Treatment outcomes and risk factors of extra-pulmonary tuberculosis in patients with co-morbidities

Distinct Clinical Features of Extrapulmonary and Disseminated Tuberculosis in HIV- and Non-HIV-Associated Immunosuppression: A Retrospective Cohort Study

Background

There is scarce information regarding the clinical differences between extrapulmonary and disseminated tuberculosis (TB) in patients with different types of immunosuppression. We aimed to compare the clinical characteristics and outcomes of extrapulmonary and disseminated TB in patients with non-human immunodeficiency virus (HIV)-associated and HIV-associated immunocompromise.

Methods

In this retrospective cohort study, we included immunocompromised adults with extrapulmonary or disseminated TB in a referral center in Mexico City from January 2000 to December 2023. We compared clinical characteristics, treatments, and death. Multivariate logistic regression analysis for death-related characteristics and Kaplan-Meier survival estimates were performed.

Results

We included 180 patients: 81 with non-HIV-associated and 99 with HIV-associated immunosuppression (CD4+ <200 cells/µL). Most were male (62%), with a median age of 34 (interquartile range, 29-47) years. Among all patients, 55% had HIV infection and 33% had autoimmune disease. Disseminated disease was more frequent in the HIV group (80% vs 63%, P = .02). Infections by Mycobacterium bovis were more prevalent in the non-HIV group (54% vs 36%, P = .02). Death occurred in 23% of cases. Factors related to death (odds ratio [95% confidence interval]) were age ( 1.05 [1.01-1.10]), unemployment (31.62 [1.65-605.18]), tobacco use (4.21 [1.03-17.21]), disseminated disease (6.13 [1.24-30.35]), and central nervous system (CNS) involvement (10.10 [1.91-53.53]) in the non-HIV group, and malignancy (33.82 [2.37-483.33]) and intensive care unit admission (7.26 [1.93-27.29]) in the HIV group.

Conclusions

Disseminated TB was more frequent in the HIV group. Factors associated with mortality differed, highlighting CNS involvement in the non-HIV group and malignancy in the HIV group.

Prevalence of extrapulmonary tuberculosis and factors influencing successful treatment outcomes among notified cases in South India

Tuberculosis (TB) remains a significant public health issue globally, with extra pulmonary tuberculosis (epTB) accounting for a considerable number of TB cases. This study aims to improve our understanding of epTB epidemiology by evaluating treatment outcomes and identifying factors associated with positive and negative treatment results in epTB patients. A retrospective study was conducted from January 1, 2016, to December 31, 2019. EpTB and rifampicin-resistant epTB were identified using the GeneXpert MTB/RIF assay. Logistic regression analysis was performed to determine the associated risk factors. Among the 4,526 patients with extra pulmonary tuberculosis, the positivity rate of Mycobacteriuum tuberculosis among the epTB was 16.5%, and the rate of rifampicin-resistant epTB was 4.83%. Most of patients had lymphadenitis TB (n = 348, 38.79%), followed by those with pus (n = 241, 31.95%). Of 746 epTB cases, 679 patients (91.02%) achieved successful treatment outcomes. Of the 36 patients with rifampicin-resistant epTB, 30 (83.3%) exhibited successful treatment outcomes. Tuberculous peritonitis (OR: 1.58), aspirate (OR: 1.59), gastric lavage (OR: 1.45), biopsy (OR: 1.73), Tuberculosis meningitis (TBM) (OR: 1.46), and tissue samples (OR: 3.33) were all significantly associated with unfavourable treatment outcomes. Patients with extrapulmonary tuberculosis (epTB) aged between 35 and 44 had a significantly higher likelihood of experiencing unsuccessful outcomes (OR = 1.79; 95% CI: 0.74-4.31, p = 0.0912). Additionally, individuals with a history of alcohol use showed a higher likelihood of poor outcomes (OR = 1.90; 95% CI: 0.25-14.42). Moreover, tuberculosis patients who used tobacco also had an increased likelihood of unfavourable treatment outcomes (OR = 2.62; 95% CI: 0.35-19.68).The study indicated that the rate of favourable treatment outcomes among epTB patients surpassed the World Health Organization's target of ≥ 90%. However, a significant number of patients were lost to follow-up during treatment.

Risk Factors for Extrapulmonary Tuberculosis Among US Veterans, 1990-2022

Purpose

To determine factors that put US veterans with active tuberculosis at risk for extrapulmonary tuberculosis (EPTB) compared with pulmonary tuberculosis.

Methods

We included veterans with laboratory-confirmed tuberculosis from 1990-2022 in our retrospective cohort study. Multivariable logistic regression was used to estimate the association of demographic and clinical risk factors with EPTB.

Results

Of 7493 veterans aged 20-100 years (median, 58 years) with laboratory-confirmed tuberculosis, 1397 (19%) had EPTB. The most common EPTB infection among veterans was pleural (31.4%), while meningitis carried the highest mortality risk at 90 days. Factors independently associated with EPTB among veterans were non-Hispanic black race/ethnicity, diabetes mellitus, human immunodeficiency virus infection, severe kidney disease, and all-cause mortality within 90 days after tuberculosis diagnosis.

Conclusions

Our study demonstrated several risk factors for EPTB among US veterans. Healthcare providers should be educated regarding patient populations at risk for EPTB, especially given the challenges in diagnosing this disease and the importance of instituting early treatment to prevent severe illness and death.

Interferon-gamma release assays as a tool for differential diagnosis of gastrointestinal tuberculosis

In this editorial, we comment on an article published in a recent issue of the World Journal of Clinical Cases. There is a pressing need for reliable tools for diagnosing tuberculosis (TB) of the gastrointestinal tract. Despite advancements in the diagnosis and treatment, TB remains a global health challenge. Ali et al demonstrated that TB may mimic gastrointestinal conditions, such as gastric outlet obstruction, causing a delay in the diagnosis. Furthermore, the latter complication is frequently observed during infections, including Helicobacter pylori, and rarely is related to TB, as in the presented case. In line with this, we think that laboratory tests based on interferon-gamma release assays can be a helpful tool for diagnosing latent TB paced in the gastrointestinal tract. Innovative strategies and approaches for diagnosing latent/active extra pulmonary TB are crucial for establishing the diagnosis early and enhancing treatment strategies to mitigate the global burden of TB.

Factors Associated With Extrapulmonary Tuberculosis in Southeastern Mexico: A Case-Control Study

INTRODUCTION

Extrapulmonary tuberculosis (EPTB) is a disease that can affect any organ or tissue. Due to its potential to cause more dangerous sequelae and the barriers to its timely diagnosis, greater clinical awareness of this disease is crucial. This study aimed to identify the factors associated with EPTB in the population of Oaxaca, Mexico.

METHODS

This is an unpaired case-control study. The cases were patients with EPTB+ while the controls were patients with pulmonary tuberculosis (PTB+) registered in the Tuberculosis Epidemiological Surveillance System. Sociodemographic, clinical, and microbiological variables were recovered. Bivariate analyses were performed and logistic regression analyses were performed to calculate the odds ratio (OR).

RESULTS

A total of 75 EPTB+ cases and 300 PTB+ controls were included. Of the total sample, 57.1% were men and 60.3% indigenous. The most frequent clinical presentations of EPTB+ were nodal (21.3%), miliary (21.3%), and breast (20.0%). According to logistic regression analysis, age <40 years (OR: 2.25 (95% CI: 1.13-4.49), female sex (OR: 1.92 (95% CI: 1.03-3.56)], urban residence (OR: 2.25 (95% CI: 1.11-4.55)), comorbidity with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (OR: 3.46 (95% CI: 1.31-9.10)), dyspnea (OR: 2.67 (1.22-5.82)), and adenopathy (OR: 3.38 (95% CI: 1.42-8.06)) were positively associated with EPTB+.

CONCLUSION

These results can serve as a basis for screening EPTB+, thus improving the preventive and diagnostic capacity of local health services, taking as a starting point women under 40 years of age and patients with HIV/AIDS in urban areas, as well as the presence of adenopathy and dyspnea as clinical characteristics of the disease.

Novelty of Physiotherapy Protocols in a Classic Case of Extrapulmonary Tuberculosis in a 35-Year-Old Male Patient: A Case Report

Tuberculosis is the most frequent cause of death, specifically caused by a single infectious agent, Mycobacterium tuberculosis. There are two types of tuberculosis: pulmonary tuberculosis and extrapulmonary tuberculosis. Patients with extrapulmonary tuberculosis often have reduced lung function due to the disease's structural abnormalities, which also significantly impair their quality of life. The suggested standard of care for the treatment of extrapulmonary tuberculosis patients is pulmonary rehabilitation. A 35-year-old male patient who complained of shortness of breath, dry cough, and on-and-off fever diagnose with extrapulmonary tuberculosis was the subject of the case study. The patient had extrapulmonary tuberculosis with a history of pleural effusion, which was managed with proper medications. After increasing symptoms of the disease, the patient was referred for pulmonary rehabilitation. Physiotherapy protocol includes breathing exercises, relaxation techniques, and mobility exercises for the upper limb and lower limb. Effective physical rehabilitation was necessary to minimize complications and allow him to resume daily activities. Several outcome measures, like the dyspnea scale, visual analog scale, six-minute walk test, and World Health Organization-Quality of Life (WHO-QOL) questionnaire, were used to monitor the patient's progress during rehabilitation. The benefits of physiotherapy protocols emphasize the need for tailored approaches to addressing individual patient needs for comprehensive recovery as it significantly enhances clinical, physical, psychosocial, and overall quality of life, making it crucial for patients with extrapulmonary tuberculosis. The protocols are beneficial to improve exercise capacity, muscle force, symptoms such as dyspnea, cough, and health-related quality of life in these patients. In this study, the focus was more on breathing exercises such as segmental breathing exercises for lung expansion and increasing air entry in the lungs followed by improving functional capacity and strength.

Epidemiology of extrapulmonary tuberculosis in Brunei Darussalam: a retrospective cohort study

OBJECTIVES

We reported the incidence and associated factors of extrapulmonary tuberculosis (EPTB).

DESIGN

A retrospective cohort study.

SETTING

Brunei Darussalam, an intermediate tuberculosis (TB)-burden country with stagnating annual TB rates.

PARTICIPANTS

All active TB cases identified in the country between January 2001 and December 2018 (18 years).

PRIMARY AND SECONDARY OUTCOME MEASURES

Annual proportions of EPTB (overall and specific) were calculated. Multiple logistic regression was done to investigate factors associated with developing EPTB, when compared with pulmonary TB (PTB). Χ2 trend test was used to determine any trends during the 18-year study period.

RESULTS

We identified 3916 TB cases, among which 743 (19.0%) were EPTB cases. Lymphatic (44.8%) and pleural (19.4%) EPTB were most common. The main modes of diagnosis were tissue biopsy (73.6%) and radiological assessment (18.3%). Treatment success and mortality rate were 79.7% and 7.0%, respectively. Associations with specific EPTB types varies with age-group and gender. Younger age-group (adjusted OR (aOR)≥1.94) and women (aOR: 2.45 (95% CI: 1.94 to 3.11)) had higher adjusted odds of developing lymphatic EPTB, but had lower adjusted odds of developing pleural EPTB (younger age-group (aOR≤0.54) and women (aOR: 0.41 (95% CI: 0.17 to 0.90)). When compared to foreign residents, locals had higher adjusted odds of skeletal (aOR: 4.44 (95% CI: 2.04 to 11.69)), gastrointestinal (aOR: 3.91 (95% CI: 1.84 to 9.66)) and other types of EPTB (aOR: 3.42 (95% CI: 1.53 to 9.14)). No significant trend differences were observed for overall and specific EPTB types.

CONCLUSION

Despite being generally non-infectious and less recognised than PTB, understanding EPTB epidemiology is important as it also contributes to the overall TB burden in a country. Examining EPTB cases by their specific anatomical site would provide more information on risk factors. Raising public awareness on the EPTB symptoms and that TB affects lungs and other parts of the body could promote early health seeking behaviour and early EPTB diagnosis.

Epidemiology of extrapulmonary tuberculosis in central Guangxi from 2016 to 2021

The burden of extrapulmonary tuberculosis (EPTB) has gradually increased in recent years, but not enough epidemiological data is available from central Guangxi. To better understand the epidemiology of EPTB in central Guangxi and identify risk factors associated with them, we retrospectively investigated the epidemiology of tuberculosis (TB), especially EPTB, among patients admitted to the Chest Hospital of Guangxi Zhuang Autonomous Region between 2016 and 2021. We excluded those infected with both pulmonary tuberculosis (PTB) and EPTB, reported the proportion and incidence of PTB or EPTB, and compared the demographic characteristics and risk factors of EPTB and PTB cases using univariate and multivariate logistic regression models. Among 30,893 TB patients, 67.25% (20,774) had PTB and 32.75% (10,119) had EPTB. Among EPTB, pleural, skeletal, lymphatic, pericardial, meningeal, genitourinary, intestinal, and peritoneal TB accounted for 49.44%, 27.20%, 8.55%, 4.39%, 3.36%, 1.48%, 0.87%, and 0.79%, respectively. Patients who were younger (age < 25), from rural areas, Zhuang and other ethnic groups, and diagnosed with anemia and HIV infection were more likely to develop EPTB. However, patients with diabetes and COPD were less likely to have EPTB. From 2016 to 2021, the proportion of PTB cases decreased from 69.73 to 64.07%. The percentage of EPTB cases increased from 30.27 to 35.93%, with the largest increase in skeletal TB from 21.48 to 34.13%. The epidemiology and risk factors of EPTB in central Guangxi are different from those of PTB. The incidence of EPTB is increasing and further studies are needed to determine the reasons for it.

Treatment outcome and its associated factors among HIV-MTB co-infected patients in Sichuan, China: A retrospective study

Human immunodeficiency virus (HIV)-Mycobacterium tuberculosis (MTB) co-infection has become a pressing global public health problem. Although tuberculosis (TB) is both treatable and curable, it has been exacerbated by the HIV/acquired immune deficiency syndrome (AIDS) epidemic. HIV-MTB co-infected patients have a variety of disease-specific, and treatment-related factors that can adversely affect their treatment outcomes. This study was conducted to assess the outcomes of TB treatment and its associated factors among HIV-MTB co-infected patients in Sichuan, Southwest China. A retrospective study was performed on HIV-MTB co-infected patients who were diagnosed and registered in TB designated hospitals in Sichuan from January 1, 2016, to December 31, 2020. Data were collected from patients' electronic medical records regarding their demographic, clinical, and social support information, and categorical data, such as sex, were reported using numbers and percentages. χ2 and t-tests were conducted to compare groups in relation to different levels of medical institutions. A binary logistic regression model was used to identify the factors associated with unsuccessful TB treatment outcomes. For logistic regression analysis performed using an α of 0.05, odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were calculated for various risk factors. A total of 3677 registered HIV-MTB co-infected patients were enrolled. After adjusting for other variables, male, advanced age, receiving TB treatment at the municipal medical institution, being diagnosed with external pulmonary TB, referral or tracing, being sputum smear positive, not initiating antiretroviral therapy (ART) and not using fixed-dose combinations were the main risk factors for treatment failure of HIV-MTB co-infected patients in Sichuan province. Sex, age, hospital level, patient source, other diagnostic factors (e.g., sputum smear results, anatomical site of TB), and factors of therapeutic schemes (e.g., antiretroviral therapy, fixed-dose combinations) may serve as risk factors to estimate the likely treatment outcome of HIV-TB co-infection.

Survival Trend of Tuberculosis Patients and Risk Factors Associated with Mortality and Developing Drug-Resistant Tuberculosis in Hospital Pulau Pinang, Malaysia: A Retrospective Study

BACKGROUND

Multidrug resistance TB (MDR-TB) has emerged as a public health issue worldwide, and the mortality rate is worrying. Therefore, this study was conducted to investigate the factors related to MDR-TB occurrence and the survival experience of TB patients.

METHODS

A retrospective cohort study was conducted at Hospital Pulau Pinang in Malaysia. Medical records of active TB patients from 2014-2018 were reviewed. Cox regression was used to identify the factors associated with MDR-TB development and mortality among TB patients.

RESULTS

The patients had a mean age of 48.84 ± 16.713 years, and a majority of the Chinese race (46.4%). Out of 351 TB patients, 325 (92.6%) were drug-susceptible TB, and 26 (7.4%) were diagnosed with MDR-TB. Among drug-susceptible TB patients, 245 (75.4%) achieved successful outcomes, and 73 (22.5%) passed away. In multivariable Cox regression, drug addiction, levels of white blood cells, urea, platelets, and albumin were significantly associated with death. Relapsed TB, alcohol consumption, and being single were significant risk factors for MDR-TB development.

CONCLUSION

Patients achieved a success rate of 75.4%, which is encouraging but still far below the WHO target (at least an 85% success rate) and has room for further improvement.

Host-directed therapies in pulmonary tuberculosis: Updates on anti-inflammatory drugs

Tuberculosis (TB) is a lethal disease and remains one of the top ten causes of mortality by an infectious disease worldwide. It can also result in significant morbidity related to persistent inflammation and tissue damage. Pulmonary TB treatment depends on the prolonged use of multiple drugs ranging from 6 months for drug-susceptible TB to 6-20 months in cases of multi-drug resistant disease, with limited patient tolerance resulting from side effects. Treatment success rates remain low and thus represent a barrier to TB control. Adjunct host-directed therapy (HDT) is an emerging strategy in TB treatment that aims to target the host immune response to Mycobacterium tuberculosis in addition to antimycobacterial drugs. Combined multi-drug treatment with HDT could potentially result in more effective therapies by shortening treatment duration, improving cure success rates and reducing residual tissue damage. This review explores the rationale and challenges to the development and implementation of HDTs through a succinct report of the medications that have completed or are currently being evaluated in ongoing clinical trials.

A Five-Year Epidemiological Study of Extra-Pulmonary Tuberculosis and Its Related Risk Factors in Iran

BACKGROUND

Tuberculosis is the most common worldwide cause of death from microbial diseases. Extra-pulmonary tuberculosis accounts for 20% to 25% of all cases. In this study, we used generalized estimation equations to investigate the trend of changes in extra-pulmonary tuberculosis incidence.

MATERIALS AND METHODS

The recorded data of all patients with extra-pulmonary tuberculosis from 2015 to 2019 in Iran's National Tuberculosis Registration Center were included. The trend of standardized incidence changes in provinces of Iran was calculated and reported linearly. Also, we identified the risk factors related to the extra-pulmonary tuberculosis incidence in five consecutive years using generalized estimating equations.

RESULTS

We studied the data of 12,537 patients with extra-pulmonary tuberculosis, of whom 50.3% were female. The mean age of the subjects was 43.61±19.88 years. Around 15.4% of all patients had a history of contact with a tuberculosis patient, 43% had a history of hospital stay, and 2.6% had a human immunodeficiency virus infection. Regarding disease types, 25% were lymphatic, 22% were pleural, and 14% were bone. Golestan province had the highest (average of 28.50 ± 8.65 cases), and Fars province had the lowest (average of 3.06 ± 0.75 cases) standardized incidences in these five years. Also, time trend (P < 0.001), employment rate (P = 0.037), and average annual rural income (P = 0.001) had a significant effect on reducing extra-pulmonary tuberculosis incidence.

CONCLUSION

Extra-pulmonary tuberculosis has a decreasing trend in Iran. Still, Golestan, Sistan and Baluchestan, Hormozgan, and Khuzestan provinces have a higher incidence rate compared to the other provinces.

A Retrospective Study on Tuberculous Lymphadenitis: A Finding from Multicenter Referral Hospitals

Background

Extrapulmonary tuberculosis represents about 14% of all cases of tuberculosis (TB) in Malaysia. The aim of the study includes the evaluation of sociodemographic factors, clinical manifestations, comorbidities among patients with tuberculous lymphadenitis and their treatment outcomes.

Methods

The retrospective study was conducted from 2006 to 2008. Data on sociodemographic along with histopathological results were collected. The signs and symptoms were also recorded from TB registers, treatment cards, and TB medical personal files using the standard data collection tool. Among multiple variables, the significant factors identified by univariate analysis were included in the multivariate logistic regression to estimate the odds ratios with the 95% confidence intervals. The statistically significant P value was considered <0.05.

Results

There were 348 (57%) males, and on the other hand, 262 (43%) females which shows almost equal incidence rate of lymphadenitis in both genders. The age group was observed from 2 to 83 years old. Therefore, the age group between 26 and 35 years showed 194 (31.8%) patients diagnosed with lymphadenitis and followed by 16-25 years (21%). The mean age was found as 34.3 ± 14.6 years were majorly reported with positive diagnosis. One hundred and ninety-six (32.1%) Malay population were found with tuberculous lymphadenitis followed by the Chinese population of 148 (24.3%). The other prominent races were Pilipino, Indonesians, and other expatriates. Geographically, patients were from 386 (63.3%) urban population were found positive for lymphadenitis and over 224 (36.7%) population of the rural region. The treatment outcome was observed 444 (72.8%) with successful treatment. The World Health Organization states the types of treatment failures, and accordingly, 85 (13.9%) patients were continued with the therapy that can be due to noncompliance or relapse of TB. Among the unsuccessful outcomes, 194 patients of age group 26-35 years, 65 (33.5%) were reported and 38 (29.7%) patients out of 128 between ages of 16-25 years. Blood test results showed erythrocyte sedimentation rate >10 in 280 (45.9%) patients. Therefore, among 280, there were 115 (41.1%) patients were found to have unsuccessful treatment showing very strong association with P < 0.001.

Conclusion

The finding signifies that effect of weight loss on poor treatment outcomes' and active screening measures for patients with comorbidities are therefore recommended in patients with tuberculous lymphadenitis along with improvements in the diagnosis and early management of comorbidities complications. As young age group was found to have poor or unsuccessful treatment outcomes and required aggressive strategy together with educating patients can further increase the treatment success rate.

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.

Tuberculous pleural effusion in a patient with sympathetic ophthalmia on immunosuppression: a case report

BACKGROUND

Tuberculous pleural effusion (TPE) is paucibacillary, making its diagnosis difficult based on laboratory investigations alone. We present a case of a patient with a TPE who was initially misdiagnosed to have azathioprine-induced lung injury. The diagnosis of TPE was arrived at with the help of clinical assessment, laboratory and radiological investigations.

CASE PRESENTATION

A 25-year-old chronic smoker with sympathetic ophthalmia on long-term immunosuppression, latent tuberculosis infection and a significant family history of tuberculosis presented with a three-week history of productive cough, low-grade fever, night sweats and weight loss. Examination of the lungs showed reduced breath sounds at the right lower zone. Chest x-ray showed minimal right pleural effusion with a small area of right upper lobe consolidation. The pleural fluid was exudative with predominant mononuclear leukocytes. Direct smears of sputum and pleural fluid; polymerase chain reaction of pleural fluid; and sputum, pleural fluid and blood cultures were negative for M. tuberculosis (MTB) and other organisms. As he did not respond to a course of broad-spectrum antibiotics, he was then treated as a case of azathioprine-induced lung injury. However, his condition did not improve despite the cessation of azathioprine. A contrast-enhanced computed tomography of the thorax showed right upper lobe consolidation with tree-in-bud changes, bilateral lung atelectasis, subpleural nodule, mild right pleural effusion and mediastinal lymphadenopathy. Bronchoalveolar lavage was negative for malignant cells and microorganisms including, MTB. However, no pleural biopsy was done. He was empirically treated with anti-tubercular therapy for 9 months duration and showed complete recovery.

CONCLUSION

A high index of suspicion for TPE is required in individuals with immunosuppression living in regions endemic to tuberculosis. Targeted investigations and sound clinical judgement allow early diagnosis and prompt treatment initiation to prevent morbidity and mortality.

Gastrointestinal tuberculosis: A systematic review of epidemiology, presentation, diagnosis and treatment

Tuberculosis (TB) once considered a disease of the developing world is infrequent in the developing world too. Its worldwide prevalence with a huge impact on the healthcare system both in economic and health terms has prompted the World Health Organization to make it a top priority infectious disease. Tuberculous infection of the pulmonary system is the most common form of this disease, however, extrapulmonary TB is being increasingly recognized and more often seen in immunocompromised situations. Gastrointestinal TB is a leading extrapulmonary TB manifestation that can defy diagnosis. Overlap of symptoms with other gastrointestinal diseases and limited accuracy of diagnostic tests demands more awareness of this disease. Untreated gastrointestinal TB can cause significant morbidity leading to prolonged hospitalization and surgery. Prompt diagnosis with early initiation of therapy can avoid this. This timely review discusses the epidemiology, risk factors, pathogenesis, clinical presentation, current diagnostic tools and therapy.

Hiding in plain sight: Diagnosing pleural tuberculosis using lung ultrasound

Introduction

Diagnosing pleural tuberculosis can be difficult in patients with ambiguous presentation, especially in resource-limited health centres. Thus, lung ultrasound had been studied as a novel method in helping clinicians to diagnose this condition.

Case presentation

A 48-year-old woman presented with worsening dyspnoea and orthopnoea for one week. She had also experienced weight loss, minimal dry cough and right-sided pleuritic chest pain for several weeks. A chest radiograph showed a right lower zone pleural effusion with no apparent lung consolidation. Lung ultrasound showed a right apical consolidation and right lower zone septated pleural effusion. Pleural fluid investigations showed exudative features of mixed lymphocytic, mesothelial and neutrophilic cellular components. Tuberculin skin test was strongly positive. She was subsequently treated for pleural tuberculosis. One month after treatment, her symptoms had improved considerably.

Discussion

Lung ultrasound has been found to be more effective than chest radiograph in detecting consolidation and diagnosing pneumonia. The portability and efficacy of today's ultrasound machines, including the handheld types, show that lung ultrasound is a practical, reliable and valuable diagnostic tool in managing pulmonary conditions including tuberculosis, provided that the operators are adequately trained.

Conclusion

Lung ultrasound in tuberculosis is the next frontier for clinicians and researchers.

Incidence, risk factors and clinical characteristics of extra-pulmonary tuberculosis patients: a ten-year study in the North of Iran

OBJECTIVE

To determine the incidence of extra-pulmonary tuberculosis (EPTB) and examine the risk factors and the clinical features of the disease over a ten-year period.

METHODS

Retrospective study of records of patients who were followed and registered in the TB registry programme in the health district of Gorgan, Iran from January 1, 2008, through December 31, 2017.

RESULTS

Among 2280 TB records, 609 (26.71%) were EPTB. They were mostly female patients (53.7%) and residents in rural areas (56.5%) with a mean age of 40.55 years [±16]. The average age of female patients (37.55 years [±16.99]) was lower than of male patients (44.07 years [±20.59]). The median of the incidence rate was 7.5 per 100 000 inhabitants for EPTB; biopsy and pathology were the best methods for the detection of EPTB. The most frequent forms of EPTB were lymphatic TB (193/609 = 31.7%) and pleural TB (158/609 = 25.9%). In most cases (245/609 = 40.2%), one to three months elapsed between occurrence of symptoms and final confirmation of EPTB. The outcome of EPTB was weaker than of pulmonary TB (PTB).

CONCLUSION

Our most important finding was the increasing incidence of EPTB, which shows the importance of attention to this disease. Lymph node and pleural tissue were the most commonly infected tissues. Skeletal TB presents a challenge in the diagnosis and treatment of EPTB.

Effect of smoking on treatment outcome among tuberculosis patients in Malaysia; a multicenter study

BACKGROUND

Smoking plays a key role in the development of tuberculosis (TB) infection and is also a predictor of poor TB treatment prognosis and outcomes. The current study was conducted to determine the prevalence of smoking and to assess the effects of smoking on treatment outcomes among TB patients.

METHODS

A multi-center retrospective study design was used to collect data from TB patients in four different states of Malaysia, namely Penang, Sabah, Sarawak, and Selangor. The study included medical records of TB patients admitted to the selected hospitals in the period from January 2006 to March 2009. Medical records with incomplete data were not included. Patient demographics and clinical data were collected using a validated data collection form.

RESULTS

Of all patients with TB (9337), the prevalence of smokers was 4313 (46.2%). Among smokers, 3584 (83.1%) were associated with pulmonary TB, while 729 (16.9%) were associated with extrapulmonary TB. Male gender (OR = 1.43, 95% CI 1.30-1.58), Chinese ethnicity (OR = 1.23, 95% CI 1.02-1.49), Sarawak indigenous ethnicity (OR = 0.74, 95% CI 0.58-0.95), urban residents (OR = 1.46, 95% CI 1.33-1.61), employed individuals (OR = 1.21, 95% CI 1.09-1.34), alcoholics (OR = 4.91, 95% CI 4.04-5.96), drug abusers (OR = 7.43, 95% CI 5.70-9.60) and presence of co-morbid condition (OR = 1.27, 95% CI 1.16-1.40) all showed significant association with smoking habits. This study found that 3236 (75.0%) patients were successfully treated in the smokers' group, while 4004 (79.7%) patients were non-smokers. The proportion of deaths (6.6%, n = 283), defaulters (6.6%, n = 284) and treatment interruptions (4.7%, n = 204) was higher in the smokers' group.

CONCLUSIONS

Smoking has a strong influence on TB and is a major barrier towards treatment success (OR = 0.76, 95% CI 0.69-0.84, p < 0.001). Therefore, the findings indicate that smoking cessations are an effective way to decrease treatment failure and drug resistance.