Disseminated MDR-TB missed in a patient treated with TNF inhibitor

A previously healthy man developed pulmonary symptoms 2 weeks after starting treatment with a tumour necrosis factor (TNF) inhibitor. A negative interferon-gamma release assay (IGRA) test was obtained prior to TNF inhibitor exposure, without consideration of the fact that the patient was already immunosuppressed and had a previous positive IGRA test 17 months earlier. The patient was treated for pneumonia twice but did not achieve remission. His physical health progressively deteriorated over the following months. Malignancy was suspected but not found. Eight months after the onset of symptoms, Mycobacterium tuberculosis was found in samples from mediastinal lymph nodes, and the patient was diagnosed with multidrug-resistant tuberculosis (MDR-TB).This case illustrates the diagnostic challenge of TB, the need to raise awareness of the increased risk of TB in patients treated with TNF inhibitors and the need to increase knowledge regarding the effect of immunosuppressive agents on IGRA tests.

Genomic characteristics of prospectively sequenced Mycobacterium tuberculosis from respiratory and non-respiratory sources

Understanding the differences between Mycobacterium tuberculosis strains isolated from respiratory and non-respiratory sources may inform clinical care and control strategies. We examined demographic and genomic characteristics of all culture-confirmed M. tuberculosis cultures isolated from respiratory and non-respiratory sources in New South Wales, Australia, from January 2017 to December 2021, using logistic regression models. M. tuberculosis strains from 1,831 patients were sequenced; 64.7% were from respiratory, 32.1% from non-respiratory, and 2.2% from both sources. Female patients had more frequent isolation from a non-respiratory source (p = 0.03), and older adults (≧65 years) from a respiratory source (p < 0.0001). Lineage 2 strains were relatively over-represented among respiratory isolates (p = 0.01). Among 39 cases with sequenced isolates from both sources, 43.6% had 1-10 single nucleotide polymorphism differences. The finding that older adults were more likely to have M. tuberculosis isolated from respiratory sources has relevance for TB control given the expected rise of TB among older adults.

Epidemiology and effects of sociodemographic factors on extrapulmonary tuberculosis in Ambala, India

BACKGROUND

An ambitious plan was set into motion with the aim of TB elimination from India in 2025. To achieve this, it is high time to give emphasis on other prevalent forms of TB, such as extra pulmonary TB (EPTB).

OBJECTIVES

The study aims to discern the differences in patient characteristics and management practices between pulmonary TB and EPTB using data from district Ambala.

METHODS

This retrospective study used data of 12,985 TB patients from district Ambala, India. The differences in patient characteristics and management practices between pulmonary TB and EPTB were analyzed using the NIKSHAY database.

RESULTS

In the studied population, extra pulmonary TB (EPTB) formed 29.7% of all TB cases. Among all EPTB cases, pleural TB was found to be the most common form, accounting for 27%. The study also revealed that female gender, young age, non-diabetic status, and high BMI were associated with an increased propensity to have EPTB. Interestingly, unlike pulmonary TB, which had increased odds for contracting the disease in diabetic individuals (OR - 2.02), there were no increased odds for contracting EPTB in diabetic individuals. However, HIV infection significantly increased the odds for both pulmonary TB and EPTB. The results also showed diagnostic discrepancies between the private and public sectors, along with a low microbiological confirmation rate of 7.1% in EPTB cases.

CONCLUSION

The study highlights the importance of focusing on EPTB in addition to pulmonary TB for effective TB elimination in India. The differences in patient characteristics and management practices warrant further investigation and targeted interventions for both forms of the disease. Efforts should be made to improve diagnostic accuracy and reduce discrepancies between the private and public sectors.

Tuberculous pleuritis: clinical presentations and diagnostic challenges

PURPOSE OF REVIEW

Tuberculous pleuritis (TBP) is one of the most common types of extrapulmonary tuberculosis. We highlight the latest epidemiology of TBP, the heterogeneity of its presentation and the performance of different diagnostic strategies.

RECENT FINDINGS

There are differential trends in the incidences of TBP worldwide. Its incidence increased in China but decreased in the United States in the past decade. The presentation of TBP is heterogeneous regarding clinical symptoms, radiological findings and pleural fluid analysis results. Conventional microbiological tests have low sensitivities to diagnose TBP. Recent research focused on various diagnostic tools with better yield. The sensitivity of nucleic acid amplification tests (NAAT) in pleural fluid, including the latest generation of PCR and sequencing-based techniques for detecting tuberculosis, remains suboptimal. Various pleural fluid biomarkers have been explored, but there is a lack of consensus on their clinical utility and cutoff levels.

SUMMARY

The heterogeneity of clinical presentation poses obstacles to diagnosing TBP. Further development of diagnostic tools, including more robust NAAT and biomarkers with additional validation, is needed before incorporation into routine clinical practice.

Prevalence of extra-pulmonary tuberculosis in Africa: A systematic review and meta-analysis

OBJECTIVE

The burden of extra-pulmonary tuberculosis (EPTB) is not well quantified in TB endemic countries such as those in sub-Saharan Africa. This study aimed to quantify that burden via a systematic review of the prevalence of EPTB in African countries.

METHODS

Studies were retrieved by searching five databases; 105 studies published between 1990 and 2023 were included. The studies described the prevalence of EPTB among the general population (4 studies), TB patients (68) and patients with other conditions, including HIV (15), meningitis (3), renal failure (3) and other comorbidities, some of which are cancer (12). Due to the low number of studies reporting EPTB in patients with conditions other than TB, the meta-analysis was performed on studies reporting on EPTB among TB patients (68 studies). Meta-analysis was performed on the 68 studies (271,073 participants) using a random-effects model to estimate the pooled prevalence of EPTB. Meta-regression was used to explore possible explanations for heterogeneity according to regions and time periods.

RESULTS

The pooled prevalence of EPTB among TB patients was 26% (95% CI 23-29%). There was substantial heterogeneity of prevalence for the five African regions. The Eastern region had the highest prevalence of 32% (95% CI 28-37%) and the lowest in Western Africa, 16% (95% CI 10-24%). There was no significant difference in the prevalence of EPTB between the 3 eleven-year time periods.

CONCLUSIONS

Our systematic review and meta-analysis give insight into the burden of EPTB in Africa. This review could inform clinical and programmatic practices-a higher suspicion index for clinicians and more effort for better services. This could contribute to efforts aiming to end TB, which have historically been focused on PTB.Coordinated efforts that target both EPTB and PTB are needed.

Evaluation of Xpert MTB/RIF Ultra for the Diagnosis of Extrapulmonary Tuberculosis: A Retrospective Analysis in Saudi Arabia

The incidence of extrapulmonary tuberculosis (EPTB) in low- and middle-income countries, as well as, high-income countries has increased over the last two decades. The acid-fast bacillus (AFB) smear test is easy to perform and cost-effective with a quick turnaround time but the test has low sensitivity. Culture remains the gold standard for detecting TB; however, it has low sensitivity and slow bacterial growth patterns, as it may take up to 6 to 8 weeks to grow. Therefore, a rapid detection tool is crucial for the early initiation of treatment and ensuring an improved therapeutic outcome. Here, the Xpert Ultra system was developed as a nucleic acid amplification technique to accelerate the detection of MTB in paucibacillary clinical samples and endorsed by the World Health Organization. From March 2020 to August 2021, Xpert Ultra was evaluated for its sensitivity and specificity against EPTB and compared with those of the routinely used Xpert, culture, and AFB tests in 845 clinical samples in Saudi Arabia. The results indicate the overall sensitivity and specificity of Xpert Ultra to be 91% and 95%, respectively, compared with the Xpert (82% and 99%, respectively) and AFB smear (18% and 100%, respectively) tests. The results also indicated that despite the low microbial loads that were categorized as trace, very low, or low on Xpert Ultra, yet, complete detection was achieved with some sample types (i.e., 100% detection). Consequently, Xpert Ultra has great potential to replace conventional diagnostic approaches as a standard detection method for EPTB.

The epidemiological characteristics and infection risk factors for extrapulmonary tuberculosis in patients hospitalized with pulmonary tuberculosis infection in China from 2017 to 2021

BACKGROUND

Pulmonary tuberculosis (PTB) complicated with extrapulmonary tuberculosis (EPTB) infection can aggravate the disease, but there have been few reports.

METHODS

Retrospective analysis was used to collect the clinical data of PTB patients with pathogen positive in a teaching hospital from 2017 to 2021. We describe the incidence, the invasive site of EPTB patients, and analyze the infection risk factors for PTB with EPTB by univariate and multivariate logistic regression models. We also compared the complications, disease burden with chi-square test and rank-sum test.

RESULTS

A total of 1806 PTB were included, of which 263 (14.6%) were complicated with EPTB. The common invasive sites for EPTB were neck lymph nodes (16.49%), intestines (16.13%), and meninges (10.75%). Age ≤ 40 (OR = 1.735; 95%CI [1.267-2.376]; P = 0.001), malnutrition (OR = 2.029; 95%CI [1.097-3.753]; P = 0.022), anemia (OR = 1.739; 95%CI[1.127-2.683]; P = 0.012), and osteoporosis (OR = 4.147; 95%CI [1.577-10.905]; P = 0.004) were all independent risk factors for PTB infection with EPTB. The incidence of extrathoracic hydrothorax, intestinal bacterial infection, urinary tract bacterial infection, and abdominal bacterial infection were higher in patients with PTB with EPTB. PTB with EPTB patients also had longer median hospitalization durations (19 vs. 14 days), during which time they incurred higher total costs, laboratory test costs, imaging examination costs, and drug use costs.

CONCLUSION

This study found important risk factors for PTB complicated with EPTB, such as age ≤ 40, malnutrition, anemia, and osteoporosis. PTB with EPTB patients have more extrapulmonary complications and higher hospitalization disease burden.

The incidence of tuberculous pleurisy in mainland China from 2005 to 2018

Background

Currently, tuberculous pleurisy (TP) remains a serious problem affecting global public health, including in China. Our purpose was to comprehensively understand and identify the incidence of TP in mainland China between 2005 and 2018.

Methods

The data on registered TP cases from 2005 to 2018 were acquired from the National Tuberculosis Information Management System. We analyzed the demographics, epidemiology, and time-space distribution of TP patients. Then, the effects of potentially influential factors on TP incidences, such as medical expenses per capita, GDP per capita, and population density, were assessed using the Spearman correlation coefficient.

Results

The incidence of TP increased in mainland China from 2005 to 2018, with a mean incidence of 2.5 per 100,000 population. Interestingly, spring was the peak season for TP, with more notified cases. Tibet, Beijing, Xinjiang, and Inner Mongolia had the highest mean annual incidence. A moderate positive relationship was found between TP incidence, medical expenses per capita, and GDP per capita.

Conclusions

The notified incidence of TP had an elevated trend from 2005 to 2018 in mainland China. The findings of this study provide insight into the knowledge of TP epidemiology in the country, which can help optimize resource allocation to reduce the TP burden.

A retrospective analysis of 1019 cases of tuberculous cervical lymphadenitis in a rural setup in 20 years

BACKGROUND

This article is to review cervical lymphadenitis due to tuberculosis (TB), their presentation, their aetiology, the methods used to diagnose them, the treatment modalities offered and the response to treatment.

METHODS

1019 patients were diagnosed and treated for TB of the lymph nodes of the neck from 1st November 2001 to 31st August 2020 at a tertiary ENT hospital, Nadiad, Gujarat, India. Study consisted about 61% males and 39% females with the mean age being 37.3 years.

RESULT

Commonest factor or habit among those diagnosed for tuberculous cervical lymphadenitis was consumption of unpasteurized milk. HIV and diabetes were the most common co-morbid conditions found with this disease. Swelling in the neck was most common clinical feature followed by loss of weight, formation of abscess, fever and fistula. Rifampicin resistance was found in 1.5% of patients among those tested for the same.

CONCLUSION

The most commonly affected site for extra pulmonary TB is posterior triangle of neck than the anterior triangle. Patients with HIV and diabetes are at higher risk for the same. Testing for drug susceptibility has to be done due to increased resistant of drugs for extra pulmonary TB. GeneXpert and histopathological examination are important for its confirmation.

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.

Extrapulmonary Tuberculosis: An Otorhinolaryngologist's Perspective

Objective

The study aimed to determine the clinical manifestations and epidemiology of extrapulmonary tuberculosis (EPTB) of the head and neck in the otorhinolaryngeal regions. There is an increase in the incidence of EPTB in recent years because of increase in immunocompromised states and development of resistant bacteria. The clinical symptoms and signs of EPTB of the otorhinolaryngeal regions overlap with that of malignancies and other diseases in otorhinolaryngology thereby requiring correct early diagnosis so as to avoid unnecessary surgeries and procedures with initiation of appropriate anti tuberculous treatment under RNTCP.

Study design

Our prospective study was done on 45 patients who attended the ENT OPD at a tertiary care centre in Southern India over a period of 18 months with diagnosed EPTB of the otorhinolaryngeal regions.

Results

The study included 29 (64.4%) patients who presented with cervical lymphadenopathy, 11 (24.4%) patients with tuberculous laryngitis, 3 (6.6%) patients with tuberculous otitis media and 1 each with nasal and oral cavity tuberculosis. In our study 6 (13.3%) patients had co-existing pulmonary tuberculosis, 8 (18%) had diabetes, 5 (11%) had past history of tuberculosis and 7 (16%) had contact with patient with tuberculosis.

Conclusion

A high index of suspicion of EPTB must be kept among patients where (i) the clinical symptoms are out of proportion to the signs, (ii) common treatment fails or (iii) there is persistence or recurrence of symptoms despite therapy. The challenge is in confirming diagnosis which requires histopathological examination (HPE) of the tissue specimen. The timely diagnosis and initiation of anti tuberculous treatment (ATT) as per RNTCP helps in complete recovery thereby reducing morbidity.

Xpert MTB/RIF Ultra outperformed the Xpert assay in tuberculosis lymphadenitis diagnosis: a prospective head-to-head cohort study

OBJECTIVES

Xpert MTB/RIF Ultra (Xpert-Ultra) has shown better sensitivity in comparison with Xpert MTB/RIF (Xpert) in extra-pulmonary tuberculosis, while the head-to-head comparison of these methods in tuberculosis lymphadenitis had barely been performed.

METHODS

Patients with undiagnosed lymphadenopathy were recruited prospectively and consecutively, and fine-needle aspirates biopsy (FNA) or lymph node tissue was collected. The specimen was subjected to smear, culture, Xpert and Xpert-Ultra assays. Culture and/or smear for AFB or AFB observed on histopathology were performed as a reference.

RESULTS

106 participants were recruited, including 41 confirmed TB, 33 probableTB and 32 non-TB lymphadenopathy. The head-to-head comparison for Mtb detection showed that Xpert-Ultra produced the highest sensitivity when compared with smear, culture and Xpert (75.7% vs. 5.4 %, 13.5% and 48.7%).When Xpert-Ultra outcomes were integrated for diagnosis, the percentage of confirmed TB lymphadenitis case increased from 55.4% (41/74) to 85.1% (63/74). The sensitivities of Xpert-Ultra and Xpert on tissue were 73.6% (95%CI,59.4-84.3) and 39.6% (95%CI,26.8-54.0), respectively. The sensitiviyt of Xpert-Ultra on FNA samples (81.0%,95%CI 57.4-93.7) was higher than that of Xpert (71.4%,95% CI 47.7-87.8).

CONCLUSIONS

Xpert-Ultra detected significantly more TB lymphadenitis cases than Xpert or culture. This superiority was particularly distinct using lymph node tissue than FNA detection.

Difficulties in differential diagnosis tuberculosis and Crohn's disease. Case report

We present a clinical case of intestinal tuberculosis in a young patient with a clinical simulation of Crohn's disease. The article addresses clinical presentation, challenges of differential diagnostics of intestinal tuberculosis, and nonsurgical and surgical treatment approaches.

Manifestation of Subclinical Extrapulmonary Tuberculosis after COVID-19 Vaccination as Supraclavicular Lymphadenopathy

Lymphadenopathy after coronavirus disease 2019 (COVID-19) vaccination is a common side effect that usually resolves within several days to weeks, and only observation is recommended. However, for prolonged lymphadenopathy, other possibilities, including malignancy or other lymphoproliferative diseases, may be considered. Herein, we report the case of a 66-year-old woman who experienced prolonged ipsilateral supraclavicular lymph node enlargement after the second dose of the ChAdOx1 (Oxford-AstraZeneca) COVID-19 vaccine, which was eventually diagnosed as extrapulmonary tuberculosis.

Bone Penetration of Cycloserine in Osteoarticular Tuberculosis Patients of China

The cycloserine concentrations in plasma and bone that were collected during operations on 28 osteoarticular tuberculosis (TB) patients treated daily with a 500-mg cycloserine-containing regimen were determined. The median concentrations in plasma and bone were 16.29 μg/mL (interquartile range [IQR], 6.47 μg/mL) and 24.33 μg/g (IQR, 14.68 μg/g), respectively. The median bone/plasma penetration ratio was 0.76 (range, 0.33 to 1.98). Cycloserine could effectively penetrate bone and acquire concentrations comparable to those in plasma, which favors its usage in osteoarticular TB treatment.

HIV-Negative Rifampicin Resistance/Multidrug-Resistant Extrapulmonary Tuberculosis in China from 2015 to 2019: A Clinical Retrospective Investigation Study from a National Tuberculosis Clinical Research Center

Background

China is the region with a high global burden of rifampicin resistance/multidrug-resistant tuberculosis (RR/MDR-TB) and low HIV incidence. Our aim was to assess the clinical and demographic characteristics of RR/MDR-extrapulmonary tuberculosis (EPTB) from 2015 to 2019 to provide evidence for the prevention and control of the disease in high TB burden areas.

Methods

We investigated the clinical and demographic data of all MDR/RR-EPTB cases in a TB specialized hospital from China and compared the cases with the MDR/RR-pulmonary tuberculosis (PTB) patients over the same period.

Results

Of the RR/MDR-TB patients enrolled, 15.4 were EPTB. The most common anatomical site was pleural/chest wall (25.9%). Compared with RR/MDR-PTB, females were more likely to be susceptible to RR/MDR-EPTB (OR 1.65, 95% CI 1.52–1.77); the risk of RR/MDR-EPTB for 25–44 years group increased (OR 1.61, 95% CI 1.52–1.77), and then decreased with the increasing age (OR 1.48, 95% CI 0.74–1.69 for 44–65 years group and OR 2.23, 95% CI 0.98–2.71 for ≥65 years group); more likely to be newly diagnosed (p < 0.01) and less likely to to combine with diabetes (P < 0.01), more dependent on GeneXpert MTB/RIF (Xpert, 90.9%) for diagnosis, with significantly higher rates of pre-XDR/XDR and significantly lower favorable treatment outcomes (both p < 0.01).

Conclusion

There are clinical and demographic differences between RR/MDR-PTB and RR/MDR-PTB. Xper should be recommended at an early stage for suspected patients, and fluoroquinolones should be used cautiously for anti-infective therapy in this population.

Endometrial Cytokine Expression from Clinically Suspected Genital Tuberculosis Patients at Tertiary Care Hospitals in Dhaka

Objective

The objective of this study was to measure gamma interferon (IFN-γ) and tumor necrosis factor alpha (TNF-α) expression in endometrial tissue and/or aspirate from suspected genital tuberculosis patients with ectopic pregnancy and infertility in Bangladesh.

Methodology

A total 78 women of clinically suspected genital tuberculosis patients were enrolled as study population. These patients underwent manual vaccum aspiration (MVA) procedure, and endometrial tissues and/or aspirates were collected. Ziehl -Neelsen staining (Z-N staining) and Lowen–Stein Jensen (L-J) culture were done to detect Mycobacterium. The study participants were categorized as genital tuberculosis positive cases, genital tuberculosis negative cases and presumptive for tuberculosis cases based on the case definition used in this study. TNF-α and IFN-γ were measured by ELISA. Statistical analysis was done using SPSS (version-22).

Results

Out of 78 participants, pro-inflammatory cytokines IFN-γ and TNF-α were significantly increased in TB positive patients than TB negative patients (p < 0.05). IFN-γ value of TB positive patients (41.26 ± 41.05) was higher than TB negative (22.94 ± 44.51) patients. TNF-α value (44.31 ± 64.22) of TB positive patients was higher than TB negative (15.86 ± 41.45) patients. IFN-γ and TNF-α value of presumptive for tuberculosis cases were not statistically significant. According to ROC analysis, cut off value for IFN-γ was 23.5 and for TNF-α was 10 with highest sensitivity and specificity of 66.7%, 89.3%, and 66.7% and 73.1% respectively.

Conclusion

IFN-γ and TNF-α were significantly higher in TB positive patients and it may act as a potential biomarker for diagnosis of genital tuberculosis.

Primary adrenal tuberculosis infection in patients with Behcet's disease presenting as isolated adrenal metastasis by 18F-FDG PET/CT: a rare case report and literature review

Primary adrenal tuberculosis (TB) is a rare type of extrapulmonary tuberculosis (EPTB). A pathological biopsy is usually required to make a definite diagnosis due to nonspecific symptoms. Antituberculous chemotherapy is the main treatment regimen, and cortisol replacement therapy should be added when adrenal insufficiency is involved. Here, we present a 59-year-old man who had recurrence of oral and genital aphthosis for 3 years and was diagnosed with Behcet's disease (BD), which was cured by thalidomide. After 10 days of admission, the patient had sudden abdominal pain in the right upper quadrant with high fever and was diagnosed with acute cholecystitis attack, which was treated by percutaneous transhepatic gallbladder drainage (PTGBD). Further contrast-enhanced CT showed a right adrenal mass with a diameter of 2.0 cm, and PET-CT indicated intense ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) uptake in the right adrenal mass with a maximum standardized uptake value (SUV_max) of 15.2. As a metastatic adrenal mass was suspected, the patient underwent retroperitoneal laparoscopic adrenalectomy. Histopathological and immunohistochemical analysis revealed primary adrenal TB. After routine anti-tuberculosis treatment with isoniazid, rifampin, pyrazinamide and ethambutol for six months, the patient was cured and discharged. In summary, primary unilateral adrenal TB without adrenal insufficiency is difficult to diagnose only on the basis of clinical manifestations and examinations. Further studies are needed to develop an easier and more accurate diagnostic examination.

Disseminated tuberculosis mimicking abdominal metastatic carcinoma: A case report

RATIONALE

Extra-pulmonary tuberculosis (TB) has long been a diagnostic challenge for clinicians, often requiring extensive workup and invasive procedures, with the risk of significant complications. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a minimally invasive and highly accurate diagnostic modality for the evaluation of mediastinal and abdominal lymphadenopathy and masses. Several reports on the utility of EUS-FNA as a favorable method for diagnosing extrapulmonary TB have been published.

PATIENT CONCERNS

A 54-year-old man complained of intermittent melena.

DIAGNOSES

18 fluorine-fluorodeoxyglucose positron emission tomography/computed tomography revealed suspected carcinoma metastasis. EUS-FNA did not reveal any evidence of malignancy.

INTERVENTIONS AND OUTCOMES

Laparoscopy was performed, and frozen section pathology during surgery showed granulomas with focal necrosis. Mycobacterium tuberculosis polymerase chain reaction was positive, but acid-fast bacilli staining was negative. Anti-TB treatment was initiated, and the patient was advised to visit the local TB dispensary regularly.

LESSONS

The presence of atypical inflammation of inadequate material or non-representative samples of extra-pulmonary TB was observed on EUS-FNA cytology. Mycobacterium tuberculosis polymerase chain reaction and acid fast bacilli should be performed to diagnose TB because of its higher sensitivity.

The epidemiology of concurrent extrapulmonary tuberculosis in inpatients with extrapulmonary tuberculosis lesions in China: a large-scale observational multi-center investigation

AIMS

A high proportion of all tuberculosis (TB) cases present with extrapulmonary tuberculosis (EPTB), including concurrent EPTB involving more than one extrapulmonary lesion site within the body. However, previous reports only characterised lesions of single-site EPTB cases. This study aimed to investigate epidemiological characteristics and association rules of concurrent EPTB cases in China.

METHODS

An observational multi-centre study was carried out in China from Jan 2011 to Dec 2017 that included a total of 208,214 patients with EPTB lesions. Multivariable logistic regression analysis was used to identify associations between gender and age with concurrent EPTB. Association rules were analysed for significance using the Apriori algorithm.

RESULTS

The most prevalent form of EPTB lesion was tuberculous pleurisy (49.8%), followed by bronchial tuberculosis (14.8%) and tuberculous meningitis (7.6%). The most predominant concurrent EPTB case type was tuberculous pleurisy concurrent with tuberculous peritonitis (1.80%). Altogether 22 association rules were identified that included 20 strong association rules, among which highest confidence rates were found for tuberculous myelitis concurrent with tuberculous meningitis and sacral TB concurrent with lumbar vertebral TB. Moreover, association rules of EPTB concurrent with other EPTB types were found to vary with gender and age. The confidence rate of tuberculous myelitis concurrent with tuberculous meningitis was higher in females (83.67%) than males and highest in patients of ages 25-34 years (87.50%).

CONCLUSIONS

Many types of concurrent EPTB were found. Thus, greater awareness of concurrent EPTB disease characteristics is needed to ensure timely clinical diagnosis and treatment of this disease.

Rare manifestation of a large stenosing gastrointestinal tumor caused by Mycobacterium tuberculosis in a previously healthy man from Austria

BACKGROUND

Gastrointestinal tuberculosis (TB) is a rare manifestation in low TB-incidence countries such as Austria. It is usually seen in immunocompromised patients or in migrants being more susceptible for extrapulmonary disease manifestations.

CASE DESCRIPTION

We report a very rare manifestation of severe gastrointestinal TB in a 49-year-old previously healthy man from Upper Austria. Endoscopy showed a large tumor mass obstructing about 2/3 of the lumen of the cecum. Positron emission tomography/computed tomography scan revealed not only a high metabolic activity in the tumor mass, but also active pulmonary lesions in both upper lung lobes. Bronchial secretion showed acid-fast bacilli in the microscopy and polymerase chain reaction was positive for M. tuberculosis complex. Phenotypic resistance testing showed no resistance for first-line anti-TB drugs. Treatment with isoniazid, rifampicin, pyrazinamide and ethambutol was initiated. Based on therapeutic drug monitoring, the standard treatment regime was adapted to rifampicin high dose. TB treatment was well tolerated and the patient achieved relapse-free cure one year after the end of treatment.

CONCLUSION

Gastrointestinal involvement mimicking an intestinal tumor is a very rare TB manifestation in previously healthy Austrians. However, it should be kept in mind due to increasing migration from countries with higher rates of extrapulmonary TB and due to an increasing number of immunocompromised patients. TB telephone consultations can support medical professionals in the diagnosis and the management of complex TB patients. TB management is currently at a transitional stage from a programmatic to personalized management concept including therapeutic drug monitoring or biomarker-guided treatment duration to achieve relapse-free cure.

The negative impact of increasing age and underlying cirrhosis on the sensitivity of adenosine deaminase in the diagnosis of tuberculous peritonitis: a cross-sectional study in eastern China

BACKGROUND

Our study aimed to evaluate the correlation between the sensitivity of adenosine deaminase (ADA) testing for the diagnosis of tuberculous peritonitis (TBP) and patient age or cirrhosis status.

METHODS

Clinical data for patients clinically diagnosed with TPB (n = 132) or not (n = 147) were assessed. ADA activity was compared among three age groups (< 45 yr, 45-60 yr, and ≥ 60 yr) and among cirrhosis-related subgroups. Cut-off values for the ADA test were analyzed among three patient populations (young non-cirrhotic, n = 97; older non-cirrhotic, n = 115; cirrhotic, n = 67), and validated in a cohort of 259 participants.

RESULTS

According to the multivariate regression analyses, age < 45 yr is highly predictive of TBP risk. The young non-cirrhotic TBP patients had higher ADA activity than the middle-aged or old controls (p < 0.01). Significantly decreased activity and efficacy of ADA were observed in the cirrhotic subgroup/population, regardless of age or cohort. For the above-mentioned two non-cirrhotic populations in the validation cohort, the ADA test showed excellent performance using thresholds of 30.5 IU/L and 20.5 IU/L, with respective sensitivities of 91.1% and 92.6%.

CONCLUSIONS

ADA activity is negatively associated with increasing age and underlying cirrhosis. Optimizing cut-off values for the ADA test can increase its sensitivity in non-cirrhotic individuals older than 45 years.

Evaluation of effectiveness of pathology reports in active surveillance of tuberculosis

OBJECTIVE

Despite advancing technology, national TB surveillance systems are still inadequate in terms of patient detection around the world. It was aimed to investigate suspicious cases detected by active surveillance method in pathology laboratories and to evaluate the effectiveness of this method in terms of finding new TB cases.

METHODS

This is a descriptive cross-sectional study. It was administrated in Samsun, Turkey, between January 2012-December 2017. Within the scope of active surveillance, pathology laboratories were regularly visited and reported cases with granulomatous inflammation were assessed. The obtained patient list was compared with the records of the Electronic Tuberculosis Management System (ETMS). Patients who were not included in these records were invited to the dispensary and evaluated for TB. They were also referred to the relevant hospitals for diagnosis if necessary. Frequency values and descriptive statistics were calculated using SPSS method.

RESULTS

It was found that 35.6% of 703 patients with the diagnosis of granulomatous inflammation were previously diagnosed, treated or currently undergoing treatment in the ETMS registry. As a result of the assessment of remaining 453 cases, 46 patients (10.1%) were newly diagnosed with TB. Newly diagnosed TB patients were reported, and their treatment started.

CONCLUSION

As a result, active surveillance method conducted in pathology laboratories are used to detect unknown or late reported TB cases and allows to start treatment without further delay.

Multifocal bone tuberculosis simulating metastasis

Multiple skeletal tuberculosis can be the first sign of tuberculosis. In such cases, physicians should consider tuberculosis diagnosis and take biopsies for anatomopathological evidence to make the correct diagnosis.

Risk factors associated with postoperative respiratory failure in tuberculous empyema patients

Our objective was to identify independent risk factors for predicting which patients in the Chinese population would likely develop respiratory failure.A descriptive analysis was conducted of demographic and clinical data of patients with tuberculous empyema (TE) admitted to the Beijing Chest Hospital, Capital Medical University between January 2001 and January 2020. Risk factors associated with postsurgical respiratory failure in TE patients were identified based on results of analyses based on univariable and multivariable logistic regression models.A total of 139 TE patients who underwent surgical treatment in the Beijing Chest Hospital, Capital Medical University from January 2001 to January 2020 were enrolled in this study. Cases included 109 male and 30 female patients, with an overall mean age (range 17-73) of 39.3 years. Of 139 TE patients, 26 (18.7%) experienced respiratory failure after surgery. Among significant risk factors for postsurgical respiratory failure, intraoperative blood loss volume greater than 1000 mL had the highest odds ratio value of 6.452. In addition, a pathologic preoperative pulmonary function test result showing a high partial pressure of carbon dioxide level was an independent risk factor for respiratory failure. Moreover, the presence of tuberculosis lesions in the contralateral lung was another significant risk factor for respiratory failure, as determined using multivariate analysis.Respiratory failure is a predominant complication experienced by TE patients undergoing surgery. High intraoperative blood loss, high preoperative high partial pressure of carbon dioxide level, and tuberculosis lesion(s) in the contralateral lung of TE patients were associated with increased risk of postoperative respiratory failure.

Tuberculosis in the Head and Neck: Changing Trends and Age-Related Patterns

OBJECTIVE

To evaluate changing trends in patient collectives, age-related patterns of manifestation, and diagnostic pathways of patients with extrapulmonary head and neck tuberculosis (TB), and to provide strategies to fasten diagnosis in these patients.

STUDY DESIGN

Case control study.

METHODS

A 10-year retrospective analysis of 35 patients diagnosed with extrapulmonary TB in the head and neck at a tertiary university institution from 2009 to 2019, with special focus on the influence of the patient's age on consideration of TB and clinical patterns.

RESULTS

The vast majority of patients younger than 40 years had their origin in countries with high TB burden (P = .0003), and TB was considered very early as a differential diagnosis (P = .0068), while most patients older than 40 years were domestic citizens initially suspected for a malignancy, who more often had an underlying immunosuppressive condition (0.0472). Most frequent manifestations in both groups were the lymph nodes, larynx, and oropharynx. Surprisingly, no differences in the rates of open TB or history of TB infection in the family anamnesis were found.

CONCLUSION

The two groups of patients found most often are younger patients migrating from regions with high TB burden and elderly domestic patients suffering from immunosuppressive conditions, with the latter often being misdiagnosed as malignancies. TB remains an important but difficult differential diagnosis, due to the initially unspecific symptoms and the great variety in the presentation of manifestations in the head and neck.

LEVEL OF EVIDENCE

4 "case-control study" Laryngoscope, 2021.

Total Hip Arthroplasty in 52 Active Advanced Tubercular Arthritic Hips

BACKGROUND

The role of total hip arthroplasty (THA) in healed tuberculosis (TB) of the hip has been reported with success in the past. However, the role and success of THA in active TB of the hip has remained controversial.

METHODS

We retrospectively evaluated a prospective study of 52 THAs done for active TB of the hip in 51 patients. The protocol includes 3-6 months of effective preoperative and 9-18 months postoperative anti-TB therapy. All THAs were performed by the same surgeon (author 1). The selection criteria excluded patients with poor immunity, HIV +ve patient, and presence of discharging sinus. The type of THA implant includes 12 cemented, 38 uncemented, and 2 hybrid fixations.

RESULTS

The mean follow-up was 10.5 years (2-29). Six patients were (6 THAs) lost to follow up after 4 years, including 2 deaths unrelated to TB or THA. There was no reactivation of TB. Mean Harris Hip Score improved from preop 31.77 (20-51) to postop 88 (72-100) in the last follow-up. Two patients had delayed wound healing up to 21 days postop with no evidence of subsequent episode till last follow-up. There was no case of dislocation, neurological complication in any patient. Seven THAs underwent revision for aseptic loosening unrelated to TB.

CONCLUSION

Single-stage THA is safe in active advanced tubercular arthritic hips with good immunity status under cover of effective anti-TB therapy using strict preop selection protocol.

Epidemiology and the diagnostic challenge of extra-pulmonary tuberculosis in a teaching hospital in Ethiopia

BACKGROUND

Ethiopia reported a high rate of extra-pulmonary tuberculosis (EPTB) and the cases are increasing since the last three decades. However, diagnostic evidence to initiate TB treatment among EPTB cases is not well known. Therefore, we described the epidemiology and assessed how EPTB is diagnosed in a teaching hospital in Ethiopia.

METHODS

We conducted a retrospective review among all adult EPTB cases diagnosed in Yekatit 12 Hospital Medical College from 2015 to 2019. Using a standardized data abstraction sheet, we collected data from patients' medical records on sociodemographic, sites, and laboratory diagnosis of EPTB cases.

RESULTS

Of the 965 total TB cases, 49.8%(481) had a recorded diagnosis of EPTB during the study period. The mean age of EPTB patients was 32.9 years (SD±13.9) and 50.7% were males. Tubercular lymphadenitis (40.3%), abdominal (23.4%), and pleural TB(13.5%) were the most common sites of EPTB involvement, followed in descending order by the genitourinary, skeletal, central nervous system, abscess, breast, and laryngeal TB. We found a histopathology finding consistent with EPTB in 59.1% of cases, Acid-fast bacilli positive in 1.5%, and the rest diagnosed on radiological grounds. In the majority of cases, more than one diagnostic method was used to diagnose EPTB cases.

CONCLUSIONS

Nearly half of TB patients had a recorded diagnosis of EPTB that comprise heterogeneous anatomical sites. All EPTB patients were started anti-TB therapy without definitive microbiology results. This indicates the diagnostic challenge of EPTB faced in our setting and proves to be significant for TB control in Ethiopia.

Disseminated Tuberculosis Mimicking Lung Cancer with Multiple Bone Metastasis: A Case Report

Tuberculosis (TB) is a contagious infectious disease caused by Mycobacterium tuberculosis (Mtb) of which attacking various organs particularly the lungs. Tuberculosis can occur together with malignancy or manifest as malignancy. Lung tuberculosis may appear in a variety of clinical and radiological manifestations caused by other diseases including tumors. These tumors are called pseudo-tumors. TB pseudo-tumor is a rare manifestation that can occur in immunocompetent patients in both primary and post-primary TB. The clinical presentation of TB pseudo-tumor is nonspecific and the clinical suspicion must be increased to diagnose related diseases. Radiological features can also be challenging to be distinguished from actual tumors. The classic manifestations of pulmonary TB are generally easy to diagnose due to the distinctive clinical and radiological characteristics nonetheless some pulmonary TB symptoms are also often found in patients with lung cancer. Infection patients resemble malignancies most were asymptomatic (> 27%) and the remaining 27% showed symptoms that varied with the average symptoms experienced about 1 month earlier. Clinical presentations that require a lot of misdiagnosis result in delayed treatment and unnecessary procedures. Establishing a diagnosis in cases of tuberculosis that causes malignancy is very important since the management and outcomes of the infection and malignancy process are quite different. Consequently we report a 24-year-old man with tuberculosis possible lung cancer with multiple bone metastase. Extrapulmonary tuberculosis which attacks bones and joints constitutes 10% to 20% of all TB cases. The location of bone and joint TB generally develops in the lumbar or thoracic vertebrae

Use of Xpert MTB/RIF and Xpert Ultra in extrapulmonary tuberculosis

INTRODUCTION

Tuberculosis (TB) remains a major global health burden. There still remains a large gap between the notified and estimated incident cases. Extrapulmonary (EP) TB represents 15% of all TB cases and the diagnosis is more challenging due to the paucity of the organism. Smear microscopy is often insensitive and culture methods are prolonged. With the introduction of Xpert MTB/RIF and more recently Xpert Ultra, this has changed TB diagnostics by providing a rapid accessible platform to diagnose TB and identify rifampicin resistance within 2 h.

AREAS COVERED

The diagnostic accuracy and the clinical role of Xpert MTB/RIF and Xpert Ultra in the different forms of EPTB.

EXPERT OPINION

Whilst significant advances have been made in TB diagnostics, there is still a need to optimize the diagnostic yield of Xpert MTB/RIF and Xpert Ultra in EPTB samples. Research is needed to facilitate standardization and optimal preparation of samples as well as understanding the role of Xpert MTB/RIF and Xpert Ultra in different burden settings. Alongside the current GeneXpert platform, the launch of rapid second-line drug resistance polymerase chain reactions and whole genome sequencing may help tackle the global health burden with a more comprehensive diagnostic approach and appropriate treatment.

Trends in tuberculosis notification and mortality and factors associated with treatment outcomes in Serbia, 2005 to 2015

Background

Previously a country with medium tuberculosis (TB) burden, Serbia almost reached a low TB burden during the period 2005 to 2015.

Aim

The aim of this study was to analyse the trends in notification rates and treatment success rates as well as to identify predictors of treatment outcomes.

Methods

We performed a trend analysis and logistic regression analysis of 17,441 TB cases registered from 2005 to 2015 in all health facilities in Serbia, to identify predictors of treatment success, loss to follow-up and mortality.

Results

From 2005 to 2015, TB notification rate and mortality in Serbia decreased but treatment success remained below the global target. Loss to follow-up was associated with retreatment (odds ratio (OR) = 2.38; 95% confidence interval (CI): 2.08–2.77), male sex (OR = 1.57; 95% CI: 1.39–1.79), age younger than 65 years (OR = 1.37; 95% CI: 1.20–1.51), lower education level (OR = 2.57; 95% CI: 1.74–3.80) and pulmonary TB (OR = 1.28; 95% CI: 1.06–1.56). Deaths were more frequent in retreatment cases (OR = 1.39; 95% CI: 1.12–1.61), male patients (OR = 1.34; 95% CI: 1.19–1.52), those 65 years and older (OR = 4.34; 95% CI: 4.00–5.00), those with lower education level (OR = 1.63; 95% CI: 1.14–2.33) and pulmonary TB (OR = 2.24; 95% CI: 1.78–2.83).

Conclusions

Special interventions should be implemented to address groups at risk of poor treatment outcome.

Epidemiology of Extrapulmonary Tuberculosis among Inpatients, China, 2008-2017

We investigated the epidemiology of extrapulmonary tuberculosis (TB) among patients admitted to Beijing Chest Hospital, Beijing, China, during January 2008-December 2017. Of 19,279 hospitalized TB patients, 33.4% (6,433) had extrapulmonary TB and 66.6% (12,846) had pulmonary TB. The most frequent forms of extrapulmonary TB observed were skeletal TB (41.1%) and pleural TB (26.0%). Younger, female patients from rural areas were more likely to have extrapulmonary TB. However, patients with diabetes mellitus were less likely to have extrapulmonary TB compared with patients without diabetes. A higher proportion of multidrug-resistant (MDR) TB was observed among patients with extrapulmonary TB than among patients with pulmonary TB. We observed a large increase in MDR TB, from 17.3% to 35.7%, for pleural TB cases. The increasing rate of drug resistance among extrapulmonary TB cases highlights the need for drug susceptibility testing and the formulation of more effective regimens for extrapulmonary TB treatment.

Epidemiology of tuberculous lymphadenitis in Denmark: A nationwide register-based study

BACKGROUND

Tuberculous lymphadenitis (TBLA) is the most common extrapulmonary manifestation of tuberculosis (TB), often claimed to be reactivation. We aimed to describe the epidemiology of TBLA in Denmark, as it has not previously been investigated specifically although extrapulmonary TB has been associated with an increased long-term mortality and delays in the diagnosis.

METHODS

Register-based study of all patients notified with TBLA in Denmark from 2007 through 2016 utilizing six different nationwide registers. Patients were identified through the national TB surveillance register, and the diagnosis evaluated based on microbiology, pathology and/or clinical assessment.

RESULTS

In total, 13.5% (n = 489) of all TB patients in Denmark had TBLA with annual proportions from 9.4 to 15.7%. Most patients were immigrants between 25-44 years. Incidence rates ranged from as high as 1,014/100,000 for Nepalese citizens to as a low as 0.06/100,000 for Danes. Danes had a significant higher median age and significant more risk factors and comorbidities, as well as an increased overall mortality, compared with immigrants (p<0.05). A significant and much higher proportion of unique MIRU-VNTR genotypes were seen among TBLA patients compared to other TB manifestations.

CONCLUSION

In Denmark, TBLA is a common manifestation of TB, especially in young immigrants from high-incidence countries. In Danes, it is a rare disease manifestation and associated with higher morbidity and mortality. To our knowledge, this is the first study suggesting that TBLA is predominantly associated with reactivation of latent TB infection based on genotyping although this remains to be clarified.

Tuberculous pleural effusion: diagnosis & management

Background: Tuberculosis (TB) is the world's leading cause of death from infectious disease. The World Health Organization (WHO) recognized 6.3 million new TB cases in 2017, 16% corresponding to extrapulmonary forms; pleural tuberculosis (PT) is the most common extrapulmonary form in adults. PT diagnosis is often challenging because the scarcity of bacilli in pleural fluid (PF), sometimes requiring invasive procedures to obtain pleural tissue for histological, microbiological or molecular examination. In regions of medium and high disease prevalence, adenosine deaminase (ADA), interferon gamma (IFN-γ) and interleukin 27 (IL-27) dosages are useful to establish presumptive diagnosis in patients with compatible clinical/radiological picture who present with lymphocytic pleural effusion. PT treatment is similar to the pulmonary TB treatment regimen recommended by WHO. Area covered: In this update, we present a PT review, including epidemiology, pathogenesis, clinical features, diagnosis, and therapy. Expert opinion: There is no PF test alone accurate for PT diagnosis, despite the evolution in clinical laboratory. ADA, IFN-γ and IL-27 are valuable laboratory biomarkers; however, IFN-γ and IL-27 are quite expensive. Molecular tests present low sensitivity in PF, being useful for diagnostic confirmation. Multidrug therapy remains the PT treatment choice. Advancing research in immunotherapy may bring benefits to PT patients.

IP-10 dried blood spots assay monitoring treatment efficacy in extrapulmonary tuberculosis in a low-resource setting

Treatment efficacy is difficult to evaluate in extrapulmonary tuberculosis (EPTB) patients. Interferon-γ inducible protein (IP-)10 has been suggested as a biomarker for response to treatment. We have investigated if IP-10 from dried plasma spots (DPS) or dried blood spots (DBS) can be used in treatment monitoring of EPTB patients in a low-resource setting of Zanzibar. IP-10 levels in plasma, DPS and DBS samples collected before, during (2 months) and after TB treatment of 36 EPTB patients (6 culture and/or Xpert MTB/RIF positive and 30 clinically diagnosed) and 8 pulmonary tuberculosis (PTB) patients, were quantified by an enzyme-linked immunosorbent assay. There was a high positive correlation between IP-10 measured in plasma and DPS and DBS, respectively. We found a significant decline in IP-10 levels from baseline to end of treatment in plasma, DPS and DBS, both in EPTB and PTB patients. The declines were observed already after 2 months in HIV negative patients. In conclusion, the DPS/DBS IP-10 assay allows for easy and manageable monitoring in low-resource settings and our findings suggest that IP-10 may serve as a biomarker for treatment efficacy in EPTB patients, albeit further studies in cohorts of patients with treatment failure and relapse are needed.

The Performance of Pleural Fluid T-SPOT.TB Assay for Diagnosing Tuberculous Pleurisy in China: A Two-Center Prospective Cohort Study

The performance of T-SPOT.TB (T-SPOT) assay in diagnosing pleural tuberculosis (plTB) is inconsistent. In this study, we compared the performance of peripheral blood (PB) and pleural fluid (PF) T-SPOT assay in diagnosing plTB. Between July 2017 and March 2018, 218 and 210 suspected plTB patients were prospectively enrolled from Wuhan (training) and Guangzhou (validation) cohort, respectively. PB T-SPOT, PF T-SPOT, and other conventional tests were simultaneously performed. Our data showed the performance of PB T-SPOT in diagnosing plTB was limited, especially with low sensitivity. However, the results of early secreted antigenic target 6 (ESAT-6) and culture filtrate protein 10 (CFP-10) in PF T-SPOT were significantly increased compared with those in PB T-SPOT in plTB patients. If using 76 as the cutoff value of MAX (the larger of ESAT-6 and CFP-10) in Wuhan cohort, the sensitivity and specificity of PF T-SPOT to diagnose plTB were 89.76 and 96.70%, respectively. The diagnostic accuracy of PF T-SPOT was better than other routine tests such as pathogen detection methods and biochemical markers. The diagnostic accuracy of PF T-SPOT in Guangzhou cohort was similar to that in Wuhan cohort, with a sensitivity and specificity of 91.07 and 94.90%, respectively. Furthermore, CD4⁺ T cells were more activated in PF compared with PB, and the frequency of mycobacterium tuberculosis-specific CD4⁺ T cells in PF was significantly higher than that in PB in plTB patients. In conclusion, the performance of PF T-SPOT is obviously better than PB T-SPOT or other laboratory tests, which suggests that PF T-SPOT assay has been of great value in the diagnosis of pleural tuberculosis.

Impact of Mycobacterium tuberculosis complex lineages as a determinant of disease phenotypes from an immigrant rich moderate tuberculosis burden country

Background

Growing evidences suggested that the Mycobacterium tuberculosis complex (MTBC) lineages can determine the clinical outcome of pulmonary and extra-pulmonary tuberculosis. However, limited data only available revealing such association of bacterial genotypes and clinical phenotypes from immigrant rich countries.

Methods

A multicenter study has been carried out on a collection of 2092 (1003 extrapulmonary and 1089 pulmonary) MTBC isolates. Genotyping of all the isolates were carried out by spoligotyping and 24 loci based MIRU-VNTR typing.

Results

Demographically domination of young Saudi nationals (61.4%) and men (61.2%) were found in this cohort. Lymph nodes (62.4%) and gastrointestinal sites (16.7%) were the most common anatomical sites of infection. The predominant lineages were Delhi/CAS (26.9%), EAI (14.2%) and Ghana (9.9%). Mycobacterium africanum type I and II were reported for the first time in the country among extrapulmonary cases. ‘Ancestral’ lineages M.bovis (OR-5.22; 95% CI-2.23-8.22, p- < 0.001) and Delhi/CAS (OR-0.57; 95% CI-0.411-0.734, p- < 0.001) were directly associated with lymph node tuberculosis and gastrointestinal tuberculosis (M. bovis-OR-0.33; 95% CI-0.085-0.567, p-0.001 and Delhi/CAS-OR-1.87; 95% CI-1.22-2.53, p- < 0.001) respectively. Among the ‘Modern’ lineages, EAI showed significant association to central nervous system tuberculosis (OR-1.98; 95% CI-0.76-3.19, p-0.04) and Uganda-I to gastrointestinal tuberculosis (OR-2.41; 95% CI-0.77-4.06, p-0.02).

Conclusions

The findings substantially contribute to the emerging evidences that MTBC lineages influence disease phenotypes and epidemiological consequences.

Electronic supplementary material

The online version of this article (10.1186/s12931-018-0966-x) contains supplementary material, which is available to authorized users.

The Use of TB-Specific Antigen/Phytohemagglutinin Ratio for Diagnosis and Treatment Monitoring of Extrapulmonary Tuberculosis

Extrapulmonary tuberculosis (EPTB) has become more common in recent years; however, the diagnosis of EPTB remains a challenge. In this study, we analyzed the performance of the ratio of TB-specific antigen (TBAg) to phytohemagglutinin (PHA) (TBAg/PHA ratio) in T-SPOT.TB (T-SPOT) assay for diagnosis and treatment monitoring of EPTB. Between 2012 and 2017, 734 EPTB patients were diagnosed and recruited from Tongji hospital, and 1,137 suspected EPTB patients who had other diagnoses were recruited as non-EPTB controls. To validate the study, another small group of EPTB patients and non-EPTB controls were recruited from Sino-French New City Branch of Tongji Hospital. The positive rate of peripheral blood T-SPOT in EPTB and non-EPTB were 88.15 and 32.28%. In T-SPOT positive patients, the direct T-SPOT results had limited value in distinguishing these two conditions. A further calculation of the TBAg/PHA ratio of T-SPOT showed improved performance in each form of EPTB. If using 0.20 as the threshold value of the TBAg/PHA ratio, the pooled sensitivity and specificity were 70.79 and 91.55% in distinguishing EPTB from non-EPTB. The validation results showed a better performance of the TBAg/PHA ratio in distinguishing these two conditions, with a sensitivity and specificity of 81.82 and 97.56%, respectively. Comparing with directly using T-SPOT results, the TBAg/PHA ratio was less affected by immunosuppression. Furthermore, PHA value reflected immunosuppression and could help to judge the credibility of T-SPOT results in EPTB patients with different immune status. The TBAg/PHA ratio was significantly decreased during anti-tuberculosis (TB) treatment, which suggests that it can also be used to monitor therapeutic efficacy. These data provide new insights into the role of T-SPOT assay in TB disease, and the TBAg/PHA ratio might be a useful tool for diagnosis and treatment monitoring of EPTB.

Localized hepatic tuberculosis presenting as severe hypercalcemia

Hypercalcemia might present itself in association with granulomatous diseases such as tuberculosis. We report a rare case of a 62-year-old man with hypercalcemia due to hepatic tuberculosis. The diagnosis was based on laparoscopic and a histopathological examination. After treatment with anti-tuberculosis medication, the patient's serum calcium levels were within normal limits. Tuberculosis needs to be excluded as a diagnosis in any febrile patient with hypercalcemia, especially in countries where tuberculosis is endemic.

Estimating the impact of tuberculosis anatomical classification on treatment outcomes: A patient and surveillance perspective analysis

Introduction

Tuberculosis anatomical classification is inconsistent in the literature, which limits current tuberculosis knowledge and control. We aimed to evaluate whether tuberculosis classification impacts on treatment outcomes at patient and aggregate level.

Methods

We analyzed adults from São Paulo State, Brazil with newly diagnosed tuberculosis from 2010–2013. We used an extended clinical classification of tuberculosis, categorizing cases as pulmonary, pulmonary and extrapulmonary, extrapulmonary and miliary/disseminated. Our primary outcome was unsuccessful outcome of treatment. To investigate the reported treatment outcome at the aggregate level, we sampled 500 different “countries” from the dataset and compared the impact of pulmonary and extrapulmonary classifications on the reported treatment success.

Results

Of 62,178 patients, 49,999 (80.4%) were pulmonary, 9,026 (14.5%) extrapulmonary, 1,651 (2.7%) pulmonary-extrapulmonary and 1,502 (2.4%) miliary/disseminated. Pulmonary-extrapulmonary cases had similar unsuccessful outcome of treatment compared with pulmonary (adjusted-OR 1.00, 95%CI, 0.88–1.13, p = 0.941), while extrapulmonary were associated with better (adjusted-OR 0.65, 95%CI, 0.60–0.71, p<0.001) and miliary/disseminated with worse outcomes (adjusted-OR 1.51, 95%CI, 1.33–1.71, p<0.001). We found that 60 (12%) countries would report a difference ≥10% in treatment success depending on whether they reported all clinical forms together (current WHO recommendation) or pulmonary forms alone, overestimating the treatment success of pulmonary forms.

Conclusions

The expanded anatomical classification of tuberculosis was strongly associated with treatment outcomes at the patient level. Remarkably, pulmonary with concomitant extrapulmonary forms had similar treatment outcomes compared with pulmonary forms after adjustment for potential confounders. At the aggregate level, reporting treatment success for all clinical forms together might hide differences in progress between pulmonary and extrapulmonary tuberculosis control.

Determinants of site of tuberculosis disease: An analysis of European surveillance data from 2003 to 2014

Background

We explored host-related factors associated with the site of tuberculosis (TB) disease using variables routinely collected by the 31 EU/EEA countries for national surveillance.

Methods

Logistic regression models were fitted to case-based surveillance data reported to the European Centre for Disease Prevention and Control for TB cases notified from 2003 to 2014. Missing data on HIV infection and on susceptibility to isoniazid and rifampicin for many patients precluded the inclusion of these variables in the analysis. Records from Finland, Lithuania, Spain and the United Kingdom were excluded for lack of exact details of disease localisation; other records without one or more variable (e.g. previous treatment history, geographical origin) or who had mixed pulmonary and extrapulmonary disease or more than one form of extrapulmonary disease were also removed (total exclusion = 38% of 913,637 notifications).

Results

564,916 TB cases reported by 27 EU/EEA countries had exclusive pulmonary (PTB; 83%) or extrapulmonary (EPTB; 17%) disease. EPTB was associated with age <15 years (aOR: 5.50), female sex (aOR: 1.60), no previous TB treatment (aOR: 3.10), and geographic origin (aOR range: 0.52–3.74). Origin from the Indian subcontinent or Africa was most strongly associated with lymphatic, osteo-articular and peritoneal/digestive localization (aOR>3.7), and age <15 years with lymphatic (aOR: 17.96) and central nervous system disease (aOR: 11.41).

Conclusions

Awareness of host-related determinants of site of TB is useful for diagnosis. The predilection for EPTB among patients originating from countries outside Europe may reflect strain preferences for disease localization, geographic/ethnic differences in disease manifestation and other factors, like HIV.

Diagnostic Potential of Circulating Biomarkers in Adenosine Deaminase Diagnosed Pleural Tuberculosis Cases

Pleural tuberculosis accounts for nearly 20% of Extra pulmonary tuberculosis. Adenosine deaminase, commonly used biomarker for the diagnosis, is non specific and there is paucity of literature on its correlation with conventional or newer methods for the diagnosis of extra pulmonary forms of TB. The aim of the study was to assess diagnostic potential of T cell function markers [interferon (IFN-γ), interleukin (IL-2) and IFN-γ/IL-2 ratio]; macrophage activation marker [neopterin]; and oxidative stress markers [protein carbonyl and malondialdehyde (MDA)] in pleural tuberculosis. 26 pleural TB cases diagnosed on the basis of suggestive chest X-ray and raised serum ADA levels and healthy controls were included in the study. Pleural fluid specimens were subjected to Zeihl Neelsen staining and culture on Lowenstein Jensen medium. Serum IFN-γ, IL-2, neopterin and protein carbonyl levels detection were done by ELISA and MDA levels were determined by measuring the thiobarbituric acid reactive substances. Median serum levels of IFN-γ, IL-2, IFN-γ/IL-2 ratio, neopterin, protein carbonyl and MDA were significantly different between cases and controls. Levels of all biomarkers except IL-2 were significantly higher in cases with contact history. Mean levels of ADA and ESR were 46.27 U/L and 46.62 mm/hr in PTB cases. AUC for IFN-γ, IL-2, IFN-γ/IL-2 ratio, neopterin, protein carbonyl and MDA were significantly discriminative for cases and controls. IFN-γ/IL-2 ratio was best discriminatory biomarker with highest area under ROC curve. Though no correlation was seen between ADA and any of the six biomarkers, ESR levels correlated significantly with all biomarkers except IL-2 by spearman's correlation coefficient. Though all the circulating biomarkers under study provide useful supportive evidence for the diagnosis of PTB, further studies involving diverse control groups particularly non-PTB effusion are needed to validate these results.

Validity of tuberculous pleuritis diagnosed in a resource-constrained setting in Dindigul district of Tamil Nadu

Context:

Majority of the Indians live in rural areas where resource constrained settings depend on cheaper and less invasive tests to diagnose extrapulmonary tuberculosis (TB). The decline in prevalence of TB in the country could affect the validity of the diagnosis. The aim was to measure validity of the pleural fluid study of proteins, lactate dehydrogenase (LDH), and cell counts in diagnosis of tuberculous pleuritis.

Materials and Methods:

This was a cross-sectional study conducted in a 300 bedded secondary care hospital in rural Tamil Nadu. Exhaustive sampling was performed during April 2013 to March 2014. Pleural fluid study of 54 patients with exudative pleural effusion was conducted. Diagnosis was established by closed needle pleural biopsy. Receiver operator curves were plotted and area under curve (AUC) was calculated for various parameters. Sensitivity, specificity, and predictive values were calculated for different cut-off values of the parameter with significant AUC.

Results:

Prevalence of tuberculous pleural effusion was 56% (95% confidence interval [95% CI] - 42.5–69.5%). Lymphocyte predominance in pleural fluid was the only valid test, and cut-off >80% had sensitivity of 70.0% (95% CI - 53.3–86.7%) and specificity of 70.8% (95% CI - 52.2–89.4%). Pleural fluid pH, protein or its ratio with serum protein, sugar, total leukocyte count, LDH or its ratio with serum LDH; erythrocyte sedimentation rate were not valid screening tests.

Conclusions:

Lymphocyte predominance > 80% can be used as a marker of tuberculous pleuritis. Since the prevalence of tuberculous pleuritis in India has come down considerably, newer tests need to be included to make a valid diagnosis.

Understanding cutaneous tuberculosis: two clinical cases

Tuberculosis (TB) is an ancient human disease and remains today one of the most important public health problems and the second most frequent cause of death from an infectious disease worldwide. While pulmonary TB is the most common form, extra-pulmonary TB is on the rise due to the increase in immunosuppressed subjects. Cutaneous TB manifestations are rare forms of extra-pulmonary TB due to systemic dissemination of bacilli or direct inoculation, involving skin or skin-associated tissue, more common in immunocompromised subjects. Some risk factors and the features of the lesion may prompt the suspicion of cutaneous TB, but only microbiological assays can confirm the diagnosis. Our work summarizes cutaneous TB manifestations and differences from other skin mycobacterial infections, also describes two characteristic clinical cases.