Evaluation of treatment response in extrapulmonary tuberculosis in a low-resource setting

Orbital tuberculosis: a case report and update on the role of imaging in treatment

Orbital tuberculosis is a manifestation of extra-pulmonary tuberculosis that is challenging to diagnose and treat. Here, we describe the pivotal role of serial imaging in the diagnosis and treatment of orbital tuberculosis. A 28-year-old male presented with recurrent right upper eyelid swelling and a supraduction deficit associated with a firm painless orbital mass, seen on initial computed tomography to be an extensive superomedial lesion producing mass effect. Biopsy revealed a tuberculosis-like granulomatous inflammation, which, coupled with a positive QuantiFERON gold test, led to empiric anti-tuberculin treatment. Serial radiologic imaging following initiation of treatment showed progressive reduction in mass size, supporting the diagnosis and determining the length of treatment. This rare case demonstrates the utility of serial radiologic exams in the diagnosis and treatment of orbital tuberculosis.

Identification of host biomarkers from dried blood spots for monitoring treatment response in extrapulmonary tuberculosis

There is a lack of objective tools for monitoring treatment response in extrapulmonary tuberculosis (EPTB). This study aimed to explore the utility of inflammatory biomarkers from the dry blood spots (DBS) as a tool for monitoring treatment response in EPTB. In a prospective cohort study, 40 inflammatory biomarkers were investigated in DBS samples from 105 EPTB cases using a Luminex platform. The samples were taken before, and, at the end of the 2nd and 6th months of treatment. A total of 11 inflammatory host biomarkers changed significantly with treatment in all EPTB patients. CXCL9/MIG, CCL20, CCL23, CXCL10/IP-10, CXCL1, CXCL2, and CXCL8 significantly declined in our cohort of EPTB (48 TB pleuritis and 57 TB lymphadenitis) patients at both time points. A biosignature consisting of MIG, CCL23, and CXCL2, corresponded with the treatment response in 81% of patients in the 2nd month and 79% of patients at the end of treatment. MIG, CCL23, IP-10, and CXCL2 changed significantly with treatment in all patients including those showing partial clinical response at the 2nd month of treatment. The changes in the levels of inflammatory biomarkers in the DBS correspond with the treatment success and can be developed as a routine test in low-resource settings.

Improving diagnosis of tuberculous lymphadenitis by combination of cytomorphology and MPT64 immunostaining on cell blocks from the fine needle aspirates

BACKGROUND

Extra pulmonary tuberculosis (EPTB) constitutes 18% of all tuberculosis (TB) cases and tuberculous lymphadenitis (TBL) constitutes 20-40% of EPTB. Diagnosis of TBL is challenging because of the paucibacillary nature of the disease.

OBJECTIVE

To investigate the diagnostic potential of a new antigen detection test based on the detection of M. tuberculosis complex specific antigen MPT64 from fine needle aspirate (FNA) cytology smears and biopsies obtained from patients with clinically suspected TBL using immunohistochemistry (IHC).

MATERIALS AND METHODS

This study was conducted at Khyber Teaching Hospital and Rehman Medical Institute, Peshawar, Pakistan, from January 2018 to April 2019. Samples, including FNA (n = 100) and biopsies (n = 8), were collected from 100 patients with presumptive TBL. Direct smears and cell blocks were prepared from the FNA samples. All samples were subjected to hematoxylin-eosin (H&E) staining, Ziehl-Neelsen (ZN) staining, and immunostaining with polyclonal anti-MPT64 antibody. The culture was performed only for biopsy specimens. All patients were followed until the completion of anti-TB treatment. The response to treatment was included in the composite reference standard (CRS) and used as the gold standard to validate the diagnostic tests.

RESULTS

The sensitivity, specificity, positive and negative predictive values for ZN staining were 4.4%,100%,100%,56%, for culture were 66%,100%,100%,50%, for cytomorphology were 100%,90.91%,90%,100%, and for immunostaining with anti-MPT64 were all 100%,respectively. The morphology and performance of immunohistochemistry were better with cell blocks than with smears.

CONCLUSION

MPT64 antigen detection test performed better than ZN and cytomorphology in diagnosing TBL. This test applied to cell blocks from FNA is robust, simple, and relatively rapid, and improves the diagnosis of TBL.

Correlation of serum amyloid A1 and interleukin-1beta in response to anti-tubercular therapy

BACKGROUND

Host biomarkers are needed to monitor the response to anti-tubercular therapy (ATT) for ensuring effective therapy and preventing drug-resistant tuberculosis. We sought to find the correlation between the serum levels of SAA1 and IL-1beta in response to ATT in adult patients with pulmonary TB (PTB) or extra-pulmonary TB (EPTB).

METHODS

Blood samples of 32 patients with PTB and 28 patients with EPTB were analyzed. The blood samples were collected at baseline, two months and six months following treatment initiation. SAA1 and IL-1beta levels were measured by enzyme linked immunosorbent assay (ELISA).

RESULTS

In the PTB group, the mean levels of SAA1 decreased significantly (p <0.001) after the intensive phase (two months) and continuous phase (six months) of ATT in comparison with the baseline value. IL-1beta values also decreased significantly (p = 0.005) after the intensive phase (two months) compared with the baseline values. In the EPTB group, there was a significant reduction in the mean serum level of SAA1 (p <0.001) and IL-1beta (p = 0.001) after the intensive phase (two months) in comparison with the baseline value, whereas the reduction at six months was not significant.

CONCLUSIONS

SAA1 and IL-1beta may be useful potential treatment-monitoring biomarkers, especially in the intensive phase of therapy for both PTB and EPTB.

Primary Breast Tuberculosis Mastitis Manifested as Nonhealing Abscess

Primary breast tuberculosis (TB) is a rare extrapulmonary TB mainly affecting young women of childbearing age from endemic countries. Its incidence is increasing in immunocompromised and HIV-infected people and with the emergence of drug-resistant strains of Mycobacterium tuberculosis (MTB). There are no specific clinical signs suggestive of this disease, it often presents as a hard mass or breast abscess. There is an overlap of features with other inflammatory, infectious, benign lesions, fat necrosis and malignant neoplasms of the breast. The detection of MTB remains the gold standard for diagnosis. Several other diagnostic modalities are used, with varying lack of sensitivity and specificity, and with a range of false negatives. A quarter of cases were treated solely on the basis of clinical, imaging or histological suspicion, without confirmation of the diagnosis. Therefore, we report the case of a young Vietnamese woman, presented for a nonhealing breast abscess, and diagnosed with breast TB based on the patient's ethnicity, histological findings, lack of clinical response to conventional antibiotic therapy, and a good clinical response to anti-TB treatment.

A rare presentation of blastomycosis as a multi-focal infection involving the spine, pleura, lungs, and psoas muscles in a Saudi male patient: a case report

Background

Blastomycosis is a disease caused by the fungus Blastomyces—a thermally dimorphic fungus that can cause granulomatous and/or purulent infection.

Case presentation

We report here a case of chronic blastomycosis infection in a 24-year-old male patient from Saudi Arabia who presented with recurrent skin abscesses associated with deep-seated and multilevel paraspinal (dorsal and lumbar) collections and bilateral empyema with pulmonary involvement and bilateral psoas abscesses. The diagnosis was made after a CT-guided pleural biopsy revealed the characteristic histopathological findings of blastomycosis. The patient underwent several drainage procedures and was successfully treated with a long-term course of oral itraconazole.

Conclusions

Chronic blastomycosis may have clinical and radiologic features similar to thoracic tuberculosis or malignant disease. There is no definite clinical symptom of blastomycosis, and thus a high degree of suspicion is required for early diagnosis. This case is a rare form of blastomycosis with chronic multifocal purulent infection and is the second case of blastomycosis reported in Saudi Arabia.

Predictors of slow clinical response and extended treatment in patients with extra-pulmonary tuberculosis in Pakistan, A hospital-based prospective study

The optimal duration of treatment in different forms of extrapulmonary tuberculosis (EPTB) is not clearly defined. This study aimed to identify predictors of slow clinical response and extended anti-TB treatment in EPTB patients. Socio-demographic, clinical, and microbiological characteristics of EPTB patients registered for anti-TB treatment at a tertiary care hospital, were analysed for identification of predictors of extended treatment. A total of 251 patients (137 lymphadenitis, and 114 pleuritis) were included in the analysis. Treatment was extended to more than 6 months in 58/251 (23%) patients. In the multivariate regression analysis, culture-positive EPTB (p = 0.007) [OR (95% CI) = 3.81 (1.43, 10.11)], history of diabetes (p = 0.014) [OR (95% CI) = 25.18 (1.94, 325.83)], smokeless tobacco use (p = 0.002) [OR (95% CI) = 17.69 (2.80, 111.72)], and slow regression of local signs and symptoms after 2 months of treatment (p < 0.001) [OR (95% CI) = 17.09 [(5.79, 50.39)] were seen to be significantly associated with treatment extension. Identification of predictors of extended treatment can help clinical decisions regarding optimal duration of treatment. Further studies are needed to identify subgroups of EPTB patients who can benefit from a shorter or longer treatment regimen.

Magnetic resonance imaging in response assessment of mediastinal tuberculous lymphadenopathy: Going beyond size

Background:

Assessment of response to antitubercular treatment (ATT) in mediastinal tuberculous lymph nodes (LNs) is challenging. Gold standard techniques such as biopsy and culture involve invasive procedures. Radiographic persistence of mediastinal LNs even after completion of ATT poses a treatment dilemma. In this study, we evaluated the changes in signal intensity (SI) and apparent diffusion coefficient (ADC) values of mediastinal LNs on magnetic resonance imaging (MRI), for response assessment to ATT.

Materials and Methods:

After institute ethics approval, a retrospective analysis of MRI images of 22 patients with 55 mediastinal tuberculous LNs was done. Clinically responsive patients of mediastinal tuberculous LNs who underwent chest MRI prior to ATT, or within 1 month of starting ATT, and second MRI performed at least after 2 months of start of the treatment were included. LN size, T1 and T2 signal characteristics (homogenously/heterogeneously and hyperintense or hypointense), T2 and T1 SI ratio, ADC values, and contrast enhancement characteristics were compared. Paired t-test and McNemar test were performed at a significance level of α =0.05.

Results:

Size of LN reduced, but 45 LNs measured >8 mm in second MRI. There was statistically significant decrease in the T2 and T1 SI ratios in second MRI, P = 0.026 and 0.008, respectively. No statistically significant difference was found in ADC values, P = 0.31.

Conclusions:

Decrease in T2 and T1 SI ratios of mediastinal tuberculous LNs can be used as a noninvasive imaging parameter to suggest response to ATT. However, ADC value is not a useful indicator of treatment response.

Hospitalizations and Treatment Outcomes in Patients with Urogenital Tuberculosis in Tashkent, Uzbekistan, 2016-2018

Despite the global shift to ambulatory tuberculosis (TB) care, hospitalizations remain common in Uzbekistan. This study examined the duration and determinants of hospitalizations among adult patients (≥18 years) with urogenital TB (UGTB) treated with first-line anti-TB drugs during 2016–2018 in Tashkent, Uzbekistan. This was a cohort study based on the analysis of health records. Of 142 included patients, 77 (54%) were males, the mean (±standard deviation) age was 40 ± 16 years, and 68 (48%) were laboratory-confirmed. A total of 136 (96%) patients were hospitalized during the intensive phase, and 12 (8%) had hospital admissions during the continuation phase of treatment. The median length of stay (LOS) during treatment was 56 days (Interquartile range: 56–58 days). LOS was associated with history of migration (adjusted incidence rate ratio (aIRR): 0.46, 95% confidence interval (CI): 0.32–0.69, p < 0.001); UGTB-related surgery (aIRR: 1.18, 95% CI: 1.01–1.38, p = 0.045); and hepatitis B comorbidity (aIRR: 3.18, 95% CI: 1.98–5.39, p < 0.001). The treatment success was 94% and it was not associated with the LOS. Hospitalization was almost universal among patients with UGTB in Uzbekistan. Future research should focus on finding out what proportion of hospitalizations were not clinically justified and could have been avoided.

Host biomarkers for monitoring therapeutic response in extrapulmonary tuberculosis

PURPOSE

The aim of this study was to explore the utility of inflammatory biomarkers in the peripheral blood to predict response to treatment in extrapulmonary tuberculosis (EPTB).

METHODS

A Luminex xMAP-based multiplex immunoassay was used to measure 40 inflammatory biomarkers in un-stimulated plasma of 91 EPTB patients (48 lymphadenitis, and 43 pleuritis) before and at 2 and 6 months of treatment.

RESULTS

Overall a significant change was observed in 28 inflammatory biomarkers with treatment in EPTB patients. However, MIG/CXCL9, IP-10/CXCL10, and CCL23 decreased in all patients' groups with successful treatment at both time points. At 2 months, 29/64 (45%) patients responded partially while 35/64 (55%) showed complete regress. Among good responders, a higher number of biomarkers (16/40) reduced significantly as compared to partial responders (1/40). Almost half (14/29) of partial responders required longer treatment than 6 months to achieve satisfactory response. The levels of MIG, IP-10, MIF, CCL22 and CCL23 reduced significantly among 80, 74, 60, 71, 51% good responders, as compared to 52, 52, 52, 59, 52% partial responders, respectively. A biosignature, defined by a significant decrease in any one of these five biomarkers, corresponded with satisfactory response to treatment in 97% patients at 2 month and 99% patients at 6 months of treatment.

CONCLUSION

Change in inflammatory biomarkers correlates with treatment success. A five biomarker biosignature (MIG, IP-10, MIF, CCL22 and CCL23) could be used as an indicator of treatment success.

Clinical features of tuberculous lymphadenitis in a low-incidence country

BACKGROUND

Tuberculous lymphadenitis (TBLA) is the most common extrapulmonary manifestation of tuberculosis (TB) in Denmark. However, the clinical features of patients with TBLA have never been systematically studied in this setting.

METHODS

Patients treated for TBLA in Central Region Denmark from 2007 to 2016 were identified using the national TB surveillance register and The Danish Hospital Patient Registry. Data of clinical characteristics and treatment were extracted from hospital records.

RESULTS

Eighty-three TBLA patients were identified. The median age was 32 years (IQR 23-42); 71 (85.5%) were migrants; 58 (69.9%) presented with cervical lymphadenopathy; and 45 (54.2%) had one or more systemic TB symptom such as fever, chills, night sweats, fatigue, and weight loss. Sixty-five patients had no comorbidities (78.3%). HIV co-infection was seen in five (7.2%) of the 69 who were tested for HIV. Abscesses and/or draining sinuses were noted in 13 (15.7%) patients and 15 (18.1%) had concurrent pulmonary infection. The median time from first hospital contact to treatment initiation was 42 days (IQR 16-82) and admitted patients were hospitalised for a median of 7 days (IQR 3-13.5). For 24 patients (28.9%), lymph node material was not sent for mycobacterial culture and 52 (62.7%) had microbiologically confirmed TB. Treatment outcome was successful for 70 patients (84.3%).

CONCLUSION

In Denmark, TBLA is mainly seen among young and previously healthy migrants presenting with cervical lymphadenopathy and sparse systemic symptoms. The diagnosis is often considerably delayed and not microbiologically verified, implying diagnostic difficulties. Treatment outcome needs to be improved.

Extrapulmonary tuberculosis

Extrapulmonary tuberculosis can be confused with other pathologies because of the variety of symptoms it generates according to the affected organ. So, extrapulmonary tuberculosis must always be taken into account by medical staff within the differential diagnosis. In this paper, a review of the literature on extrapulmonary tuberculosis is carried out with emphasis on the most frequently affected organs.