion is a must while evaluating these cases.
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Affiliation(s)
- Shital Patil
- Department of Pulmonary Medicine, MIMSR Medical College, Latur, India
| | - Swati Narwade
- Department of Obstetrics & Gynecology, Government Medical College, Latur, India
| | - Mazhar Mirza
- Department of Internal Medicine, MIMSR Medical College, Latur, India
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Lewinsohn DM, Leonard MK, LoBue PA, Cohn DL, Daley CL, Desmond E, Keane J, Lewinsohn DA, Loeffler AM, Mazurek GH, O'Brien RJ, Pai M, Richeldi L, Salfinger M, Shinnick TM, Sterling TR, Warshauer DM, Woods GL. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children. Clin Infect Dis 2016; 64:e1-e33. [PMID: 27932390 DOI: 10.1093/cid/ciw694] [Citation(s) in RCA: 258] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 10/14/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Individuals infected with Mycobacterium tuberculosis (Mtb) may develop symptoms and signs of disease (tuberculosis disease) or may have no clinical evidence of disease (latent tuberculosis infection [LTBI]). Tuberculosis disease is a leading cause of infectious disease morbidity and mortality worldwide, yet many questions related to its diagnosis remain. METHODS A task force supported by the American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America searched, selected, and synthesized relevant evidence. The evidence was then used as the basis for recommendations about the diagnosis of tuberculosis disease and LTBI in adults and children. The recommendations were formulated, written, and graded using the Grading, Recommendations, Assessment, Development and Evaluation (GRADE) approach. RESULTS Twenty-three evidence-based recommendations about diagnostic testing for latent tuberculosis infection, pulmonary tuberculosis, and extrapulmonary tuberculosis are provided. Six of the recommendations are strong, whereas the remaining 17 are conditional. CONCLUSIONS These guidelines are not intended to impose a standard of care. They provide the basis for rational decisions in the diagnosis of tuberculosis in the context of the existing evidence. No guidelines can take into account all of the often compelling unique individual clinical circumstances.
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Affiliation(s)
| | | | - Philip A LoBue
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - David L Cohn
- Denver Public Health Department, Denver, Colorado
| | - Charles L Daley
- National Jewish Health and the University of Colorado Denver, and
| | - Ed Desmond
- California Department of Public Health, Richmond
| | | | | | - Ann M Loeffler
- Francis J. Curry International TB Center, San Francisco, California
| | | | | | - Madhukar Pai
- McGill University and McGill International TB Centre, Montreal, Canada
| | | | | | | | - Timothy R Sterling
- Vanderbilt University School of Medicine, Vanderbilt Institute for Global Health, Nashville, Tennessee
| | | | - Gail L Woods
- University of Arkansas for Medical Sciences, Little Rock
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Caulfield AJ, Wengenack NL. Diagnosis of active tuberculosis disease: From microscopy to molecular techniques. J Clin Tuberc Other Mycobact Dis 2016; 4:33-43. [PMID: 31723686 PMCID: PMC6850262 DOI: 10.1016/j.jctube.2016.05.005] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 05/12/2016] [Accepted: 05/19/2016] [Indexed: 11/03/2022] Open
Abstract
Methods used for the laboratory diagnosis of tuberculosis are continually evolving in order to achieve more rapid, less expensive, and accurate results. Acid-fast staining and culture for mycobacteria remain at the core of any diagnostic algorithm. Following growth in culture, molecular technologies such as nucleic acid hybridization probes, MALDI-TOF MS, and DNA sequencing may be used for definitive species identification. Nucleic acid amplification methods allow for the direct detection of Mycobacterium tuberculosis complex within respiratory specimens without relying on culture growth, leading to more rapid diagnoses and appropriate patient care.
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Affiliation(s)
- Adam J Caulfield
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States
| | - Nancy L Wengenack
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States
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Agrawal M, Bajaj A, Bhatia V, Dutt S. Comparative Study of GeneXpert with ZN Stain and Culture in Samples of Suspected Pulmonary Tuberculosis. J Clin Diagn Res 2016; 10:DC09-12. [PMID: 27437212 DOI: 10.7860/jcdr/2016/18837.7755] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 03/25/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Tuberculosis remains one of the deadliest communicable diseases. There are number of tests available for the diagnosis of tuberculosis but conventional microscopy has low sensitivity and culture although gold standard, but takes longer time for positivity. On the other side, Nucleic acid amplification techniques due to its rapidity and sensitivity not only help in early diagnosis and management of tuberculosis especially in patients with high clinical suspicion like immunocompromised patients, history of contact with active tuberculosis patient etc., but also curtail the transmission of the disease. AIM To evaluate the sensitivity, specificity, positive predictive value and negative predictive value of Nucleic acid amplification assay (GeneXpert) using respiratory samples in patients with suspected pulmonary tuberculosis and compare with AFB smear microscopy (Ziehl Neelsen stain) and Acid Fast Bacilli (AFB) culture. MATERIALS AND METHODS We retrospectively reviewed the respiratory samples of suspected pulmonary tuberculosis (including Bronchoalveolar lavage and sputum) of 170 patients from Jan 2015 to Nov 2015 for ZN stain, culture and GeneXpert (Xpert(®) MTB/Rif assay). The sensitivity, specificity, PPV and NPV of GeneXpert and ZN microscopy were calculated using Liquid culture of Mycobacterium tuberculosis as gold standard. RESULTS A total of 170 patient samples were evaluated in final analysis. Of these, 14 samples were positive by all three methods used in our study. The overall sensitivity, specificity, PPV and NPV of GeneXpert were 86.8%, 93.1%, 78.5% and 96% respectively and for BAL sample, 81.4%, 93.4%, 73.3% and 95.7% respectively. The overall sensitivity and specificity of AFB smear microscopy were 22.2%, % and 78.5% respectively and for BAL sample 22.2% and 100% respectively. For AFB negative samples sensitivity and specificity were 79.1% and 93.1% respectively. CONCLUSION GeneXpert has a higher sensitivity than AFB smear microscopy in respiratory samples. GeneXpert can be a useful tool for early diagnosis of patients with high clinical suspicion of pulmonary tuberculosis. Positive GeneXpert, but culture negative results should be read cautiously and be well correlated with clinical and treatment history of the patient. The other major advantage of Gene Xpert is that it simultaneously detects Rifampicin resistance and especially beneficial in patient with MDR and HIV associated tuberculosis and should be studied further.
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Affiliation(s)
- Monika Agrawal
- Consultant Microbiologist, Department of Microbiology, Oncquest Laboratories Limited , New Delhi, India
| | - Ashish Bajaj
- Junior Consultant Microbiologist, Department of Microbiology, Oncquest Laboratories Limited , New Delhi, India
| | - Vinay Bhatia
- Manager Molecular Biology, Department of Molecular Biology, Oncquest Laboratories Limited , New Delhi, India
| | - Sarjana Dutt
- Director, Department of Molecular Biology and R&D, Oncquest Laboratories Limited , New Delhi, India
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12
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Gopathi NR, Mandava V, Namballa UR, Makala S. A Comparative Study of Induced Sputum and Bronchial Washings in Diagnosing Sputum Smear Negative Pulmonary Tuberculosis. J Clin Diagn Res 2016; 10:OC07-10. [PMID: 27134911 DOI: 10.7860/jcdr/2016/18767.7474] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 02/10/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Tuberculosis is one of the most important public health problem worldwide. Detecting patients with active pulmonary Koch's disease is an important component of tuberculosis control programs. However, at times in patients even with a compatible clinical picture, sputum smears do not reveal acid-fast bacilli and smear-negative pulmonary tuberculosis remains a common problem. AIM The present study is aimed to compare the results of induced sputum and bronchial washings smear in patients suspected to have sputum smear negative pulmonary tuberculosis. MATERIALS AND METHODS A prospective study conducted from August 2014 to July 2015, comprising 120 patients fulfilling study criteria. Patients with respiratory symptoms and chest roentgenogram suspicious of pulmonary tuberculosis with no previous history of anti-tuberculosis treatment and two spontaneous sputum smear samples negative for acid fast bacilli were included. Patients with active haemoptysis and sputum positive were excluded from the study. Sputum induction was done by using 5-10 ml of 3% hypertonic saline through ultrasonic nebulizer taking safety precautions. All the patient underwent fibreoptic bronchoscopy after six hours fasting on the same day. About 20 ml of normal saline instilled into the suspected pathology area and washings were taken with gentle suction. The sample processing and fluorescent staining for acid fast bacilli was done in a designated microscopy lab. RESULTS Out of 120 sputum smear negative pulmonary tuberculosis patients, induced sputum smear examination detected acid fast bacilli in 76 patients (63.3%) and acid fast bacilli detected from bronchial washings in 94 patients (78.3%). Smear positivity was higher in cavitary and infiltrative lesions as compared to consolidation and infrahilar pattern disease. CONCLUSION Even though both induced sputum and bronchial washings procedures were valuable for the diagnosis of sputum smear negative, sputum induction with hypertonic saline should be the initial procedure of choice, which can be repeated twice / thrice in a day or two consecutive days. If the patient still remains induced sputum smear negative and if the clinical probability of tuberculosis is high, starting anti-tuberculosis treatment and closely monitoring patient and reserving bronchoscopy to those patients who do not improve and to exclude alternative diagnosis seems to be a practically useful approach.
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Affiliation(s)
- Nageswar Rao Gopathi
- Assistant Professor, Department of Pulmonology, Katuri Medical College , Guntur, Andhra Pradesh, India
| | - Venu Mandava
- Assistant Professor, Department of Pulmonology, Katuri Medical College , Guntur, Andhra Pradesh, India
| | - Usha Rani Namballa
- Professor, Department of Pulmonology, Andhra Medical College , Visakhapatnam, India
| | - Sravani Makala
- Assistant Professor, Department of Dermatology, Katuri Medical College , Guntur, Andhra Pradesh, India
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Rao GN, Venu M, Rani NU, Sravani M. Induced sputum versus bronchial washings in the diagnosis of sputum negative pulmonary tuberculosis. J Family Med Prim Care 2016; 5:435-439. [PMID: 27843856 PMCID: PMC5084576 DOI: 10.4103/2249-4863.192336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction: Tuberculosis (TB) is one of the most important public health problems worldwide. Detecting patients with active pulmonary TB (PT) is an important component of TB control programs. However, at times in patients even with a compatible clinical picture, sputum smears do not reveal acid-fast bacilli (AFB) and smear-negative PT remains a common problem. This study compares the results of induced sputum (IS) and bronchial washings (BWs) in detecting sputum negative PT. Materials and Methods: A prospective study conducted from June 2014 to June 2015, comprising 120 patients fulfilling study criteria. Patients with respiratory symptoms and chest roentgenogram suspicious of PT with no previous history of antiTB treatment (ATT) and two spontaneous sputum smear samples negative for AFB were included in the study. Patients with active hemoptysis and sputum positive were excluded from the study. Sputum induction was done using 5–10 ml of 3% hypertonic saline through ultrasonic nebulizer taking safety precautions. All the patients underwent fiberoptic bronchoscopy after 6 h fasting on the same day. About 20 ml of normal saline instilled into the suspected pathology area and washings were taken with gentle suction. The sample processing and fluorescent staining for AFB were done in a designated microscopy laboratory. Results: Of 120 smear-negative PT patients, IS smear examination detected AFB in 76 patients (63.3%) and AFB detected from BWs in 94 patients (78.5%). Smear positivity higher in cavitary and infiltrative lesions compared to consolidation and infrahilar pattern disease. Conclusions: Even though both IS and BWs procedures were valuable for the diagnosis of smear-negative TB, sputum induction with hypertonic saline should be the initial procedure of choice, which can be repeated twice/thrice in a day or 2 consecutive days. If the patient remains IS smear-negative and if the clinical probability of TB is high, starting ATT and closely monitoring patient and reserving bronchoscopy to those patients who do not improve and to exclude alternative diagnosis seems to be a practically useful approach.
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Affiliation(s)
- Gopathi Nageswar Rao
- Department of Pulmonology, Government Hospital for Chest and Communicable Diseases, Katuri Medical College, Guntur, Andhra Pradesh, India
| | - Mandava Venu
- Department of Pulmonology, Government Hospital for Chest and Communicable Diseases, Katuri Medical College, Guntur, Andhra Pradesh, India
| | - Namballa Usha Rani
- Department of Pulmonology, Government Hospital for Chest and Communicable Diseases, Katuri Medical College, Guntur, Andhra Pradesh, India
| | - Makala Sravani
- Department of Pulmonology, Government Hospital for Chest and Communicable Diseases, Katuri Medical College, Guntur, Andhra Pradesh, India
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Korkut E, Akcay MN, Karadeniz E, Subasi ID, Gursan N. Granulomatous Mastitis: A Ten-Year Experience at a University Hospital. Eurasian J Med 2015; 47:165-73. [PMID: 26644764 DOI: 10.5152/eurasianjmed.2015.118] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE In this study we aimed to define clinical, radiologic and pathological specialties of patients who applied to General Surgery Department of Atatürk University Medical Faculty with granulomatous mastitis and show medical and surgical treatment results. With the help of this study we will be able to make our own clinical algorithm for diagnosis and treatment. MATERIALS AND METHODS We searched retrospectively addresses, phone numbers and clinical files of 93 patients whom diagnosed granulomatous mastitis between a decade of January 2001 - December 2010. We noted demographic specialties, ages, gender, medical family history, main complaints, physical findings, radiological and laboratory findings, medical treatments, postoperative complications and surgical procedures if they were operated; morbidity, recurrence and success ratios, complications after treatment for patients discussed above. RESULTS In this study we evaluated 93 patients, 91 females and 2 males, with granulomatous mastitis retrospectively who applied to General Surgery Department of Atatürk University Medical Faculty between January 2001 and December 2010. Mean age was 34.4 years. The diagnosis was confirmed by histopathologic examination of the lesions. Seventy three patients had idiopathic granulomatous lobular mastitis and 20 patients had specific granulomatous mastitis IGM (18 tuberculosis mastitis, 1 alveolar echinococcosis and 1 silk reaction). All the patients had surgical debridement or antibiotic, and anti-inflammatory treatment with results bad clinical response before applied our clinic. CONCLUSION Empiric antibiotic therapy and drainage of the breast lesions are not enough for complete remission of idiopathic granulomatous mastitis. The lesion must be excised completely. In selected patients, corticosteroid therapy can be useful. In the patients with tuberculous mastitis, abscess drainage and antituberculous therapy can be useful, but wide excision must be chosen for the patients with recurrent disease.
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Affiliation(s)
- Ercan Korkut
- Department of General Surgery, Atatürk University Faculty of Medicine, Erzurum, Turkey
| | - Mufide Nuran Akcay
- Department of General Surgery, Atatürk University Faculty of Medicine, Erzurum, Turkey
| | - Erdem Karadeniz
- Department of General Surgery, Atatürk University Faculty of Medicine, Erzurum, Turkey
| | - Irmak Durur Subasi
- Department of Radiology, Atatürk University Faculty of Medicine, Erzurum, Turkey
| | - Nesrin Gursan
- Department of Pathology, Atatürk University Faculty of Medicine, Erzurum, Turkey
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Rueda ZV, López L, Marín D, Vélez LA, Arbeláez MP. Sputum induction is a safe procedure to use in prisoners and MGIT is the best culture method to diagnose tuberculosis in prisons: a cohort study. Int J Infect Dis 2015; 33:82-8. [PMID: 25578262 DOI: 10.1016/j.ijid.2015.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 12/04/2014] [Accepted: 01/01/2015] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVES To evaluate the concordance and safety of induced sputum (IS) and spontaneous sputum (SS), and estimate concordance and time to detection of M. tuberculosis between Lowenstein-Jensen (LJ), thin-layer agar (TLA), and the Mycobacteria Growth Indicator Tube system (MGIT). METHODS This was a cohort study. Prisoners with pulmonary tuberculosis (PTB) were followed for 2 years. At baseline and every follow-up visit, three sputum samples were taken on consecutive days (one IS and two SS) and adverse events occurring before, during, and 30 min after IS were registered. All sputum samples were stained with auramine and cultured in LJ, TLA (to test resistance), and MGIT. RESULTS Five hundred eighty-six IS and 532 SS were performed on 64 PTB patients. Breathlessness (1.6%), cough (1.2%), hemoptysis (0.3%), and cyanosis (0.2%) were the only complications. Concordance between IS and SS was 0.78 (95% confidence interval 0.69-0.87); 11 positive cultures from IS samples were negative in SS, and 11 positive cultures from SS samples were negative in IS. One hundred seventy-eight cultures were positive by any technique: MGIT 95%, LJ 73%, and TLA 57%. Time to detection of M. tuberculosis in LJ, TLA, and MGIT was 31, 18, and 11 days, respectively. CONCLUSIONS The IS procedure is safe in prisons. The MGIT system is better and faster than LJ and TLA in the diagnosis of M. tuberculosis.
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Affiliation(s)
- Zulma Vanessa Rueda
- Grupo Investigador de Problemas en Enfermedades Infecciosas, Facultad de Medicina, Calle 62 # 52-59, lab 630, Sede de Investigación Universitaria, Universidad de Antioquia, Medellín, Colombia.
| | - Lucelly López
- Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Diana Marín
- Grupo Demografía y Salud, Facultad Nacional de Salud Pública, Universidad de Antioquia, Medellín, Colombia
| | - Lázaro A Vélez
- Grupo Investigador de Problemas en Enfermedades Infecciosas, Facultad de Medicina, Calle 62 # 52-59, lab 630, Sede de Investigación Universitaria, Universidad de Antioquia, Medellín, Colombia
| | - María Patricia Arbeláez
- Grupo de Epidemiología, Facultad Nacional de Salud Pública, Universidad de Antioquia, Medellín, Colombia
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Geldenhuys HD, Whitelaw A, Tameris MD, Van As D, Luabeya KKA, Mahomed H, Hussey G, Hanekom WA, Hatherill M. A controlled trial of sputum induction and routine collection methods for TB diagnosis in a South African community. Eur J Clin Microbiol Infect Dis 2014; 33:2259-66. [PMID: 25022447 DOI: 10.1007/s10096-014-2198-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 06/27/2014] [Indexed: 01/26/2023]
Abstract
The diagnostic yield of pulmonary tuberculosis (TB) by sputum induction (SI) at the first point of contact with health services, conducted in all patients with suspected TB regardless of the ability to expectorate spontaneously, has not been evaluated. We compared the diagnostic yield of SI to routine sputum collection in a South African community setting. Ambulatory patients with suspected TB provided a 'spot' expectorated sputum sample, an SI sample by hypertonic (5 %) saline nebulization, and early morning expectorated sputum sample. The diagnostic yield of sputum smear microscopy and liquid culture (denominator all subjects with any positive Mycobacterium tuberculosis culture), and time-to-positivity of culture were compared between SI and expectorated samples. A total of 555 subjects completed the SI procedure, of whom 132 (24 %) were human immunodeficiency virus (HIV)-infected. One hundred and twenty-nine samples (129, 23 %) were M. tuberculosis culture-positive. The time-to-positivity of Mycobacteria Growth Indicator Tube (MGIT) culture was shorter for SI (median difference 2 days, p = 0.63) and for early morning expectorated sputum (median difference 2 days, p = 0.02) compared to spot expectorated sputum. However, there was no difference in the culture-positive diagnostic yield between SI and spot expectorated sputum [difference +0.7 %; confidence interval (CI) -7.0 to +8.5 %, p = 0.82] or SI and early morning expectorated sputum (difference +4.7 %; CI -3.2 to +12.5 %, p = 0.20) for all subjects or for HIV-infected subjects. SI reduces the time to positive M. tuberculosis culture, but does not increase the rate of positive culture compared to routine expectorated sputum collection. SI cannot be recommended as the routine collection method at first contact among ambulatory patients with suspected TB in high-burden communities.
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Affiliation(s)
- H D Geldenhuys
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa,
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Seong GM, Lee J, Lee JH, Kim JH, Kim M. Usefulness of sputum induction with hypertonic saline in a real clinical practice for bacteriological yields of active pulmonary tuberculosis. Tuberc Respir Dis (Seoul) 2014; 76:163-8. [PMID: 24851129 PMCID: PMC4021263 DOI: 10.4046/trd.2014.76.4.163] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 01/07/2014] [Accepted: 02/19/2014] [Indexed: 11/24/2022] Open
Abstract
Background Mycobacterial identification in active pulmonary tuberculosis (APTB) is confirmative, even though successful rates using self-expectorated sputum are limited. Sputum specimens collected by hypertonic saline nebulization showed higher bacteriologic diagnostic sensitivities over those of self-expectoration, mostly studied in smear-negative or sputum-scarce patients. The efficacy of induced sputum was rarely assessed in real clinical settings. Methods A prospective randomized case-control study was performed in one hospital. The subjects highly suspicious of APTB were asked to provide 3 pairs of sputum specimens in 3 consecutive days. The first pairs of the specimens were obtained either by self-expectoration (ES) from the next day of the visit or sputum induction with 7% saline nebulization in clinic (SI), and the other specimens were collected in the same way. The samples were tested in microscopy, culture, and polymerase chain reaction (PCR). The outcomes of the bacteriological diagnosis were compared. Results Seventy six patients were assigned to either ES (38 subjects, median age of 51, 65.8% male) or SI (38 subjects, median age of 55, 52.6% male). APTB was clinically confirmed in 51 patients (70.8%), 27 in ES and 24 in SI. Among the APTB, more adequate specimens were collected from SI (41/65, 63.1%) than ES (34/80, 42.5%) (p=0.01). Bacteriological confirmation was achieved in 14 (58.3%) patients in SI, and 13 (48.1%) in ES (p=0.46). In the same-day bacteriological diagnosis with microscopy and PCR, there were positive results for 9 patients (37.5%) in SI and 7 patients (25.9%) in ES (p=0.37). Conclusion Sputum induction improves sputum specimen adequacy. It may be useful for the same-day bacteriological diagnosis with microscopic examination and PCR.
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Affiliation(s)
- Gil Myeong Seong
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Jaechun Lee
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Jong Hoo Lee
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Jeong Hong Kim
- Department of Otorhinolaryngology, Jeju National University School of Medicine, Jeju, Korea
| | - Miok Kim
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
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Abstract
BACKGROUND Endobronchial tuberculosis (EBTB) is a special form of pulmonary tuberculosis. In spite of much progress in the diagnosis of this disease in past years, delayed or mistaken diagnosis is still commonly seen. OBJECTIVE The aim of this study is to try to find out some useful clues for the diagnosis of EBTB, especially the early diagnosis. METHODS The medical records of patients with EBTB were analyzed retrospectively. RESULTS The male-to-female ratio was 1:2.2 out of 22 patients. Patients aged below 60-years-old constituted 72.7% of the cases. 22.7% of these patients were smokers. The male-to-female ratio of smokers was 4:1. 68.2% of these patients tested all showed negative result for the HIV test. The frequent complaints were cough, sputum, shortness of breath and fever, and antibiotic treatments were usually inefficacious. Multiple lobes lesion, exudative shadow and atelectasis were the frequent radiological findings. Acid-fast bacilli staining for sputum smear was positive in only 13.6% of these patients. Tuberculin skin test was positive in 59.1% of these patients. Granular lesion was the most common bronchoscopic appearance in these patients. Histological changes showed distinctive tuberculose lesion in 72.2% of 18 patients undergoing bronchoscopic biopsy. CONCLUSION The diagnosis of EBTB is easily delayed or mistaken because of nonspecific clinical manifestations and the low incidence of positive acid-fast bacilli staining. A high index of awareness of this disease is required for diagnosis. Bronchoscopy should be performed as soon as possible in suspected patients, especially when patients present positive tuberculin skin test or no response to antibiotic treatments.
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Jacomelli M, Silva PRAA, Rodrigues AJ, Demarzo SE, Seicento M, Figueiredo VR. Bronchoscopy for the diagnosis of pulmonary tuberculosis in patients with negative sputum smear microscopy results. J Bras Pneumol 2012; 38:167-73. [PMID: 22576423 DOI: 10.1590/s1806-37132012000200004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 01/01/2012] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate the diagnostic accuracy of bronchoscopy in patients with clinical or radiological suspicion of tuberculosis who were unable to produce sputum or with negative sputum smear microscopy results. METHODS A prospective cross-sectional study involving 286 patients under clinical or radiological suspicion of having pulmonary tuberculosis and submitted to bronchoscopy-BAL and transbronchial biopsy (TBB). The BAL specimens were submitted to direct testing and culture for AFB and fungi, whereas the TBB specimens were submitted to histopathological examination. RESULTS Of the 286 patients studied, 225 (79%) were diagnosed on the basis of bronchoscopic findings, as follows: pulmonary tuberculosis, in 127 (44%); nonspecific chronic inflammation, in 51 (18%); pneumocystis, fungal infections, or nocardiosis, in 20 (7%); bronchiolitis obliterans organizing pneumonia, alveolites, or pneumoconiosis, in 14 (5%); lung or metastatic neoplasms, in 7 (2%); and nontuberculous mycobacterium infections, in 6 (2%). For the diagnosis of tuberculosis, BAL showed a sensitivity and a specificity of 60% and 100%, respectively. Adding the TBB findings significantly increased this sensitivity (to 84%), as did adding the post-bronchoscopy sputum smear microscopy results (total sensitivity, 94%). Minor post-procedure complications occurred in 5.6% of the cases. CONCLUSIONS Bronchoscopy is a reliable method for the diagnosis of pulmonary tuberculosis, with low complication rates. The combination of TBB and BAL increases the sensitivity of the method and facilitates the differential diagnosis with other diseases.
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Affiliation(s)
- Márcia Jacomelli
- Serviço de Endoscopia Respiratória Divisão de Pneumologia Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
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Winetsky DE, Negoescu DM, DeMarchis EH, Almukhamedova O, Dooronbekova A, Pulatov D, Vezhnina N, Owens DK, Goldhaber-Fiebert JD. Screening and rapid molecular diagnosis of tuberculosis in prisons in Russia and Eastern Europe: a cost-effectiveness analysis. PLoS Med 2012; 9:e1001348. [PMID: 23209384 PMCID: PMC3507963 DOI: 10.1371/journal.pmed.1001348] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2011] [Accepted: 10/17/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Prisons of the former Soviet Union (FSU) have high rates of multidrug-resistant tuberculosis (MDR-TB) and are thought to drive general population tuberculosis (TB) epidemics. Effective prison case detection, though employing more expensive technologies, may reduce long-term treatment costs and slow MDR-TB transmission. METHODS AND FINDINGS We developed a dynamic transmission model of TB and drug resistance matched to the epidemiology and costs in FSU prisons. We evaluated eight strategies for TB screening and diagnosis involving, alone or in combination, self-referral, symptom screening, mass miniature radiography (MMR), and sputum PCR with probes for rifampin resistance (Xpert MTB/RIF). Over a 10-y horizon, we projected costs, quality-adjusted life years (QALYs), and TB and MDR-TB prevalence. Using sputum PCR as an annual primary screening tool among the general prison population most effectively reduced overall TB prevalence (from 2.78% to 2.31%) and MDR-TB prevalence (from 0.74% to 0.63%), and cost US$543/QALY for additional QALYs gained compared to MMR screening with sputum PCR reserved for rapid detection of MDR-TB. Adding sputum PCR to the currently used strategy of annual MMR screening was cost-saving over 10 y compared to MMR screening alone, but produced only a modest reduction in MDR-TB prevalence (from 0.74% to 0.69%) and had minimal effect on overall TB prevalence (from 2.78% to 2.74%). Strategies based on symptom screening alone were less effective and more expensive than MMR-based strategies. Study limitations included scarce primary TB time-series data in FSU prisons and uncertainties regarding screening test characteristics. CONCLUSIONS In prisons of the FSU, annual screening of the general inmate population with sputum PCR most effectively reduces TB and MDR-TB prevalence, doing so cost-effectively. If this approach is not feasible, the current strategy of annual MMR is both more effective and less expensive than strategies using self-referral or symptom screening alone, and the addition of sputum PCR for rapid MDR-TB detection may be cost-saving over time.
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Affiliation(s)
- Daniel E. Winetsky
- Stanford University School of Medicine, Stanford, California, United States of America
| | - Diana M. Negoescu
- Department of Management Science and Engineering, Stanford University, Stanford, California, United States of America
| | - Emilia H. DeMarchis
- Stanford University School of Medicine, Stanford, California, United States of America
| | | | | | | | | | - Douglas K. Owens
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, United States of America
- Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University, Stanford, California, United States of America
| | - Jeremy D. Goldhaber-Fiebert
- Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University, Stanford, California, United States of America
- * E-mail:
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Lee JE, Lee BJ, Roh EY, Kim DK, Chung HS, Lee CH. The diagnostic accuracy of tuberculosis real-time polymerase chain reaction analysis of computed tomography-guided bronchial wash samples. Diagn Microbiol Infect Dis 2011; 71:51-6. [PMID: 21795005 DOI: 10.1016/j.diagmicrobio.2010.12.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Revised: 12/14/2010] [Accepted: 12/20/2010] [Indexed: 11/16/2022]
Abstract
We evaluated the diagnostic accuracy of real-time polymerase chain reaction (RT-PCR) analysis of bronchoscopic wash specimens obtained using computed tomography (CT) guidance for diagnosis of pulmonary tuberculosis (TB) patients who were unable to produce sputum samples or were sputum smear-negative. Data from patients who had lesions likely to be pulmonary TB on CT images were analyzed retrospectively. Twenty-seven patients (23.1%) were diagnosed with definite pulmonary TB, and 72 patients (61.5%) were classified as not having TB. The sensitivity, specificity, positive predictive value, and negative predictive value of RT-PCR were 0.78 (95% CI, 0.57-0.91), 0.93 (95% CI, 0.84-0.97), 0.81 (95% CI, 0.60-0.93), and 0.92 (95% CI, 0.82-0.97), respectively. We concluded that most of the sputum-smear negative TB cases could be diagnosed microbiologically or ruled out rapidly and accurately by RT-PCR analysis of bronchial wash fluid.
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Affiliation(s)
- Ji Eun Lee
- Department of Internal Medicine, Armed Forces Capital Hospital, Seongnam-si, Gyeonggi-do, 463-040, Republic of Korea
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Molecular detection and identification of mycobacterium tuberculosis complex and four clinically important nontuberculous mycobacterial species in smear-negative clinical samples by the genotype mycobacteria direct test. J Clin Microbiol 2011; 49:2874-8. [PMID: 21653780 DOI: 10.1128/jcm.00612-11] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Although the sensitivity and specificity of nucleic acid amplification assays are high with smear-positive samples, the sensitivity with smear-negative and extrapulmonary samples for the diagnosis of tuberculosis in suspicious tuberculosis cases still remains to be investigated. This study evaluates the performance of the GenoType Mycobacteria Direct (GTMD) test for rapid molecular detection and identification of the Mycobacterium tuberculosis complex and four clinically important nontuberculous mycobacteria (M. avium, M. intracellulare, M. kansasii, and M. malmoense) in smear-negative samples. A total of 1,570 samples (1,103 bronchial aspiration, 127 sputum, and 340 extrapulmonary samples) were analyzed. When we evaluated the performance criteria in combination with a positive culture result and/or the clinical outcome of the patients, the overall sensitivity, specificity, and positive and negative predictive values were found to be 62.4, 99.5, 95.9, and 93.9%, respectively, whereas they were 63.2, 99.4, 95.7, and 92.8%, respectively, for pulmonary samples and 52.9, 100, 100, and 97.6%, respectively, for extrapulmonary samples. Among the culture-positive samples which had Mycobacterium species detectable by the GTMD test, three samples were identified to be M. intracellulare and one sample was identified to be M. avium. However, five M. intracellulare samples and an M. kansasii sample could not be identified by the molecular test and were found to be negative. The GTMD test has been a reliable, practical, and easy tool for rapid diagnosis of smear-negative pulmonary and extrapulmonary tuberculosis so that effective precautions may be taken and appropriate treatment may be initiated. However, the low sensitivity level should be considered in the differentiation of suspected tuberculosis and some other clinical condition until the culture result is found to be negative and a true picture of the clinical outcome is obtained.
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Xue Q, Wang N, Xue X, Wang J. Endobronchial tuberculosis: an overview. Eur J Clin Microbiol Infect Dis 2011; 30:1039-44. [PMID: 21499709 DOI: 10.1007/s10096-011-1205-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2011] [Accepted: 02/25/2011] [Indexed: 12/30/2022]
Abstract
Endobronchial tuberculosis (EBTB), of which the incidence has been increasing in recent years, is a special type of pulmonary tuberculosis. The endobronchial tuberculose focuses often injure the tracheobronchial wall and lead to tracheobronchial stenosis. The tracheobronchial stenosis may cause intractable tuberculosis and make patients become chronic infection sources of tuberculosis, or may even cause pulmonary complications and result in death. The etiological confirmation of Mycobacterium tuberculosis is most substantial for diagnosis. However, because the positive rate of acid-fast bacillus staining for sputum smears is low and the clinical and radiological findings are usually nondistinctive, the diagnosis of EBTB is often mistaken and delayed. For early diagnosis, a high index of awareness of this disease is required and the bronchoscopy should be performed as soon as possible in suspected patients. The eradication of Mycobacterium tuberculosis and the prevention of tracheobronchial stenosis are two most substantial treatment goals. To get treatment goals, the diagnosis must be established early and aggressive treatments must be performed before the disease progresses too far.
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Affiliation(s)
- Q Xue
- Respiratory Diseases Department , Chinese PLA General Hospital, 28 Fuxing Rd, 100853 Beijing, China
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Kalawat U, Sharma KK, Reddy PNR, Kumar AG. Study of bronchoalveolar lavage in clinically and radiologically suspected cases of pulmonary tuberculosis. Lung India 2010; 27:122-4. [PMID: 20931028 PMCID: PMC2946711 DOI: 10.4103/0970-2113.68307] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
CONTEXT About 30 to 50 % of pulmonary tuberculosis patients have sputum report negative for acid fast bacilli or present with no expectoration. A lot of research is going on to find methods to establish early and accurate diagnosis of pulmonary tuberculosis (PTB) as institutions of early treatment can have significant effects on morbidity and mortality of patients and also the development of MDR-TB. Samples other than sputum play an important role in the diagnosis of disease in such patients. AIMS To assess the significance of bronchoalveolar lavage samples and fiberoptic bronchoscopy (FOB) in the early diagnosis of occult sputum smear negative pulmonary tuberculosis. SETTINGS AND DESIGN Study was conducted in a tertiary care hospital. FOB was performed in patients with three consecutive sputum smear negative acid fast bacilli to obtain bronchoalveolar lavage (BAL) samples. Written informed consent was obtained from these patients. MATERIALS AND METHODS BAL samples were subjected to Z-N staining and culture on L-J slopes for acid fast bacilli. Sputum samples from the same patients were also cultured. RESULTS BAL samples were positive in 82.2% of sputum smear negative samples. Culture positivity of BAL samples was 90.9% as compared to sputum culture positivity which was 26.4%. Overall diagnosis could be established in 86.6% of patients with the help of fiber optic bronchoscopy. CONCLUSIONS BAL samples are very useful in early sputum smear negative pulmonary tuberculosis and FOB can play an important role in diagnosis of lower respiratory tract infections with minimal complications in hands of an expert.
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Affiliation(s)
- Usha Kalawat
- Department of Microbiology, Srivenkateswara Institute of Medical Sciences, Tirupati- 517 507, Andhra Pradesh, India
| | - Krishna K. Sharma
- Department of Microbiology, Srivenkateswara Institute of Medical Sciences, Tirupati- 517 507, Andhra Pradesh, India
| | - Prakash N. R. Reddy
- Department of Microbiology, Srivenkateswara Institute of Medical Sciences, Tirupati- 517 507, Andhra Pradesh, India
| | - A. Gururaj Kumar
- Department of Microbiology, Srivenkateswara Institute of Medical Sciences, Tirupati- 517 507, Andhra Pradesh, India
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Aderaye G, G/Egziabher H, Aseffa A, Worku A, Lindquist L. Comparison of acid-fast stain and culture for Mycobacterium tuberculosis in pre- and post-bronchoscopy sputum and bronchoalveolar lavage in HIV-infected patients with atypical chest X-ray in Ethiopia. Ann Thorac Med 2010; 2:154-7. [PMID: 19727366 PMCID: PMC2732096 DOI: 10.4103/1817-1737.36549] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2007] [Accepted: 07/14/2007] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND: Smear-negative tuberculosis occurs more frequently in human immunodeficiency virus (HIV)-infected patients than in non-HIV-infected patients. Besides, there are substantial numbers of patients who cannot produce sputum, making the diagnosis of pulmonary tuberculosis (PTB) difficult. AIMS: To evaluate the relative yield of pre- and post-bronchoscopy sputum and bronchoalveolar lavage (BAL) in ‘sputum smear’-negative, HIV-positive patients. SETTINGS: A tertiary care referral hospital in Addis Ababa. MATERIALS AND METHODS: Acid-fast stain (AFS) using the concentration technique was done on 85 pre-bronchoscopy sputum and 120 BAL samples. Direct AFS was done on all BAL and 117 post-bronchoscopy sputum samples. Culture for Mycobacterium tuberculosis (MTB) was done for all sputa and BAL. RESULTS: MTB was isolated from 26 (21.7%), 23 (19.7%) and 13 (15.3%) of BAL, post- and pre-bronchoscopy sputum cultures respectively. AFS on pre-bronchoscopy sputum using concentration technique and direct AFS on BAL together detected 11 (41%) of the 27 culture-positive cases. In patients who could produce sputum, the sensitivity of pre-bronchoscopy sputum culture (13/85, 15.3%) was comparable to BAL (12/85, 14%) and post-bronchoscopy sputum (12/85, 14%). In patients who could not produce sputum, however, both BAL (12/35, 40%) and post-bronchoscopy sputum (12/32, 31.4%) detected significantly more patients than those who could produce sputum (P=0.002, P=0.028 respectively). CONCLUSION: In HIV-infected patients, AFS by concentration method on pre-bronchoscopy sputum and direct AFS on BAL in patients who cannot produce sputum are the preferred methods of making a rapid diagnosis. BAL culture seems to add little value in patients who can produce sputum; therefore, bronchoscopy should be deferred under such circumstances.
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Affiliation(s)
- Getachew Aderaye
- Department of Internal Medicine, Medical Faculty, Addis Ababa University, Ethiopia.
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Al-Aghbari N, Al-Sonboli N, Yassin MA, Coulter JBS, Atef Z, Al-Eryani A, Cuevas LE. Multiple sampling in one day to optimize smear microscopy in children with tuberculosis in Yemen. PLoS One 2009; 4:e5140. [PMID: 19357770 PMCID: PMC2663055 DOI: 10.1371/journal.pone.0005140] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Accepted: 03/12/2009] [Indexed: 11/25/2022] Open
Abstract
Background and Aim The diagnosis of pulmonary Tuberculosis (TB) in children is difficult and often requires hospitalization. We explored whether the yield of specimens collected for smear microscopy from different anatomical sites in one visit is comparable to the yield of specimens collected from a single anatomical site over several days. Methodology and Principal Findings Children with signs/symptoms of pulmonary TB attending a reference hospital in Sana'a Yemen underwent one nasopharyngeal aspirate (NPA) the first day of consultation and three gastric aspirates (GA) plus three expectorated/induced sputa over 3 consecutive days. Specimens were examined using smear microscopy (Ziehl-Neelsen) and cultured in solid media (Ogawa). Two hundred and thirteen children (aged 2 months–15 years) were enrolled. One hundred and ninety seven (93%) underwent nasopharyngeal aspirates, 196 (92%) GA, 122 (57%) expectorated sputum and 88 induced sputum. A total 1309 specimens were collected requiring 237 hospitalization days. In total, 29 (13.6%) children were confirmed by culture and 18 (8.5%) by smear microscopy. The NPA identified 10 of the 18 smear-positives; three consecutive GA identified 10 and induced/expectorated sputa identified 13 (6 by induced, 8 by expectorated sputum and one positive by both). In comparison, 22 (3.7%) of 602 specimens obtained the first day were smear-positive and identified 14 (6.6%) smear-positive children. Conclusion/Significance The examination of multiple tests the first day of consultation identified a similar proportion of smear-positive children than specimens collected over several days; would require half the number of tests and significantly less hospitalization. Optimized smear microscopy approaches for children should be explored further.
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Affiliation(s)
| | | | - Mohammed A. Yassin
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- * E-mail:
| | | | - Zayed Atef
- Medical Faculty, Sana'a University, Sana'a, Yemen
| | | | - Luis E. Cuevas
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Comparison of bronchoscopic washing and gastric lavage in the diagnosis of smear-negative pulmonary tuberculosis. South Med J 2009; 102:154-8. [PMID: 19139707 DOI: 10.1097/smj.0b013e318183f90e] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the diagnostic contribution and utility of bacteriologic surveys using bronchoscopic washing and gastric lavage in cases of radiologically suspected tuberculosis with no detectable acid-fast bacilli (AFB) in the sputum. MATERIAL AND METHODS This prospective study performed bronchoscopic lavage following gastric washing in suspected pulmonary tuberculosis patients. The presence of AFB was determined via direct microscopy and materials were cultured in Löwenstein-Jensen medium. RESULTS Thirty-eight consecutive patients were enrolled in the study (30 males and 8 females; mean age, 33.8 +/- 10.9 years). Three patients could not give sputum. In 23 of 35 cases (66%), sputum cultures (SC) were positive. In 17 cases (49%), gastric lavage cultures (GLC) were positive. Eighteen cases (55%) had positive bronchoscopic washing cultures (BWC). No statistically significant difference was observed when SC positivity was compared to GLC and BWC, and no difference was observed when the GLC results were compared with BWC. Tuberculosis was confirmed in 30 of 38 (79%) patients when SC and GLC were evaluated together, in 33 of 38 patients (87%) when SC and BWC were evaluated together, and in 36 of 38 (95%) when SC, GLC, and BWC were evaluated together (P = 0.016, P = 0.002, and P = 0.0001, respectively). The increase in positive cultures was statistically significant when gastric lavage was evaluated together with bronchoscopic washing (P = 0.004). CONCLUSION Adding gastric lavage and bronchial washing to sputum culture could increase culture positivity for M tuberculosis bacilli in suspected pulmonary tuberculosis patients with AFB-negative sputum smears.
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Akçay MN, Sağlam L, Polat P, Erdoğan F, Albayrak Y, Povoskı SP. Mammary tuberculosis -- importance of recognition and differentiation from that of a breast malignancy: report of three cases and review of the literature. World J Surg Oncol 2007; 5:67. [PMID: 17577397 PMCID: PMC1910599 DOI: 10.1186/1477-7819-5-67] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2006] [Accepted: 06/18/2007] [Indexed: 12/29/2022] Open
Abstract
Background While tuberculosis of the breast is an extremely uncommon entity seen in western populations, it accounts for up to 3% of all treatable breast lesions in developing countries. Case presentations We reviewed three female cases of mammary tuberculosis that were diagnosed and treated in Turkey during the same calendar year. All three patients presented with a painful breast mass. In all cases, fine needle aspiration was nondiagnostic for mammary tuberculosis. However, the diagnosis of mammary tuberculosis was confirmed by histopathologic evaluation at the time of open surgical biopsy. All three patients were treated with antituberculous therapy for six months. At the end of the treatment period, each patient appeared to be clinically and radiologically without evidence of residual disease. Conclusion The diagnosis of mammary tuberculosis rests on the appropriate clinical suspicion and the histopathologic findings of the breast lesion. Its recognition and differentiation from that of a breast malignancy is absolutely necessary. Antituberculous chemotherapy, initiated immediately upon diagnosis, forms the mainstay of treatment for mammary tuberculosis.
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Affiliation(s)
- Müfide Nuran Akçay
- Department of General Surgery, Atatürk University Medical Faculty, Erzurum, Turkey
| | - Leyla Sağlam
- Department of Chest Diseases, Atatürk University Medical Faculty, Erzurum, Turkey
| | - Pınar Polat
- Department of Radiology, Atatürk University Medical Faculty, Erzurum, Turkey
| | - Fazlı Erdoğan
- Department of Pathology, Atatürk University Medical Faculty, Erzurum, Turkey
| | - Yavuz Albayrak
- Department of General Surgery, Atatürk University Medical Faculty, Erzurum, Turkey
| | - Stephen P Povoskı
- Department of Division of Surgical Oncology, Department of Surgery, The Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, 43210, USA
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Kantarci M, Karaman B, Basekim CC, Incedayi M, Mutlu H, Sildiroglu O, Yildirim S, Unver S, Kizilkaya E. Unusual Mass-Like Appearance of Tuberculous Osteomyelitis. Clin Nucl Med 2006; 31:154-6. [PMID: 16495736 DOI: 10.1097/01.rlu.0000200784.51834.8a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Mecit Kantarci
- Department of Radiology, GATA Haydarpasa Teaching Hospital, Istanbul, Turkey.
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