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

Clinical and CT characteristics of abdominal tuberculous lymphadenopathy: a comparative analysis of hematogenous and non-hematogenous dissemination

OBJECTIVES

To elucidate the differences in clinical and CT manifestations between abdominal tuberculous lymphadenopathy (ATBL) resulting from hematogenous and non-hematogenous dissemination.

METHODS

A retrospective analysis was conducted on the clinical records and CT data of 178 untreated ATBL patients from January 2012 to March 2023. Patients were categorized into two groups: hematogenous dissemination (75 cases) and non-hematogenous dissemination (103 cases). The clinical characteristics of the two groups of patients were compared, and the CT imaging features of ATBL (such as location, size, and enhancement degree) were evaluated. Statistical analyses were performed using Student's t-test or Mann-Whitney U test and Chi-squared test to identify significant differences between the groups.

RESULTS

The study found that the non-hematogenous dissemination group had a higher prevalence of males, younger patients, abdominal distension, and positive tuberculin skin test (TST) results, along with higher CD4+ T cell counts and lymphocyte counts. Conversely, the hematogenous group exhibited more HIV-positive patients, positive results of smear microscopy for acid-fast bacilli (AFB) staining, pleural effusion, and cough and sputum production. Significant differences were noted in the distribution, size, fusion, and enhancement patterns of ATBL between the two groups. ATBL in the hematogenous dissemination group predominantly involved the upper and lower para-aortic regions, the hepatoduodenal ligament, the portocaval space, the hepatogastric ligament, and the iliac vessels region. In contrast, the non-hematogenous dissemination group had more involvement in the mesenteric region. Lymph nodes in the hematogenous dissemination group were larger diameters, with irregular mass fusion and mixed enhancement pattern, while homogeneous enhancement was more common in the non-hematogenous dissemination group.

CONCLUSION

There are differences in the clinical and CT manifestations of ATBL caused by hematogenous versus non-hematogenous dissemination.

Human Mycobacterium bovis infection: A multicentre retrospective study conducted by the Madrid Study Group for Mycobacteria (GEMIMAD)

INTRODUCTION

This study aimed to evaluate trends and clinical characteristics of Mycobacterium bovis human tuberculosis cases, describe the epidemiological features, and compare risk factors associated with extrapulmonary and pulmonary tuberculosis.

METHODS

A retrospective cohort analysis was conducted on M. bovis infection cases confirmed by culture from seven clinical microbiology laboratories in Madrid, Spain, from 2010 to 2022. Sociodemographic and clinical data were extracted from the hospital database. Tuberculosis (TB) cases were classified as extrapulmonary (EPTB) and pulmonary tuberculosis (PTB), with disseminated TB cases excluded from statistical analysis.

RESULTS

Among 3670 patients with Mycobacterium tuberculosis complex infection, M. bovis was identified in 66 patients, representing 1.8% of the total. PTB and EPTB were identified in 45.5% and 39.4% of cases, respectively, with 15.1% having disseminated TB. PTB was significantly associated with males and Spanish nationality, while EPTB was more prevalent among females and those with a rural lifestyle.

CONCLUSIONS

The study revealed an escalating trend in M. bovis tuberculosis cases. Middle-aged patients, including a substantial immigrant population, were predominantly affected. Female gender and a rural lifestyle were associated to extrapulmonary disease.

Immune dysregulation of diabetes in tuberculosis

The rising prevalence of diabetes mellitus (DM) is undermining global efforts to eliminate tuberculosis (TB). Most studies found that patients with pulmonary TB and DM have more cavitary lung lesions, higher mycobacterial burden on the lungs, longer periods of infectiousness, and worse outcomes. Both human and animal studies indicate that TB-DM is associated with impaired innate and adaptive immune responses, resulting in delayed bacterial clearance. Similar observations have been noted in other infections, such as those caused by Klebsiella pneumoniae, where DM contributes to increased susceptibility and worse outcomes due to compromised immune functions including defective phagocytosis and impaired early immune cell recruitment. This review delves into the mechanisms of immune dysfunction in TB-DM, exploring how DM increases TB susceptibility and severity. By elucidating these complex interactions, this review aims to offer insights into more effective strategies for managing and improving outcomes for patients with this challenging comorbidity.

Incidence and determinants of extrapulmonary tuberculosis in Egypt: a retrospective cohort study

Tuberculosis (TB) is a significant global public health concern. The incidence of extrapulmonary tuberculosis (EPTB) is increasing; however, comprehensive data on its epidemiological and clinical characteristics remain limited, especially among populations who are co-infected with human immunodeficiency virus (HIV) or hepatitis C virus (HCV). This study aimed to assess the incidence and predictors of EPTB in patients co-infected with HIV or HCV in Egypt. We conducted a retrospective cohort study on patients infected with TB who are treated in Egyptian chest hospitals from January 1 to December 31, 2023. Patients were categorized into pulmonary TB (PTB) and EPTB. Clinical data, including HIV or HCV co-infection status, were analyzed to identify risk factors and comorbidities associated with EPTB. Multilevel logistic regression was employed to examine predictors of EPTB. Among 7,245 TB patients, 42.5% were diagnosed with EPTB. Determinant of EPTB were HIV-positive (OR = 0.46, 95% CI: 0.30-0.71, p < 0.001), being male (OR = 0.31, 95% CI: 0.27-0.35, p < 0.001 ), age (particularly children under 5 years) (OR = 4.75, 95% CI: 2.29-9.84, p < 0.001 ), urban residency (OR = 1.05, 95% CI: 0.87-1.27, p < 0.05), and comorbidities (OR = 0.59, 95% CI: 0.35-0.98, p < 0.05). The most common sites for EPTB were the lymph nodes (27.10%) and pleural cavity/effusion (24.60%). EPTB represents a substantial proportion of TB cases in Egypt, particularly among younger individuals and females. Despite the low percentage of HIV or HCV co-infection in EPTB cases, further analysis and diagnostic testing of undiagnosed patients are required. These findings underscore the need for targeted interventions and comprehensive care models for TB patients, especially in the context of HIV co-infection.

To predict cervical lymph node tuberculosis based on clinical-multimodal ultrasound radiomics model

OBJECTIVES

In practical clinical work, when sonographers extract image features, there may be large intra-observer and inter-observer variability in subjective description and visual evaluation. Lymph node tuberculosis is often confused with other diseases of lymphadenopathy. To avoid the shortcomings of ultrasound such as strong subjectivity and low repeatability, we discussed the clinical value of imaging models based on B-mode ultrasound (B-US), elastic ultrasound (EUS) and contrast-enhanced ultrasound (CEUS) images in predicting cervical lymph node tuberculosis (CLNT).

METHODS

Herein, 215 patients with cervical lymph node enlargement confirmed via international diagnostic criteria at our hospital between January 2018 and May 2023 were included. Patients were randomly divided into training (n = 151) and validation (n = 64) sets in a 7:3 ratio. Thereafter, 42 patients with cervical lymphadenopathy who underwent ultrasound-guided lymph node puncture from March 2023 to September 2023 were considered as a prospective internal validation set. Three models (radiomics model, clinical model and clinical-radiomics model) were established. Receiver operating characteristic curves (ROCs) of different models were drawn, and the area under the curve (AUC),were compared among them. Finally, the visual color band nomogram was established.

RESULTS

The AUC of the clinical-radiomics model in the training dataset, validation dataset and prospective validation dataset reached 0.959, 0.906 and 0.865, respectively. The clinical-radiomics model has good diagnostic efficacy in predicting CLNT.

CONCLUSIONS

The Multimodal ultrasound radiomics combined with clinical manifestations and imaging features, showed good judgment in identifying CLNT ability and good stability.

Application value of nucleic acid MALDI-TOF MS in mycobacterial species identification and drug resistance detection in Mycobacterium tuberculosis

Tuberculosis (TB) and non-tuberculous mycobacteria (NTM) infections pose global health threats, requiring swift and accurate identification for effective treatment. This study aims to assess the ability of nucleic acid matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) to rapidly identify Mycobacterium tuberculosis (MTB), NTM, and the drug resistance of MTB. A comparative analysis of 133 clinical samples was performed using acid-fast bacilli (AFB) staining, Lowenstein-Jensen (LJ) culture, GeneXpert, real-time PCR, and nucleic acid MALDI-TOF MS. The study focused on the diagnostic performance of nucleic acid MALDI-TOF MS in detecting MTB and NTM, as well as its accuracy in identifying the drug resistance profiles of MTB. The positive detection rate of nucleic acid MALDI-TOF MS for mycobacterium was 84.96%, which was significantly higher than that of AFB staining (29.32%). For NTM, nucleic acid MALDI-TOF MS had 89.29% sensitivity and 97.14% specificity, with an area under the curve (AUC) of 0.932, which was superior to other methods. The nucleic acid MALDI-TOF MS identified 28 NTM species, while real-time PCR identified only 12. Drug resistance detection showed concordance rates of 80% to 95% compared with drug sensitivity tests of LJ culture. Nucleic acid MALDI-TOF identified mutations, like KatG315 AGC-ACC for low-level isoniazid resistance, rpoB 531 TCG-TTG for high-level rifampicin resistance, and the InhA-15 C-T mutations, were also found in six isoniazid resistance cases and prothionamide resistance cases. Nucleic acid MALDI-TOF MS is a valuable diagnostic tool for the rapid and precise identification of mycobacterial species and the drug resistance profiles of MTB. With high sensitivity and specificity, it can guide the early initiation of effective anti-tuberculosis treatment in clinical settings.IMPORTANCETuberculosis (TB) remains a critical global health challenge, exacerbated by the emergence of drug-resistant strains. Accurate, rapid diagnosis is imperative for effective treatment and control of TB. The ability to discern MTB from NTM is equally vital, as they demand distinct therapeutic approaches. This study underscores the significance of nucleic acid matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) technology in providing a swift and precise diagnostic tool. Its high sensitivity and specificity in identifying mycobacterial species and their resistance profiles are paramount for guiding targeted anti-tuberculosis therapy. By potentially reducing the time to diagnosis and enabling personalized treatment plans, this technology could revolutionize TB management, ultimately mitigating its impact on public health.

Sclerotic Bone Adversely Affects Anti-Tuberculosis Drug Distribution in Patients with Spinal Tuberculosis: A Prospective Cross-Sectional Study

BACKGROUND

The effects of sclerotic bone on anti-tuberculosis (anti-TB) drug distribution in the blood and in spinal tuberculosis (STB) lesions were investigated.

METHODS

Fifty-six patients with STB were prospectively enrolled from January 2020 to March 2023 and were divided into 2 groups: a group with sclerotic bone and a group without sclerotic bone, as identified on preoperative computed tomography (CT) scans. Individuals in the sclerotic bone group were further divided into fragmentary and non-fragmentary sclerotic bone groups. The patients underwent surgery, and blood was collected along with normal vertebral and STB-lesion-containing bone tissue samples. Following treatment, the samples were processed by a pharmacological laboratory in order to detect the concentrations of anti-TB drugs, including pyrazinamide, rifampicin, isoniazid, and ethambutol.

RESULTS

Twenty-seven East Asian female and 29 East Asian male patients with STB were included in this study. The levels of anti-TB drugs showed a progressive decrease with increased circulatory distance, from blood to normal vertebral tissue to TB lesions, across all patient groups. Drug concentrations in TB lesions in the sclerotic bone group were significantly lower than those in the non-sclerotic bone group, as were concentrations in TB lesions in the non-fragmentary sclerotic bone group relative to those in the fragmentary sclerotic bone group. Drug levels in the blood and in normal vertebral bone tissue did not significantly differ between the sclerotic and non-sclerotic groups, nor between the fragmentary and non-fragmentary groups. Drug levels in the blood were linearly correlated with those in TB lesions in both the non-sclerotic bone group and the fragmentary sclerotic bone group.

CONCLUSIONS

These results indicate that sclerotic bone negatively affects the dissemination of anti-TB drugs, with non-fragmentary sclerotic bone posing a greater obstacle than fragmentary sclerotic bone. In patients with STB without sclerotic bone or with fragmentary sclerotic bone, anti-TB drug levels in the blood were linearly correlated with drug levels in STB lesions.

LEVEL OF EVIDENCE

Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Tuberculosis of the elbow joint: the complexity of diagnosis and treatment-A case report and review of literature

BACKGROUND

Tuberculosis is one of the deadliest diseases worldwide, with an estimated incidence of more than 10 million new cases annually. As part of bone and joint tuberculosis (5-6% of all extrapulmonary tuberculosis cases), elbow tuberculosis is a rare manifestation-especially in the Western world-and is associated with nonspecific symptoms such as swelling, redness, and painful limitation of motion. This often leads to initial misdiagnoses, such as septic arthritis or rheumatoid arthritis, resulting in a significant delay in diagnosis and treatment.

CASE PRESENTATION

A 27-year-old male patient from Bangalore, South India presented with left elbow pain and restricted motion. The clinical and imaging findings led to the suspicion of olecranon bursitis. Intraoperatively, joint tuberculosis was suspected; therefore, multiple tissue samples were taken and a diagnostic routine according to guidelines was initiated. The tuberculosis-specific interferon gamma test was positive and thus confirmed the patient's previous contact with Mycobacterium tuberculosis. Since extrapulmonary tuberculosis is often caused by multidrug-resistant mycobacterial strains, tuberculostatic therapy was started after obtaining the resistogram. Under the initiated therapy, a reduction in synovial inflammation on magnetic resonance imaging and a rehabilitation of the mobility of the elbow were achieved over a period of more than 15 months.

CONCLUSION

The basis for finding the diagnosis is a detailed, interdisciplinary diagnostic process, especially in patients with persisting unspecific symptoms, since joint tuberculosis is frequently the only site of manifestation. Despite the slow growth of mycobacteria, the microbiological findings, particularly the resistogram, should be awaited since extrapulmonary tuberculosis is often multidrug resistant. As shown in this case, surgical treatment is important for reliable diagnosis, including pathogen identification, but it is not mandatory for successful healing and regaining functionality of the affected joint.

Current Trends in Identification and Susceptibility Testing of Mycobacteria

While Mycobacterium species cause various infections, extrapulmonary tuberculosis (EPTB) and nontuberculous mycobacterial (NTM) infections were overlooked in the past. However, the incidence rates of these infections have increased over time. Similarly, there are limited testing modalities for diagnosing NTM and EPTB. In this review, we described the contemporary testing methods and associated challenges and benefits for NTM and EPTB.

Diagnostic accuracy of Mycobacterium tuberculosis-specific triple-color FluoroSpot assay in differentiating tuberculosis infection status in febrile patients with suspected tuberculosis

Objective

This study aims to evaluate the diagnostic accuracy of a Mycobacterium tuberculosis (MTB)-specific triple-color FluoroSpot assay (IFN-γ/IL-2/TNF-α) in the differentiation of tuberculosis (TB) infection status in febrile patients.

Method

Febrile patients with suspected active TB (ATB) were consecutively enrolled. The frequencies and proportions of MTB-specific T cells secreting IFN-γ, IL-2, and TNF-α were detected at the single-cell level by triple-color FluoroSpot assay. The diagnostic index was fitted with a binary logistic regression model, and the diagnostic accuracy was evaluated according to the receiver operating characteristic (ROC) curve. The sensitivity, specificity, predictive values (PV), and likelihood ratios (LR) were calculated.

Result

A total of 210 febrile patients were enrolled, 53 patients were diagnosed with ATB (28 pathogen-confirmed vs. 25 clinically diagnosed) and 157 patients were non-ATB (84 with latent tuberculosis infection (LTBI) vs. 73 uninfected with MTB). Additionally, 30 pathogen-confirmed ATB patients were assembled. When diagnosing ATB, the area under the ROC curve (AUROC) of the MTB-specific triple-color FluoroSpot assay was significantly better than that of T-SPOT.TB (0.882 vs. 0.811, p = 0.017). With the fitted diagnostic index at a cutoff value of 0.378, the sensitivity, specificity, LR+, and LR- were 74.7%, 93.0%, 10.66, and 0.27, respectively. When differentiating ATB from LTBI, the AUROC of the FluoroSpot assay and T-SPOT.TB was 0.878 and 0.692, respectively (p < 0.001). With a diagnostic index of 0.413, the sensitivity, specificity, LR+, and LR were 77.1%, 85.7%, 5.40, and 0.27, respectively.

Conclusion

The MTB-specific triple-color FluoroSpot (IFN-γ/IL-2/TNF-α) might be helpful for the differentiation of TB infection status in febrile patients.

Osteoarticular tuberculosis: imaging findings in pediatric patients

Osteoarticular tuberculosis (TB) is an uncommon form of extrapulmonary TB that has the potential to damage joints and bones, generating long-term impairment. Mainly, the initial diagnosis of osteoarticular TB relies on clinical findings and imaging. When required, imaging can aim for less invasive tissue or fluid sampling for pathology, microbiology, and molecular biology analysis. Most TB diagnosis tests have variable and frequently poor sensitivities; however, bone biopsy samples have demonstrated a high percentage of culture positivity. Clinical and imaging findings of osteoarticular TB often mimic other processes, such as rheumatoid arthritis or chronic recurrent multifocal osteomyelitis. When the infection affects the growth plates, angular deformities and extremity length discrepancies can arise. Unfortunately, several osteoarticular TB cases are detected late due to the nonspecific nature of clinical symptoms and non-characteristic imaging findings. This article reviews the most common and atypical osteoarticular TB imaging presentations to increase awareness of osteoarticular TB.

Factors associated with extrapulmonary tuberculosis in comparison to pulmonary tuberculosis in patients with and without HIV in Bogotá, Colombia: an observational study

Background

Extrapulmonary tuberculosis (EPTB) poses a public health challenge, particularly among individuals with human immunodeficiency virus (HIV). However, many EPTB cases arise in those without HIV, leaving the underlying factors unclear.

Objectives

This study aims to characterize patients with pulmonary tuberculosis (PTB) and EPTB, exploring the differences in associated factors for each type in patients with and without HIV.

Design

An analytical observational study was conducted on a cohort of tuberculosis (TB) patients diagnosed between 2014 and 2021 in a referral hospital in Bogotá, Colombia.

Methods

Patients were categorized into PTB or EPTB based on the site of infection. Data on demographic and clinical variables were collected, comparing the two groups. A multivariate logistic regression model was created to identify factors associated with EPTB compared to PTB.

Results

The study encompassed 533 patients: 310 with PTB and 223 with EPTB, of which only 65 (14.7%) were HIV positive. PTB patients exhibited higher rates of active smoking, smoking cessation, diabetes mellitus (DM), and other pulmonary diseases. The logistic regression identified HIV infection as the only factor associated with EPTB (OR 2.36 (1.54-3.61), p < 0.001). Conversely, quitting smoking (OR 0.58 (0.35-0.96) p = 0.038), DM (OR 0.41 (0.21-0.82) p = 0.011), chronic obstructive pulmonary disease (COPD) (OR 0.18 (0.08-0.4) p < 0.001), other pulmonary diseases (OR 0.21 (0.61-0.77) p = 0.019), or those using immunosuppressants (OR 0.44 (0.20-0.96) p = 0.04) exhibited a negative association with EPTB compared to PTB. Specific models for pleural and lymph node TB revealed distinct associations, with HIV strongly linked to lymph node TB (OR 3.38, 95% CI 1.57-7.26, p = 0.002).

Conclusion

EPTB is primarily associated with HIV infection, while smoking, DM, COPD, other pulmonary diseases, and immunosuppressant use are associated with PTB. Variability in associated factors for specific EPTB forms underlines the need for tailored research into the predisposing factors for EPTB, particularly in HIV-negative patients.

Reactive arthritis in connective tissue diseases; one should be vigilant for joint tuberculosis

The incidence of tuberculosis (TB) is increasing worldwide. Bone and joint TB are the most common types of extra-pulmonary TB, but can easily be misdiagnosed, since articular TB commonly mimics other joint diseases, including reactive and degenerative arthritis, and articular manifestations associated with systemic autoimmune diseases. Furthermore, patients with systemic auto-immune diseases are often more prone to mycobacterial infection. The diagnosis of joint TB can be made using a combination of the following methods: clinical evaluation, imaging, tuberculin skin test, interferon-gamma release assays, nucleic acid amplification tests, and Gene X-pert MTB/rifampicin assay.

Diagnostic Role of Tomography in Addison's Disease due to Adrenal Tuberculosis: A Case Report

INTRODUCTION

Adrenal tuberculosis remains the main cause of primary adrenal insufficiency (PAI) in tuberculosis (TB)-prevalent regions. This case report details the presentation of PAI due to adrenal TB, where the etiological diagnosis involves Abdominal Computed Tomography (CT).

CASE REPORT

A 37-year-old Peruvian woman with a history of TB contact displayed symptoms of adrenal insufficiency. PAI diagnosis was established, and CT imaging unveiled bilateral adrenal enlargement with calcifications. Treatment with prednisone and anti-TB therapy led to symptomatic improvement. Unfortunately, she succumbed to pneumonia after ten months of follow-up.

DISCUSSION

Adrenal TB must be considered in endemic regions and in the presence of a TB history. CT serves as a valuable diagnostic tool, particularly in settings with limited resources, revealing adrenal enlargement and calcifications.

CONCLUSION

In patients with PAI, epidemiological history of TB, and when a rapid biopsy is not feasible, CT proves to be a valuable diagnostic method.

Colliding Challenges Part 2: An Analysis of SARS-CoV-2 Infection in Patients with Extrapulmonary Tuberculosis Versus SARS-CoV-2 Infection Alone

Background and Objectives: Coinfection with SARS-CoV-2 and extrapulmonary tuberculosis (extraPTB) presents unique clinical challenges due to dual inflammatory responses and potential differences in patient profiles compared to those with SARS-CoV-2 infection alone. This study uniquely contributes to the underexplored interaction between extraPTB and SARS-CoV-2, focusing on systemic inflammation as a critical determinant of outcomes. Materials and Methods: This retrospective, cross-sectional study included 123 patients aged 19-91 years, hospitalized at Victor Babeș Hospital in Timișoara from March 2020 to March 2022. We compared 23 extraPTB and SARS-CoV-2 coinfected patients with 100 age-matched SARS-CoV-2-only patients. Clinical records were examined for demographic, clinical, and laboratory data. Results: The coinfected group was younger, with 65% under 40 years, and presented significantly higher IL-6, PCT, and transaminase levels. Coexisting COPD and type 2 diabetes were independent predictors of coinfection. A higher SpO2 at diagnosis was positively associated with coinfection likelihood (OR = 5.37), while CT scores indicated less pulmonary involvement in coinfected patients. Non-fatal outcomes were more frequent in the coinfection group (95.7% sensitivity), and only one coinfected patient had a fatal outcome versus 17 in the SARS-CoV-2-only group. Low SpO2 and elevated IL-6 were significant predictors of mortality, with severe symptoms tripling fatality odds. Conclusions: Coinfection with extraPTB and SARS-CoV-2 is associated with younger age, heightened systemic inflammation, and longer hospital stays but does not significantly increase mortality risk compared to SARS-CoV-2 alone. These findings underscore the importance of monitoring systemic inflammatory markers and developing tailored management strategies to improve long-term care outcomes for coinfected patients, especially in resource-limited settings.

Diagnostic value of IFN-gamma in tuberculous pleural effusion

BACKGROUND

Simple, rapid, and accurate diagnosis of tuberculous pleural effusion (TPE) remains challenging. This study aimed to determine the accuracy of IFN-γ in diagnosing TPE.

METHODS

We quantified the expression of interferon-gamma (IFN-γ) in blood (B), adenosine deaminase (ADA), and IFN-γ in pleural effusions (PE) from 25 TPE patients and 31 non-TPE patients using a combination of immunological assays and flow cytometric analysis. The diagnostic performance of these three biomarkers was evaluated using receiver operating characteristic (ROC) curves.

RESULTS

We found that IFN-γ levels in blood and pleural fluid were higher in the TPE group than in the non-TPE group. The mean concentration of IFN-γ in pleural fluid of the TPE group was 3140.90 (1817.94, 6611.05) pg/mL, while that of the non-TPE group was 4.91 (0.69, 8.6) pg/mL), and the difference was statistically significant (z = 6.39, P < 0.001). The mean blood IFN-γ was 40.19 (16.45, 59.08) pg/mL in the TPE group and 2.76 (1.96, 6.02) pg/mL in the non-TPE group, which was statistically different (z = 5.12, P < 0.001). The area under the ROC curve (AUC) for pleural fluid IFN-γ, blood IFN-γ, and ADA were 0.999 (95 % CI: 0.994-1.00), 0.901 (95 % CI: 0.798-1.00) and 0.996 (95 % CI: 0.987-1.00), respectively.

CONCLUSION

This study confirms that IFN-γ has high diagnostic validity in patients with TPE and can potentially be an excellent biomarker.

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.

A Multi Center, Epidemiological Study of Bone Tuberculosis in Southwest China from 2011 to 2023

BACKGROUND

Despite continued efforts to manage and control Tuberculosis (TB) in China, it remains a major health concern. Bone tuberculosis (Bone-TB), a common form of extrapulmonary tuberculosis, still adds considerably to the global TB case load. Diagnosing Bone-TB is often difficult as its symptoms can be similar to other bone or joint diseases, which leads to delayed detection and treatment. Currently, comprehensive reports on the epidemiological aspects of Bone-TB in China are scarce.

METHODS

This retrospective study analyzed demographic and clinical data from 2,191 patients diagnosed with Bone-TB in Southwest China between January 2011 and September 2023.This study fully reveals the characteristics of Bone-TB in Southwest China.

RESULTS

The overall trend of bone tuberculosis was a slow rise. Among 2191 patients, males, farmers, aged 42-68 years, and people with HIV and diabetes are the priority groups for the prevention and treatment of Bone-TB. The majority of the infected spines (1556/2191) were located in the thoracic vertebra (759/2191) and lumbar vertebra (715/2191). Forty-nine (2.24%) patients had drug-resistant TB (DR-TB). Forty-five (2.05%) died during the treatment. The total and actual hospitalization. Costs amounted to $3,837.10 and $1,914.35 (p < 0.01). Patients with DR-TB incurred the highest costs, amounting to $4,968.37. Cervical TB, with a prevalence of 5 patients (6.10%), exhibited the highest rates of catastrophic expenditures.

CONCLUSIONS

From 2011 to 2023, the yearly occurrence of Bone-TB in southwestern China exhibited a rising pattern, marked by notable distinctions in terms of gender, age, and regional variations, indicating localized clustering characteristics.

Analysis of the prevalence characteristics and risk factors of pulmonary tuberculosis combined with extrapulmonary tuberculosis in elderly patients

To analyze the clinical features, epidemiological characteristics, risk factors, and complication characteristics of pulmonary tuberculosis (PTB) combined with extrapulmonary tuberculosis (EPTB) in elderly patients (aged > 60 years). Clinical data were collected from pathogen positive elderly patients with PTB hospitalized in a teaching hospital in Zhejiang from 2017 to 2023. We retrospectively analyzed the risk factors for complications of EPTB in elderly patients with PTB by univariate and multivariate logistic regression models. We also described the characteristics of complications in PTB with EPTB. A total of 781 PTB elderly patients were enrolled, of whom 86 (11.01%) had complicated EPTB. The most commonly invasive sites for EPTB were thoracic spine (17.53%), cervical lymph nodes (13.40%), and meninges (12.37%). 60 < aged < 80 years (OR = 2.876, 95%CI 1.290-6.412; P = 0.010), anaemia (OR = 2.212, 95%CI 1.135-3.967; P = 0.018) and osteoporosis (OR = 4.925, 95%CI 1.501-16.160; P = 0.009) were the independent risk factors for PTB with EPTB infection. PTB with EPTB had a higher proportion of multiple serous cavity effusion (19.8% vs. 12.2%) and longer hospitalisation (17 vs. 15, P = 0.004). 60 < aged < 80 years, anaemia and osteoporosis were found to be independent risk factors for PTB with EPTB in elderly patients. We compared the epidemiological and clinical characteristics of PTB with EPTB. These results are important for improving the diagnosis of EPTB, reducing complications, and improving prognosis.

Gut microbiota: a crucial player in the combat against tuberculosis

The mammalian gastrointestinal tract quickly becomes densely populated with foreign microorganisms shortly after birth, thereby establishing a lifelong presence of a microbial community. These commensal gut microbiota serve various functions, such as providing nutrients, processing ingested compounds, maintaining gut homeostasis, and shaping the intestinal structure in the host. Dysbiosis, which is characterized by an imbalance in the microbial community, is closely linked to numerous human ailments and has recently emerged as a key factor in health prognosis. Tuberculosis (TB), a highly contagious and potentially fatal disease, presents a pressing need for improved methods of prevention, diagnosis, and treatment strategies. Thus, we aim to explore the latest developments on how the host's immune defenses, inflammatory responses, metabolic pathways, and nutritional status collectively impact the host's susceptibility to or resilience against Mycobacterium tuberculosis infection. The review addresses how the fluctuations in the gut microbiota not only affect the equilibrium of these physiological processes but also indirectly influence the host's capacity to resist M. tuberculosis. This work highlights the central role of the gut microbiota in the host-microbe interactions and provides novel insights for the advancement of preventative and therapeutic approaches against tuberculosis.

Biological and cytological-morphological assessment of tuberculous pleural effusions

AIM

Tuberculosis (TB) came back in the top of causes for infectious disease-related deaths and its pleural involvement is still in the top two extrapulmonary sites. The authors continued their studies on TB pleural effusions (Pl-Effs) with the assessment of biological and cytological variable of pleural fluid (PF), introducing in the investigation algorithm and testing a new tool, the computer-assisted evaluation of cell populations on PF smears.

PATIENTS, MATERIALS AND METHODS

A series of 85 patients with TB pleurisy (PLTB) were selected from a larger group of 322 patients with different types of Pl-Effs. The algorithm of investigation included. clinical variables, biological assays of PF, gross aspects including imagistic variables and PF cytology on May-Grünwald-Giemsa (MGG)-stained smears. All the data obtained were entered into and processed using Microsoft Excel module of the 2019 Microsoft Office Professional software along with the 2014 XLSTAT add-in program for MS Excel. The PF cellularity was assessed qualitatively by a cytologist and quantitatively with in-house software. Continuous variables were compared using Pearson's correlation test, while categorical variables were compared using χ² (chi-squared) test.

RESULTS

Our analysis showed that patients were usually males, aged between 25 and 44 years with Pl-Eff discovered at clinical imagistic examination, almost always one-sided and free in the pleural cavity. Its extension was either moderate or reduced. The PF had a serous citrine appearance in most of the cases, and biological characteristics pleaded for an exudate [high levels of proteins and lactate dehydrogenase (LDH)], with elevated adenosine deaminase (ADA) values and rich in lymphocytes (Ly). The attempt to identify the pathogen in PF was not of much help. Apart from Ly, neutrophils [polymorphonuclear neutrophils (PMNs)] were a rare presence and their amount had only a trend of direct correlation with Ly. The same situation was encountered in the case of mesothelial cells (MCs). The comparison between the qualitative and the quantitative, computer-assisted evaluations of cytological smears showed that the results of the two methods overlapped in less than one third of the cases, although the sensitivity and specificity values as well as the two calculated predictive values of the qualitative method were encouraging.

CONCLUSIONS

The assessment of biological variables and cell populations of the PF are basic tools in the diagnosis of pleural TB. The assessment of PF cell population could be improved by the use of computer-assisted quantitative analysis of the PF smears, which is simple to design, easy to introduce and handle and reliable.

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.

Analysis on the epidemiological and drug resistance characteristics of osteoarticular tuberculosis in South-central China

Objective

Osteoarticular tuberculosis (OATB) is one of the most common forms of extrapulmonary tuberculosis; however, limited epidemiological data are available on this public health concern worldwide, especially in developing countries. This study aimed to analyze the clinical epidemiology and drug resistance characteristics of OATB cases in Hunan province which located in South-central China.

Methods

We retrospectively enrolled OATB patients with Mycobacterium tuberculosis culture positive at Hunan Chest Hospital from January 2013 through March 31, 2022. The multiple demographic, clinical variables and drug susceptibility data of the patients were collected from the hospital's electronic patient records. Descriptive statistical methods, Chi-square test and logistic regression analysis were employed as statistical methods.

Results

Of the 269 OATB cases, 197 (73.23%) were males, 206 (76.85%) were farmers; patients' ages ranged from 5 to 85 years, 57 (21.19%) aged at 20-29 years old and 52 (19.33%) aged at 60-69 years old. In terms of the disease, 177 (65.80%) had spinal TB with most occurrence in lumbar vertebrae (26.02%, 70/269), multiple spinal sites (18.96%, 51/269) and thoracic vertebrae (15.24%, 41/269). Outside of the spine, OATB mainly occurred in the lower limb (13.38%, 36/269). In terms of drug resistance, 40 (14.87%) and 72 (26.77%) were resistant to rifampicin (RFP) and isoniazid (INH) respectively; 38 (14.13%) were multi-drug resistant (MDR), and a total of 78 (29.00%) isolates were drug resistant. OATB patients aged 40-49 years old (compared to those aged ≥70 years) and from the west of Hunan province, China (compared to those from the center of Hunan) were at risk for developing RR/MDR (ORs were 5.057 and 4.942, respectively; 95% CIs were 1.009-25.342 and 1.458-16.750, respectively).

Conclusion

In South-central China, OATB mainly affected males, farmers and those aged 20-29 and 60-69 years old. Spinal TB is prone to occur in the lumbar and multiple spinal sites. The resistance situation of OATB was serious, and people aged 40-49 years old and patients from the west of Hunan were risk factors of RR/MDR. All these findings will help to improve the prevention, diagnosis and treatment strategies of OATB.

Analysis of unsuccessful tests and the effect of prolonged clinical sample preprocessing in the GeneXpert MTB/RIF assay

BACKGROUND

The GeneXpert MTB/RIF (Xpert) assay is a widely used technology for detecting Mycobacterium tuberculosis (MTB) in clinical samples. However, the study on the failure of the Xpert assay during routine implementation and its potential solutions is limited.

METHODS

We retrospectively analyzed the records of unsuccessful tests in the Xpert and the GeneXpert MTB/RIF Ultra (Ultra) assays between April 2017 and April 2021 at the Shanghai Public Health Clinical Center. To further investigate the effect of prolonged preprocessing on clinical sputum, an additional 120 sputum samples were collected for Xpert testing after 15 min, 3 h, and 6 h preprocessing. The analysis was performed by SPSS version 19.0 software.

RESULTS

A total of 11,314 test records were analyzed, of which 268 (2.37%) had unsuccessful test results. Among these, 221 (1.95%) were reported as "Error", 43 (0.38%) as "Invalid", and 4 (0.04%) as "No result". The most common clinical specimen for Xpert tests was sputum, accounting for 114 (2.17%) unsuccessful tests. The failure rate of urine specimens was lower than that of sputum (OR = 0.12, 95% CI: 0.02-0.88, χ2 = 6.22, p = 0.021). In contrast, the failure rate of stool specimens was approximately twice as high as that of sputum (OR = 1.93, 95% CI: 1.09-3.40, χ2 = 5.35, p = 0.014). In the prolonged preprocessing experiment, 102 cases (85%) yielded consistent results in Xpert tests. Furthermore, 7 cases (5.83%) detected an increase in MTB load, 8 cases (6.67%) detected a decrease in MTB load, and 3 cases (2.5%) yielded incongruent results in MTB and rifampicin resistance detection.

CONCLUSIONS

The primary cause of unsuccessful tests in the Xpert assay was reported as "Error". Despite varying failure rates depending on the samples, the Xpert assay can be applied to extrapulmonary samples. For paucibacillary specimens, retesting the remaining preprocessed mixture should be carefully considered.

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.

Analysis of epidemiological characteristics of extrapulmonary tuberculosis from South-Central China

Objectives

This study aimed to investigate the epidemiological and drug resistance (DR) characteristics of extrapulmonary tuberculosis (EPTB) in South-Central China.

Methods

EPTB inpatients who were culture-positive for Mycobacterium tuberculosis were retrospectively included in a study at a provincial TB hospital in Hunan, a province in South-Central China, from January 2013 to December 2021. Demographic, clinical, and drug susceptibility data were retrieved from TB treatment records. Descriptive statistical methods and a Chi-squared test were used to analyze the epidemiological and DR characteristics of EPTB patients. A logistic regression model was used to explore the risk factors of rifampicin-resistant/multidrug-resistant (RR/MDR)-EPTB.

Results

A total of 1,324 cases were included. The majority of EPTB patients were in the age range of 20-29 years, were predominantly men (male-to-female ratio: 2.03), and were farmers (65.63%). Most EPTB cases were found in 2013 and 2017 from 2013 to 2021. The most prevalent subtypes of EPTB were lymphatic TB (29.83%, 395/1,324), multiple EPTB (20.85%, 276/1,324), and musculoskeletal TB (14.65%, 194/1,324). Musculoskeletal TB and genitourinary TB predominantly presented as exclusive EPTB forms, while lymphatic TB and pharyngeal/laryngeal TB often co-occurred with pulmonary TB (PTB). Drug susceptibility testing results showed that total DR rates (resistance to any of RFP, isoniazid [INH], streptomycin [STR], and/or ethambutol [EMB]) and RR/MDR rates in EPTB were 25.23% and 12.39%, respectively. Musculoskeletal TB exhibited the highest rates of total DR (31.40%), INH resistance (28.90%), STR resistance (20.10%), EMB resistance (6.20%), MDR (13.90%), and poly-DR (6.70%). The multivariable logistic regression model showed that patients aged from 20 to 59 years (compared to those aged 10 years), workers (compared to retirees), and EPTB patients from the south and west of Hunan (compared to those from the east of Hunan) were at an increased risk of developing RR/MDR EPTB (all OR values > 1).

Conclusion

Our study provided a detailed account of the epidemiological and DR characteristics of EPTB in Hunan province, China. The significant DR rates, particularly in musculoskeletal TB cases, highlight the need for timely diagnosis, effective drug susceptibility testing, and the development of more effective treatment regimens for EPTB, especially targeting musculoskeletal TB treatments.

Recognizing and addressing the challenges of gastrointestinal tuberculosis

In this editorial, we comment on the article by Ali et al published in the recent issue of the World Journal of Clinical Cases. This case report shed light on a particularly rare manifestation of this disease-primary gastrointestinal tuberculosis (GTB) presenting as gastric outlet obstruction. GTB presents diagnostic challenges due to its nonspecific symptoms and lack of highly accurate diagnostic algorithms. This editorial synthesizes epidemiological data, risk factors, pathogenesis, clinical presentations, diagnostic methods, and therapies to raise awareness about GTB. GTB constitutes 1%-3% of all tuberculosis cases globally, with 6%-38% of patients also having pulmonary tuberculosis. Pathogenesis involves various modes of Mycobacterium tuberculosis complex entry into the gastrointestinal system, with the terminal ileum and ileocecal valve commonly affected. Clinical presentation varies, often resembling other intra-abdominal pathologies, necessitating a high index of suspicion. Diagnostic tools include a combination of biochemical, microbiological, radiological, and endoscopic assessments. Anti-tubercular medication remains the cornerstone of treatment, supplemented by surgical intervention in severe cases. Multidisciplinary management involving gastroenterologists, surgeons, pulmonologists, and infectious disease specialists is crucial for optimal outcomes. Despite advancements, timely diagnosis and management challenges persist, underscoring the need for continued research and collaboration in addressing primary GTB.

Analysis on epidemiological and drug resistance characteristics of lymph node tuberculosis from Hunan province, China

Objectives

To investigate the clinical epidemiological and drug resistance (DR) characteristics of lymph node tuberculosis (LNTB) in Hunan Province which locates in South-central China, and to provide scientific clues for effective prevention and treatment of LNTB.

Methods

We retrospectively collected LNTB patients with Mycobacterium tuberculosis culture positive at Hunan Chest Hospital, the biggest TB reference hospital in South-central China, from January 2013 to December 2021. The multiple demographic, clinical and drug susceptibility data of patients were collected from the hospital's electronic patient records. Descriptive statistical methods, Chi-square test and logistic regression analysis were employed as statistical methods.

Results

Of the 577 LNTB cases, 373 (64.64%) were males, 352 (61.01%) were farmers; majority (161, 33.10%) aged at 20-29 years old; 147 (25.48%) had simple LNTB, 350 (60.66%) had LNTB combined with pulmonary TB (PTB) (defined as LNTB-PTB), and 80 (13.86%) had LNTB combined with other extrapulmonary TB (EPTB) (defined as LNTB-EPTB). A total of 345 (59.79%, 345/577) LNTB patients had cervical node infection, and the simple LNTB patients (81.63%, 120/147) had higher proportion of this infection than LNTB-PTB (51.71%, 181/350) and LNTB-EPTB (55.00%, 44/80) (both p values <0.017), respectively. LNTB-EPTB was more inclined to have abdominal tuberculous LNs (20%, 16/80) and at least four tuberculous lesions (22.50%, 18/80) than simple LNTB and LNTB-PTB. Seventy-seven (13.34%) and 119 (20.62%) were resistant to rifampicin (RIF) and isoniazid (INH), respectively; 72 (12.48%) were multi-drug resistant (MDR), and a total of 150 (26.00%) were DR (resistant to at least one of RIF, INH, ethambutol and streptomycin). LNTB patients aged 30-34 and 50-54 years old (compared to those aged <30 years) were independent predictors of RIF resistance (RR) (ORs were 3.47 and 2.83, respectively; 95% CIs were 1.64-7.35 and 1.08-7.46, respectively).

Conclusion

Our study disclosed the epidemiological and DR characteristics of LNTB in Hunan Province, China. High LNTB prevalence was found in younger people while high RR LNTB prevalence was found in older ones, suggesting that we should conduct further studies to clarify the occurrence of RR in LNTB, meanwhile, strengthen the diagnoses and treatments of LNTB to prevent the emergence of RR.

Blood RNA signatures outperform CRP triage of tuberculosis lymphadenitis and pericarditis

Background

Limited data are available on the diagnostic accuracy of blood RNA biomarker signatures for extrapulmonary TB (EPTB). We addressed this question among people investigated for TB lymphadenitis and TB pericarditis, in Cape Town, South Africa.

Methods

We enrolled 440 consecutive adults referred to a hospital for invasive sampling for presumptive TB lymphadenitis (n=300) or presumptive TB pericarditis (n=140). Samples from the site of disease underwent culture and/or molecular testing for Mycobacterium tuberculosis complex (Mtb). Discrimination of patients with and without TB defined by microbiology or cytology reference standards was evaluated using seven previously reported blood RNA signatures by area under the receiver-operating characteristic curve (AUROC) and sensitivity/specificity at predefined thresholds, benchmarked against blood C-reactive protein (CRP) and the World Health Organization (WHO) target product profile (TPP) for a TB triage test. Decision curve analysis (DCA) was used to evaluate the clinical utility of the best performing blood RNA signature and CRP.

Results

Data from 374 patients for whom results were available from at least one microbiological test from the site of disease, and blood CRP and RNA measurements, were included. Using microbiological results as the reference standard in the primary analysis (N=204 with TB), performance was similar across lymphadenitis and pericarditis patients. In the pooled analysis of both cohorts, all RNA signatures had comparable discrimination with AUROC point estimates ranging 0.77-0.82, superior to that of CRP (0.61, 95% confidence interval 0.56-0.67). The best performing signature (Roe3) achieved an AUROC of 0.82 (0.77-0.86). At a predefined threshold of 2 standard deviations (Z2) above the mean of a healthy reference control group, this signature achieved 78% (72-83%) sensitivity and 69% (62-75%) specificity. In this setting, DCA revealed that Roe3 offered greater net benefit than other approaches for services aiming to reduce the number needed to investigate with confirmatory testing to <4 to identify each case of TB.

Interpretation

RNA biomarkers show better accuracy and clinical utility than CRP to trigger confirmatory TB testing in patients with TB lymphadenitis and TB pericarditis, but still fall short of the WHO TPP for TB triage tests.

Funding

South African MRC, EDCTP2, NIH/NIAID, Wellcome Trust, NIHR, Royal College of Physicians London.

Research in context

Evidence before this study: Blood RNA biomarker signatures and CRP measurements have emerged as potential triage tests for TB, but evidence is mostly limited to their performance in pulmonary TB. Microbiological diagnosis of extrapulmonary TB (EPTB) is made challenging by the need for invasive sampling to obtain tissue from the site of disease. This is compounded by lower sensitivity of confirmatory molecular tests for EPTB compared to their performance in pulmonary disease. We performed a systematic review of diagnostic accuracy studies of blood RNA biomarkers or CRP measurements for EPTB, which could mitigate the need for site-of-disease sampling for the diagnosis of TB. We searched PubMed up to 1 st August 2023, using the following criteria: "extrapulmonary [title/abstract] AND tuberculosis [title/abstract] AND biomarker [title/abstract]". Although extrapulmonary TB was included in several studies, none focused specifically on EPTB or included an adequate number of EPTB cases to provide precise estimates of test accuracy. Added value of this study: To the best of our knowledge, we report the first diagnostic accuracy study of blood RNA biomarkers and CRP for TB among people with EPTB syndromes. We examined the performance of seven previously identified blood RNA biomarkers as triage tests for TB lymphadenitis and TB pericarditis compared to a microbiology reference standard among people referred to hospital for invasive sampling in a high TB and HIV prevalence setting. Multiple blood RNA biomarkers showed comparable diagnostic accuracy to that previously reported for pulmonary TB in both EPTB disease cohorts, irrespective of HIV status. All seven blood RNA biomarkers showed superior diagnostic accuracy to CRP for both lymphadenitis and pericarditis, but failed to meet the combined >90% sensitivity and >70% specificity recommended for a blood-based diagnostic triage test by WHO. Nonetheless, in decision curve analysis, an approach of using the best performing blood RNA biomarker to trigger confirmatory microbiological testing showed superior clinical utility in clinical services seeking to reduce the number needed to test (using invasive confirmatory testing) to less than 4 for each EPTB case detected. If acceptable to undertake invasive testing in more than 4 people for each true case detected, then a test-all approach will provide greater net benefit in this TB/HIV hyperendemic setting.Implications of all the available evidence: Blood RNA biomarkers show some potential as diagnostic triage tests for TB lymphadenitis and TB pericarditis, but do not provide the level of accuracy for blood-based triage tests recommended by WHO for community-based tests. CRP has inferior diagnostic accuracy to blood RNA biomarkers and cannot be recommended for diagnostic triage among people with EPTB syndromes referred for invasive sampling.

A new nomogram based on ultrasound and clinical features for distinguishing epididymal tuberculosis and nontuberculous epididymitis

Using ultrasound findings and clinical characteristics, we constructed and validated a new nomogram for distinguishing epididymal tuberculosis from nontuberculous epididymitis, both of which share similar symptoms. We retrospectively examined data of patients with epididymal tuberculosis and nontuberculous epididymitis hospitalized between January 1, 2013, and March 31, 2023. Eligible patients were randomly assigned to derivation and validation cohorts (ratio, 7:3). We drew a nomogram to construct a diagnostic model through multivariate logistic regression and visualize the model. We used concordance index, calibration plots, and decision curve analysis to assess the discrimination, calibration, and clinical usefulness of the nomogram, respectively. In this study, 136 participants had epididymal tuberculosis and 79 had nontuberculous epididymitis. Five variables-C-reactive protein level, elevated scrotal skin temperature, nodular lesion, chronic infection, and scrotal skin ulceration-were significant and used to construct the nomogram. Concordance indices of the derivation and validation cohorts were 0.95 and 0.96, respectively (95% confidence intervals, 0.91-0.98 and 0.92-1.00, respectively). Decision curve analysis of this nomogram revealed that it helped differentiate epididymal tuberculosis from nontuberculous epididymitis. This nomogram may help clinicians distinguish between epididymal tuberculosis and nontuberculous epididymitis, thereby increasing diagnosis accuracy.

Insights into changing patterns of extrapulmonary tuberculosis in North India

PURPOSE

Tuberculosis is one of the dreadful infections and India contributes to substantial burden of TB cases globally. Though majority of cases are pulmonary, extra-pulmonary tuberculosis (EPTB) share significant burden, more in HIV-positive persons. Despite the striking burden, very few studies have been conducted in India and present study was undertaken to determine trends of EPTB at our tertiary care centre.

METHODS

This was a retrospective study conducted over a period of 4 years 3 months. Diagnosis of EPTB was based on suspected clinical features, with positive micobiological evidence with cartridge based nucleic acid amplification test (CBNAAT) with/without microscopy.

RESULTS

A total of 10,560 samples (pulmonary and extra-pulmonary) were received during the study period, of which 3972 were extrapulmonary. Of these, a total of 18% were noted to be positive for EPTB. Trend of positivity revealed highest burden in 2018 and a decline was noted over the years, however, rise in cases was noted in 2022. Pleural, meningitis, musculoskeletal, peritoneal and pericardial TB was more common in males, while lymphadenitis was more common in females (p value: <0.0001). Pleural TB (31%) was the most common presentation, followed by lymphadenitis. A gradual decline in lymphadenitis was noted with significantly increasing trend only for musculoskeletal TB. Rifampicin resistance was detected in 7.45% of positive samples, of which the maximum rate of resistance was noted in lymph node aspirates (11.11%), followed by musculoskeletal and pleural samples.

CONCLUSION

The present study showed a gradual decline in positivity of EPTB cases over the years. Younger productive age group with more propensity to transmit infection was the most commonly affected, with pleural TB as the most common presentation. Rare presentations of EPTB also contributed major share. Higher rates of resistance underline requisite to strengthen ongoing programs, to achieve the End TB strategy by 2025.

Morphological manifestation of tuberculous pleurisy in children under medical thoracoscope and diagnostic value

OBJECTIVE

Our study analyzed the main manifestations of tuberculous pleurisy (TBP) in children under medical thoracoscopy (MT). This article aimed to explore the clinical application value of MT in the diagnosis and treatment of TBP in children.

METHODS

In our study, we selected 23 TBP patients diagnosed in our hospital. We analyzed the clinical data and thoracoscopic morphology of these patients. At the same time, we also observed the pathological manifestations, acid-fast staining, and treatment effects of the patient's diseased tissue under MT.

RESULTS

The MT clinical findings of TBP patients include pleural hyperemia and edema, miliary nodules, scattered or more white nodules, simple pleural adhesion, wrapped pleural effusion, massive cellulose exudation, yellow-white caseous necrosis, pleural hyperplasia and hyperplasia, and mixed pleural necrosis. The positive rate of pleural biopsy was 73.91% and that of acid-fast staining was 34.78%. The main pathologic types of these patients were tuberculous granulomatous lesions (16 cases), caseous necrosis (5 cases), and fibrinous exudative, multinucleated giant cell and other inflammatory cell infiltration lesions (13 cases). The average time of diagnosis of the 23 patients was 8.32 days (5.0-16.0 days), and they were transferred to specialized hospitals for treatment after diagnosis. The mean time of chest drainage was 3.0-5.0 days after treatment. The average time for their body temperature to return to normal was 3.31 days (2.0-5.0 days).

CONCLUSION

Thoracoscopic lesions of TBP in children are varied. The use of MT is not only helpful for the early diagnosis and treatment of TBP. It also protects and improves lung function. Therefore, the use of MT has high clinical value.

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.

Unusual presentation of bilateral tuberculous otomastoiditis with tuberculous spondylitis in a 14-year-old child: A case report

Tuberculous otomastoiditis, a rare manifestation of tuberculosis in the head and neck region, poses diagnostic and therapeutic challenges due to its non-specific clinical features and potential debilitating complications. While typically arising from direct spread from adjacent organs, the coexistence of tuberculous otomastoiditis and cervical spondylitis is rarely reported. We present the case of a 14-year-old male with a 3-month history of painless bilateral ear discharge resistant to antibiotic therapy. The clinical and radiological findings raised suspicions of tuberculous otomastoiditis and spondylitis, which was later confirmed by histopathological examination despite negative microbiological cultures. This case underscores the significance of considering tuberculosis in conditions involving multiple organs, especially when persistent extensive damage is observed despite optimal initial treatments.

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.

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.

A Study on Risk Factors for Readmission of Elderly Patients with Pulmonary Tuberculosis Within One Month Using Propensity Score Matching Method

Objective

Exploring the risk factors for readmission of elderly patients with pulmonary tuberculosis (PTB) within one month using the propensity score matching(PSM).

Methods

A retrospective analysis was conducted on the clinical data of elderly patients with PTB who were admitted to the Tuberculosis Department of Lishui Hospital of Traditional Chinese Medicine from January 2020 to October 2023. The patients were divided into two groups: non-readmission group and readmission group based on whether they were readmitted within one month after discharge. The PSM method was used to match the baseline data of the two groups of patients, and multivariate logistic regression analysis was conducted to explore the risk factors for readmission of elderly patients with PTB within one month after discharge.

Results

A total of 1268 hospitalized elderly patients with PTB were included in the study, comprising 977 readmitted patients and 291 newly admitted patients (22.95%). Using the PSM, 288 pairs of patients were successfully matched. Following matching, there were no statistically significant differences between the two groups in terms of gender, age, occupation, body mass index(BMI), past medical history, etc. (all P>0.05). Multivariate logistic regression analysis indicated that infection, drug-induced liver injury(DILI), acute heart failure(AHF), chronic kidney disease(CKD), and extrapulmonary tuberculosis(EPTB) were all identified as risk factors for readmission of elderly patients with PTB.

Conclusion

After controlling for confounding factors through PSM, the study revealed that infection, DILI, AHF, CKD, and EPTB are risk factors for readmission among elderly patients with PTB, highlighting the need for early intervention.

Integrating systemic immune-inflammation index, fibrinogen, and T-SPOT.TB for precision distinction of active pulmonary tuberculosis in the era of mycobacterial disease research

Background

The clinical challenge of differentiating suspected tuberculosis with positive T-SPOT.TB results persist. This study aims to investigate the utility of the Systemic Immune-Inflammation Index (SII), Fibrinogen, and T-SPOT.TB in distinguishing between active pulmonary tuberculosis (PTB) and non-tuberculous lung diseases.

Methods

A retrospective analysis included 1,327 cases of active PTB with positive T-SPOT.TB results and 703 cases of non-tuberculous lung diseases from May 2016 to December 2020 at Meizhou People's Hospital. These were designated as the case group and the control group, respectively. The detection indicators of T-SPOT.TB: Early Secreted Antigenic Target 6 (ESAT-6), Culture Filtrate Protein 10 (CFP-10), as well as SII and Fibrinogen levels-were compared and analyzed for association and joint diagnostic value between the two groups.

Results

The case group showed higher values of ESAT-6, CFP-10, SII, and Fibrinogen compared to the control group (all p < 0.001). In the case group, SII and Fibrinogen did not correlate with ESAT-6 and CFP-10 (∣rs∣ all < 0.3) but were positively correlated with C-reactive protein (CRP; rs all > 0.3). SII and Fibrinogen values in smear-positive pulmonary tuberculosis were higher than in smear-negative cases (all p < 0.05). The optimal diagnostic thresholds for ESAT-6, CFP-10, SII, and Fibrinogen in differentiating between active PTB and non-tuberculous lung diseases were 21.50 SFCs/106 PBMC, 22.50 SFCs/106 PBMC, 2128.32, and 5.02 g/L, respectively. Regression logistic analysis showed that ESAT-6 < 21.5 (OR: 1.637, 95% CI: 1.311-2.043, p < 0.001), CFP-10 < 22.5 (OR: 3.918, 95% CI: 3.138-4.892, p = 0.025), SII < 2128.32 (OR: 0.763, 95% CI: 0.603-0.967, p < 0.001), and FIB < 5.02 (OR: 2.287, 95% CI: 1.865-2.806, p < 0.001) were independent risk factors for active PTB. The specificity for ESAT-6 + CFP-10, ESAT-6 + CFP-10 + SII, ESAT-6 + CFP-10 + FIB, and ESAT-6 + CFP-10 + SII + FIB was 82.5%, 83.2%, 95.8%, and 80.1%, respectively, while sensitivity was 52.6%, 53.0%, 55.8%, and 44.7%, and positive predictive values were 85.0%, 85.6%, 84.1%, and 89.6%, respectively.

Conclusion

SII and Fibrinogen are positively correlated with the degree of tuberculosis inflammation and the bacterial load of Mycobacterium tuberculosis. The combined detection of SII, Fibrinogen, and T-SPOT.TB is significant in distinguishing between active PTB with positive T-SPOT.TB results and non-tuberculous lung diseases.

Predictors of tuberculosis treatment outcomes among people living with HIV in some States in Nigeria

Introduction

tuberculosis (TB) and Human Immunodeficiency Virus (HIV) remain major public health threats globally and worse when they co-exist in susceptible individuals. The study examined TB treatment outcomes and their predictive factors among people living with HIV (PLHIVs).

Methods

a review of TB/HIV co-infected patients who had TB treatments across comprehensive antiretroviral therapy (ART) sites with ≥500 patients was conducted in seven United States of America President's Emergency Plan for AIDS Relief (PEPFAR)-supported States in Nigeria. Data on patient background, HIV and TB care, and TB treatment outcomes were collected using an Excel abstraction template. The data was analyzed using SPSS and an association was examined using a chi-square test while binary logistic regression was used to determine predictors of TB treatment outcomes (P< 0.05).

Results

two thousand six hundred and fifty-two co-infected patients participated in the study. The mean age of participants was 37 ± 14 years. A majority had TB treatment success (cured = 1059 (39.9%), completed = 1186 (44.7%)). Participants who had pulmonary TB, virally suppressed and commenced isoniazid (INH) before TB diagnosis were more likely to have a favorable TB treatment outcome compared to those who had extrapulmonary TB (AOR = 7.110, 95% CI = 1.506 - 33.565), virally unsuppressed (AOR = 1.677, 95% CI = 1.036 - 2.716) or did not commence INH before TB diagnosis (AOR = 1.486, 95% CI = 1.047 - 2.109).

Conclusion

site of infection, immune status, exposure to ART, and INH prophylaxis were found to predict TB treatment outcomes among PLHIVs. Stakeholders should ensure early commencement of ART and INH prophylaxis for PLHIVs.

Assessing the risk of concurrent mycoplasma pneumoniae pneumonia in children with tracheobronchial tuberculosis: retrospective study

Objective

This study aimed to create a predictive model based on machine learning to identify the risk for tracheobronchial tuberculosis (TBTB) occurring alongside Mycoplasma pneumoniae pneumonia in pediatric patients.

Methods

Clinical data from 212 pediatric patients were examined in this retrospective analysis. This cohort included 42 individuals diagnosed with TBTB and Mycoplasma pneumoniae pneumonia (combined group) and 170 patients diagnosed with lobar pneumonia alone (pneumonia group). Three predictive models, namely XGBoost, decision tree, and logistic regression, were constructed, and their performances were assessed using the receiver's operating characteristic (ROC) curve, precision-recall curve (PR), and decision curve analysis (DCA). The dataset was divided into a 7:3 ratio to test the first and second groups, utilizing them to validate the XGBoost model and to construct the nomogram model.

Results

The XGBoost highlighted eight significant signatures, while the decision tree and logistic regression models identified six and five signatures, respectively. The ROC analysis revealed an area under the curve (AUC) of 0.996 for XGBoost, significantly outperforming the other models (p < 0.05). Similarly, the PR curve demonstrated the superior predictive capability of XGBoost. DCA further confirmed that XGBoost offered the highest AIC (43.226), the highest average net benefit (0.764), and the best model fit. Validation efforts confirmed the robustness of the findings, with the validation groups 1 and 2 showing ROC and PR curves with AUC of 0.997, indicating a high net benefit. The nomogram model was shown to possess significant clinical value.

Conclusion

Compared to machine learning approaches, the XGBoost model demonstrated superior predictive efficacy in identifying pediatric patients at risk of concurrent TBTB and Mycoplasma pneumoniae pneumonia. The model's identification of critical signatures provides valuable insights into the pathogenesis of these conditions.

Impact on tuberculosis diagnostic during COVID-19 pandemic in a tertiary care hospital

INTRODUCTION

The aim of this study is to review how did the first three COVID-19 waves affected the diagnostic of tuberculosis and to describe the extra-pulmonary Mycobacterium tuberculosis complex (TB) diagnosis.

MATERIALS AND METHODS

A retrospective observational study was done during the first three waves of pandemic to ascertain the impact on TB samples and to recover the extra-pulmonary TB cases we included the first two years of COVID-19. All relevant data was recovered from hospital and Clinical Microbiology records.

RESULTS

Prepandemic period showed an average of 44 samples per week for TB study; during the first three waves this number dropped to 23.1 per week. A reduction of 67.7% of pulmonary TB diagnosis was observed and an increase of 33.3% diagnosis of extra-pulmonary TB was noted when comparing pre-pandemic and pandemic period.

DISCUSSION

The number of declared cases and samples for TB diagnosis dropped during the first three COVID-19 waves due to the overstretched Public Health System which could lead to a delay in diagnosis, treatment and to the spread of TB disease in the general population. Surveillance programs should be reinforced to avoid this.

Risk factors for tuberculosis-related death among adults with drug-sensitive pulmonary tuberculosis in Selangor, Malaysia from 2013 to 2019: a retrospective cohort study using surveillance data

OBJECTIVES

Due to the paucity of literature on risk factors for tuberculosis (TB)-related death, we determine the sociodemographic and clinical risk factors associated with TB-related deaths among adult pulmonary TB (PTB) patients on treatment in Selangor, Malaysia.

DESIGN

Retrospective cohort study.

SETTING

Routinely collected primary care data from all government TB clinics in Selangor.

PARTICIPANTS

Data of 24 570 eligible adult PTB patients from 2013 to 2019 were obtained from Selangor's State Health Department surveillance records. We included PTB patients aged at least 15 years old at the time of diagnosis with complete documentation of the dates of diagnosis, treatment initiation, end of treatment/follow-up and treatment outcomes. We excluded patients whose diagnoses were changed to non-TB, post-mortem TB diagnosis and multidrug-resistant TB (MDR-TB) patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

TB-related death, determined from the recorded physicians' consensus during the TB mortality meeting.

RESULTS

TB-related death was significantly associated with far (adjusted HR (aHR) 9.98, 95% CI 4.28 to 23.28) and moderately advanced (aHR 3.23, 95% CI 1.43 to 7.31) radiological findings at diagnosis; concurrent TB meningitis (aHR 7.67, 95% CI 4.53 to 12.98) and miliary TB (aHR 6.32, 95% CI 4.10 to 9.74) involvement; HIV positive at diagnosis (aHR 2.81, 95% CI 2.21 to 3.57); Hulu Selangor (aHR 1.95, 95% CI 1.29 to 2.93), Klang (aHR 1.53, 95% CI 1.18 to 1.98) and Hulu Langat (aHR 1.31, 95% CI 1.03 to 1.68) residing districts; no formal education (aHR 1.70, 95% CI 1.23 to 2.35); unemployment (aHR 1.54, 95% CI 1.29 to 1.84), positive sputum smear acid-fast bacilli (AFB) at diagnosis (aHR 1.51, 95% CI 1.22 to 1.85); rural residency (aHR 1.39, 95% CI 1.13 to 1.72) and advancing age (aHR 1.03, 95% CI 1.02 to 1.03).

CONCLUSIONS

Far and moderately advanced radiological findings, concurrent TB meningitis and miliary TB involvement, HIV positive, Hulu Selangor, Klang and Hulu Langat residing districts, no formal education, unemployment, positive sputum smear AFB, rural residency and advancing age are risk factors of TB-related death. Our findings should assist in identifying high-risk patients requiring interventions against TB-related death.

Tuberculosis in Sudan: systematic review and meta analysis

Every year, 10 million people fall ill with tuberculosis (TB). Despite being a preventable and curable disease, 1.5 million people die from TB each year -making it the world's top infectious disease. TB is the leading cause of death of people with HIV and also a major contributor to antimicrobial resistance. Its presumed that TB was the cause of 1% of the total deaths among inpatients in Sudan in 2017. The current study is aimed to provide pooled prevalence of Mycobacterium tuberculosis among Sudanese as well as to determine any socio-cultural risk factors associated. A systematic review of the literature was conducted and regulated in accordance with the PRISMA Statement. After abstract and full text screening only twenty-six articles met our inclusion criteria and passed the quality assessment procedure. Pulmonary tuberculosis prevalence was assessed in sixteen included studies among participants from Khartoum, Gezira, Kassala, Blue Nile, River Nile, White Nile, Gadarif, Red sea, North Kordofan, Northern State, Sennar and West Darfur States, representing a total sample size of 11,253 participants of suspected individuals such as febrile outpatients, TB patients' contacts and other groups such as HIV/AIDS patients, hemodialysis patients, School adolescents as well as pregnant women. The pooled prevalence was 30.72% [CI: 30.64, 30.81]. Moreover, Khartoum State recorded the highest pooled prevalence as 41.86% [CI: 14.69, 69.02] based on a total sample size of 2,737 participants. Furthermore, male gender and rural residence were found to be significantly associated with TB infection. Further research with larger sample sizes targeting prevalence and risk factors of TB among Sudanese population is needed to be conducted.

Multiple cytokine analysis based on QuantiFERON-TB gold plus in different tuberculosis infection status: an exploratory study

BACKGROUND

More efficient and convenient diagnostic method is a desperate need to reduce the burden of tuberculosis (TB). This study explores the multiple cytokines secretion based on QuantiFERON-TB Gold Plus (QFT-Plus), and screens for optimal cytokines with diagnostic potential to differentiate TB infection status.

METHODS

Twenty active tuberculosis (ATB) patients, fifteen patients with latent TB infection (LTBI), ten patients with previous TB and ten healthy controls (HC) were enrolled. Whole blood samples were collected and stimulated by QFT-Plus TB1 and TB2 antigens. The levels of IFN-γ, TNF-α, IL-2, IL-6, IL-5, IL-10, IP-10, IL-1Ra, CXCL-1 and MCP-1 in supernatant were measured by Luminex bead-based multiplex assays. The receiver operating characteristic curve was used to evaluate the diagnostic accuracy of cytokine for distinguishing different TB infection status.

RESULTS

After stimulation with QFT-Plus TB1 and TB2 antigens, the levels of all cytokines, except IL-5 in TB2 tube, in ATB group were significantly higher than that in HC group. The levels of IL-1Ra concurrently showed the equally highest AUC for distinguishing TB infection from HC, followed by the levels of IP-10 in both TB1 tube and TB2 tube. Moreover, IP-10 levels displayed the largest AUC for distinguishing ATB patients from non-ATB patients. Meanwhile, the levels of IP-10 also demonstrated the largest AUC in both TB1 tube and TB2 tube for distinguishing ATB patients from LTBI.

CONCLUSIONS

In addition to conventional detection of IFN-γ, measuring IP-10 and IL-1Ra based on QFT-Plus may have the more tremendous potential to discriminate different TB infection status.

Development of a Diagnostic Model for Differentiating Tuberculous Spondylitis and Pyogenic Spondylitis With MRI: A Multicenter Retrospective Observational Study

STUDY DESIGN

Multicenter retrospective observational study.

OBJECTIVE

This study aimed to distinguish tuberculous spondylitis (TS) from pyogenic spondylitis (PS) using magnetic resonance imaging (MRI). Further, a novel diagnostic model for differential diagnosis was developed.

SUMMARY OF BACKGROUND DATA

TS and PS are the two most common spinal infections. Distinguishing between these types clinically is challenging. Delayed diagnosis can lead to deficits or kyphosis. Currently, there is a lack of radiology-based diagnostic models for TS and PS.

METHODS

We obtained radiologic images from MRI imaging of patients with TS and PS and applied the least absolute shrinkage and selection operator regression to select the optimal features for a predictive model. Predictive models were built using multiple logistic regression analysis. Clinical utility was determined using decision curve analysis, and internal validation was performed using bootstrap resampling.

RESULTS

A total of 201 patients with TS (n=105) or PS (n=96) were enrolled. We identified significant differences in MRI features between both groups. We found that noncontiguous multivertebral and single-vertebral body involvement were common in TS and PS, respectively. Vertebral bone lesions were more severe in the TS group than in the PS group (Z=-4.553, P <0.001). The patients in the TS group were also more prone to vertebral intraosseous, epidural, and paraspinal abscesses ( P <0.001). A total of 8 predictors were included in the diagnostic model. Analysis of the calibration curve and area under the receiver operating characteristic curve suggested that the model was well-calibrated with high prediction accuracy.

CONCLUSIONS

This is the largest study comparing MRI features in TS and PS and the first to develop an MRI-based nomogram, which may help clinicians distinguish between TS and PS.

Diagnostic value of chemiluminescence for urinary lipoarabinomannan antigen assay in active tuberculosis: insights from a retrospective study

Purpose

This study aimed to assess the efficacy of chemiluminescence-based urinary lipoarabinomannan (LAM) antigen assay as a diagnostic tool for identifying active tuberculosis.

Methods

A retrospective study was conducted on 166 Tuberculosis (TB), 22 Non-Tuberculous Mycobacteria (NTM), 69 Non-TB cases, and 73 healthy controls from Zhangjiagang First Peoples Hospital between July 2022 and November 2022. Clinical and laboratory data were collected, including urine samples for LAM antigen detection, sputum samples and pleural effusion for GeneXpert, TB-DNA, and culture.

Results

TB group exhibited a higher LAM positivity rate (P < 0.001). CD4 count and diabetes as independent factors influencing the diagnostic accuracy of LAM. The LAM assay showed a sensitivity of 50.6% and a specificity of 95.65%. Notably, LAM's sensitivity was superior to TB-DNA (50.60% vs. 38.16%, P < 0.05). LAM's PTB detection rate was 51.7%, superior to TB-DNA (P = 0.047). Moreover, in EPTB cases, the LAM detection rate was 42.11%, surpassing Gene Xpert (P = 0.042), as well as exceeding the detection rates of TB-DNA and sputum culture.

Conclusion

LAM antigen detection using chemiluminescence has demonstrated outstanding clinical diagnostic value for active TB, especially in the diagnosis of extrapulmonary TB. The convenience of sample collection in this diagnostic approach allows for widespread application in the clinical diagnosis of active tuberculosis, particularly in cases of EPTB and sputum-negative patients.

Clinical features, resistance patterns and treatment outcomes of drug-resistant extra-pulmonary tuberculosis: A scoping review

Background

Drug-resistant tuberculosis (DR-TB) is a threat to tuberculosis (TB) control. Extra-pulmonary forms of DR-TB (DR-epTB) are not well characterized. This review summarizes the clinical features, resistance patterns and treatment outcomes of DR-epTB.

Methods

We searched EMBASE to identify studies that reported drug-resistance among extra-pulmonary TB sites. All age groups were included in this review. Studies which did not describe drug-resistance patterns at extra-pulmonary TB sites were excluded. We summarized the proportion of resistance to individual anti-TB drugs as well as multi-drug resistant (MDR), pre-extensively drug resistant (pre-XDR) and extensively drug-resistant (XDR) TB.

Results

Eighteen studies with a total of 10,222 patients with extra-pulmonary TB of whom 1,236 (12.0%) had DR-epTB, were included in this review. DR-epTB was mostly reported in young people aged 28 to 46 years. While TB meningitis is the most commonly studied form, adenitis is the commonest form of DR-epTB reported in 21% to 47%. Central nervous system TB (3.8% to 51.6%), pleural TB (11.3% to 25.9%), skeletal TB (9.4% to 18.1%), abdominal TB (4.3% to 6.5%), and disseminated TB (3.8%) are also encountered. The HIV co-infection rate is reported to be 5.0% to 81.3% while 2.6% to 25.4 % have diabetes mellitus. Clinical symptoms of DR-epTB are consistent with morbidity in the affected body system. Among patients with DR-epTB, the proportion of MDR TB was 5% to 53% while that for pre-XDR TB and XDR TB was 3% to 40% and 4% to 33%, respectively. Treatment success is achieved in 26% to 83% of patients with DR-epTB while death, treatment loss-to-follow up, and treatment failure occur in 2% to 76%, 7% to 15%, and 0% to 4% respectively. Patients with DR-epTB were reported to have poorer outcomes than those with pulmonary DR-TB and extra-pulmonary drug-susceptible TB.

Conclusion

Clinical features of DR-epTB are similar to those observed among people with drug-susceptible EPTB but patients with DR-epTB post worse treatment outcomes.

Isolated soft tissue tuberculosis: a case report and literature review

Soft tissue tuberculosis is a rare extrapulmonary form of tuberculosis with limited experience in diagnosis and treatment. Soft tissue tuberculosis is an extrapulmonary infection with atypical clinical symptoms that can be easily misdiagnosed. In this article, we report a case of a female patient with isolated soft tissue tuberculosis who presented with a progressively enlarging subcutaneous mass as the primary symptom, and was suspected of having a subcutaneous lipoma after ultrasonography. A review of the literature revealed that soft tissue tuberculosis is insidious and mainly occurs in muscles and subcutaneous tissues. It was indicated by histopathology and qPCR testing for Mycobacterium tuberculosis complex. There is no standard treatment protocol for soft tissue tuberculosis, and a comprehensive regimen of surgical debridement of the lesion combined with chemotherapy can be used following the guidelines for treating extrapulmonary tuberculosis. Early diagnosis and standardized anti-tuberculosis treatment can significantly improve the prognosis of patients.

Xpert MTB/RIF assay for the differential diagnosis between sarcoidosis and tuberculosis intrathoracic lymphadenopathy

BACKGROUND

The aim of this study was to evaluate the role of Xpert MTB/RIF assay in the detection of Mycobacterium tuberculosis for differentiating tuberculosis intrathoracic lymphadenopathy from sarcoidosis intrathoracic lymphadenopathy.

METHODS

The patients who were suspected to having sarcoidosis or tuberculosis intrathoracic lymphadenopathy at the Shanghai Pulmonary Hospital between October 1, 2020 and June 30, 2021 were retrospectively evaluated in this study. All patients underwent endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and Xpert analysis. Differences in clinical and radiological features were recorded. The diagnostic performances of EBUS-TBNA Xpert, acid-fast bacilli, culture, and peripheral blood QuantiFERON-TB Gold (QFT) for differentiating sarcoidosis from tuberculosis intrathoracic lymphadenopathy were analyzed.

RESULTS

A total of 119 patients were included in this analysis. Of those, 83 patients were finally diagnosed with sarcoidosis (N = 50) and tuberculosis (N = 33) intrathoracic lymphadenopathy. Young individuals were more likely to have tuberculosis versus sarcoidosis intrathoracic lymphadenopathy (P = 0.006). Markers of inflammation, including fever, leukocytes, and serum ferritin levels, were significantly higher in tuberculosis versus sarcoidosis intrathoracic lymphadenopathy (P < 0.01). Bilateral lung involvement and symmetry intrathoracic lymphadenopathy were more common in sarcoidosis intrathoracic lymphadenopathy (P < 0.01). In addition, the longest diameter of intrathoracic lymphadenopathy (in cm) was significantly larger in sarcoidosis intrathoracic lymphadenopathy (P = 0.001). However, the largest diameter of lung lesions was significantly shorter (P = 0.005). The sensitivity and specificity values of Xpert and QFT for differentiating these two diseases were 69.70% and 100%, and 96.43% and 91.84%, respectively.

CONCLUSION

Xpert MTB/RIF is recommended for the diagnosis of tuberculosis intrathoracic lymphadenopathy using EBUS-TBNA samples. A negative QFT suggests the exclusion of the diagnosis of tuberculosis intrathoracic lymphadenopathy.

Reconstruction of complicated spinal tuberculosis with long-segment fibula transplantation: a case report

BACKGROUND

Treating complex cases of spinal tuberculosis (STB) that involve multiple vertebral bodies and cause destruction of the spinal structure, kyphotic deformity, and acute nerve injury can be challenging. This report describes the course of treatment and 5-year follow-up of a complex case of multisegmental STB.

CASE PRESENTATION

This report describes a case of tuberculosis affecting the vertebrae extending from thoracic 12 to lumbar 5 in a 60-year-old woman who suffered sudden paralysis in both lower extremities. The patient underwent emergency posterior paraspinal abscess clearance, laminectomy with spinal decompression. Partial correction of the kyphotic deformity via long-segment fixation from the T9 vertebral body to the ilium in a one-stage posterior procedure. The patient's neurological status was diagnosed as grade E on the American Spinal Injury Association (ASIA) scale after the one-stage operation. Following standardized 4-combination anti-tuberculosis drug therapy for three months in postoperative patients, the patient underwent two-stage transabdominal anterior abscess removal, partial debridement of the lesion and bilateral fibula graft support. One year after the two-stage operation, the patient's visual analog scale (VAS) score of back pain was 1 point, and the patient's erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels returned to normal. Five years after the second-stage operation, the Oswestry disability index (ODI) of patient quality of life was 14 points. There was a 4-degree change in the Cobb angle over five years. During the five-year follow-up period, the grafted fibula did not experience any subsidence.

CONCLUSION

For patients with spinal tuberculosis and acute paralysis, it is essential to relieve spinal cord compression as soon as possible to recover spinal cord function. For lesions that cannot be debrided entirely, although limited debridement combined with anti-tuberculosis drug therapy has the risk of sinus formation and tuberculosis recurrence, it is much safer than the risk of thorough debridement surgery. In this case, an unconventional long-segment fibula graft, pelvis-vertebral support, was an effective reconstruction method.