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Goussard P, Eber E, Venkatakrishna S, Frigati L, Greybe L, Janson J, Schubert P, Andronikou S. Interventional bronchoscopy in pediatric pulmonary tuberculosis. Expert Rev Respir Med 2023; 17:1159-1175. [PMID: 38140708 DOI: 10.1080/17476348.2023.2299336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 12/21/2023] [Indexed: 12/24/2023]
Abstract
INTRODUCTION Lymphobronchial tuberculosis (TB) is common in children with primary TB and enlarged lymph nodes can cause airway compression of the large airways. If not treated correctly, airway compression can result in persistent and permanent parenchymal pathology, as well as irreversible lung destruction. Bronchoscopy was originally used to collect diagnostic samples; however, its role has evolved, and it is now used as an interventional tool in the diagnosis and management of complicated airway disease. Endoscopic treatment guidelines for children with TB are scarce. AREAS COVERED The role of interventional bronchoscopy in the diagnosis and management of complicated pulmonary TB will be discussed. This review will provide practical insights into how and when to perform interventional procedures in children with complicated TB for both diagnostic and therapeutic purposes. This discussion incorporates current scientific evidence and refers to adult literature, as some of the interventions have only been done in adults but may have a role in children. Limitations and future perspectives will be examined. EXPERT OPINION Pediatric pulmonary TB lends itself to endoscopic interventions as it is a disease with a good outcome if treated correctly. However, interventions must be limited to safeguard the parenchyma and prevent permanent damage.
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Affiliation(s)
- Pierre Goussard
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Ernst Eber
- Division of Paediatric Pulmonology and Allergology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Shyam Venkatakrishna
- Department of Pediatric Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lisa Frigati
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Leonore Greybe
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Jacques Janson
- Department of Surgical Sciences, Division of Cardiothoracic Surgery, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Pawel Schubert
- Division of Anatomical Pathology, Tygerberg Hospital, National Health Laboratory Service, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Savvas Andronikou
- Department of Pediatric Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Goussard P, Eber E, Venkatakrishna S, Frigati L, Janson J, Schubert P, Andronikou S. Intrathoracic tuberculosis: Role of interventional bronchoscopy in diagnosis. Paediatr Respir Rev 2023; 45:23-29. [PMID: 36621398 DOI: 10.1016/j.prrv.2022.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022]
Abstract
Tuberculosis (TB) is the leading cause of death from a single infectious agent globally. Mortality is related to the delay in diagnosis and starting treatment. According to new guidelines it is very important to classify pulmonary tuberculosis (PTB) as severe or not severe disease due to the difference in treatment duration. Bronchoscopy is the gold standard for assessing the degree of airway compression and obstruction in paediatric PTB. Paediatric bronchoscopy has evolved from a primarily diagnostic procedure to include interventional bronchoscopy for diagnostic purposes. Endobronchial ultrasound (EBUS) has increased the potential of sampling mediastinal lymph nodes both for histological diagnosis and microbiological confirmation.
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Affiliation(s)
- Pierre Goussard
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa.
| | - Ernst Eber
- Division of Paediatric Pulmonology and Allergology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Shyam Venkatakrishna
- Department of Pediatric Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lisa Frigati
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
| | - Jacques Janson
- Department of Surgical Sciences, Division of Cardiothoracic Surgery, Stellenbosch University, and Tygerberg Hospital, Tygerberg, South Africa
| | - Pawel Schubert
- Division of Anatomical Pathology, Tygerberg Hospital, National Health Laboratory Service, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Savvas Andronikou
- Department of Pediatric Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Rakha MA, Ali A, Hassan W, Al-Anbay E. GeneXpert analysis of bronchoalveolar lavage (BAL) samples: promising diagnostic modality in patients with smear-negative pulmonary tuberculosis. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2022. [DOI: 10.1186/s43168-022-00171-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract
Purpose
The aim of the study is to assess the diagnostic utility of bronchoalveolar lavage (BAL) samples with GeneXpert test in diagnosis of TB in smear-negative patients.
Method
One-hundred sixty-nine cases were included in this study, as they had a radiological finding suggested to have pulmonary tuberculosis, while the sputum direct smear examination for acid-fast bacilli was negative. All cases prepared to do fiber-optic bronchoscope with bronchoalveolar lavage collection after their consent and post bronchoscope sputum collection for further molecular and microbiological examination.
Results
The combined diagnostic yield of all bronchoscopy procedures was 15.97% (27 cases of 169) and the final diagnosis of TB cases was established in 16 cases of 169 (9.4%) using BAL culture and in 20 cases of 169 (11.83%) by GeneXpert methods. Post bronchoscope direct sputum examination, culture, and GeneXpert evaluation gave diagnostic yield about 1.1%, 5.5%, and 7.1%, respectively. The specificity of GeneXpert examination of BAL and post bronchoscope sputum was 95.42% and 97.38%, respectively.
Conclusion
Early detection of pulmonary tuberculosis using fiber-optic bronchoscope BAL examination and post bronchoscope sputum with GeneXpert method promotes the accurate decision to start antituberculous therapy in patients with smear negative.
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Bhat JI, Tramboo ZM, Shah TH, Charoo BA, Qazi IA. Enhancing respiratory disease diagnosis by bronchoalveolar lavage in Kashmir: an audit of findings. Arch Dis Child 2022; 107:1079-1082. [PMID: 35948407 DOI: 10.1136/archdischild-2022-323823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 07/30/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To study bronchoalveolar lavage (BAL) findings in various respiratory diseases in children in Kashmir India. DESIGN Prospective observational study. SETTING Paediatric department of the tertiary care hospital. PATIENTS Children of both genders from 1 month to 17 years of age INTERVENTION: All studied patients underwent flexible bronchoscopy and BAL. OUTCOME MEASURE To observe the BAL findings in various respiratory diseases in the studied population. RESULTS A total of 283 patients underwent BAL procedure. The positive BAL report was received in 131 (46%) patients. Out of these, 55 (42%) patients had positive BAL culture/ microscopy for different bacterial (50) and fungal species (Candida spp (3), Mucormycosis (1) and Aspergillus (1)). MTB was isolated in 25 (19%) patients. Twenty-three (17.5%) patients had bronchoalveolar lavage fluid (BALF) positive for pulmonary hydatidosis. Foamy macrophages were seen in 13 patients, significant eosinophilia in nine patients and hemosiderin-laden macrophages were seen in three patients. CONCLUSION We found BALF a very useful sample for the evaluation of many infective and non-infective respiratory diseases in our region, which otherwise lacks high end diagnostics. 46% of our patients had some abnormalities in the BAL specimen. It provided us with valuable information regarding organism profile and drug sensitivity in case of lung infection. BALF analysis was also found useful in the diagnosis of some non-infective pulmonary disorders like acute eosinophilic pneumonia, aspiration syndromes and bronchial asthma.
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Affiliation(s)
- Javeed Iqbal Bhat
- Pediatrics, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Zubair M Tramboo
- Pediatrics, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Tajamul Hussain Shah
- Department of Pulmonary Medicine, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | | | - Iqbal Ahmad Qazi
- Pediatrics, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
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Li Z. The Value of GeneXpert MTB/RIF for Detection in Tuberculosis: A Bibliometrics-Based Analysis and Review. JOURNAL OF ANALYTICAL METHODS IN CHEMISTRY 2022; 2022:2915018. [PMID: 36284547 PMCID: PMC9588380 DOI: 10.1155/2022/2915018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 09/26/2022] [Accepted: 10/01/2022] [Indexed: 06/16/2023]
Abstract
With the continuous development of medical science and technology, especially with the advent of the era of precision diagnosis and treatment, molecular biology detection technology is widely valued and applied as an aid to early diagnosis of tuberculosis. The GeneXpert Mycobacterium tuberculosis Branching (MTB) technology is a suite of semi-nested real-time fluorescent quantitative PCR in vitro diagnostic technologies developed by Cepheid Inc. It targets the rifampicin resistance gene, rpoB, and can detect both MTB and resistance to rifampicin within 2 h. This review analyzed the papers related to GeneXpert using bibliometric software CiteSpace and Bibliometrix. A total of 151 articles were analyzed, spanning from 2011 to 2021. This bibliometrics-based review summarizes the history of the development of GeneXpert in tuberculosis diagnosis and its current status. Contributions of different countries to the topic, journal analysis, key paper analysis, and clustering of keywords were used to analyze this topic.
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Affiliation(s)
- Zhiyi Li
- Laboratory Medicine, Nanan Hospital, Nanan, Quanzhou 362300, Fujian, China
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Goussard P, Andronikou S, Fourie B, Janson JT, Schubert PT. Tuberculous bronchial stenosis: Diagnosis and role of interventional bronchoscopy. Pediatr Pulmonol 2022; 57:2445-2454. [PMID: 35775331 DOI: 10.1002/ppul.26057] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/10/2022] [Accepted: 06/14/2022] [Indexed: 11/08/2022]
Abstract
The reported prevalence of tuberculous bronchial stenosis in children is unknown and rarely reported in English-speaking literature. In adult patients with pulmonary tuberculosis, it varies from 40% in an autopsied series in the preantibiotic era to 10% in patients who have undergone routine bronchofibroscopy in modern times. We describe our experience of four cases of confirmed bronchial stenosis due to MTB collected between January 2000 and June 2021 in this case series descriptive study. The diagnosis of bronchial stenosis due to TB was made on flexible bronchoscopy. A TB diagnosis was made if MTB was cultured from respiratory secretions, when Ziehl-Neelsen smear or GeneXpert MTB/RIF test was positive, or if a chest radiograph revealed radiographic features typical of MTB. Bronchial stenosis due to TB is rare even if airway compression is frequently seen. Although an early diagnosis of bronchial stenosis due to TB is difficult on chest X-rays, all children in this series demonstrated parenchymal changes distal to the stenosis ranging from hyperinflation and lobar collaps to bronchiectasis. If bronchial stenosis resulting from TB disease is diagnosed early, balloon dilatation as described in this report, may be an effective and safe intervention, preventing long-term complications such as irreversible lung destruction, that may require pneumonectomy.
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Affiliation(s)
- Pierre Goussard
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa
| | - Savvas Andronikou
- Department of Pediatric Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Radiology, Perelman School, of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Barend Fourie
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa
| | - Jacques T Janson
- Department of Surgical Sciences, Division of Cardiothoracic Surgery, Stellenbosch University, and Tygerberg Hospital, Tygerberg, South Africa
| | - Pawel T Schubert
- Division of Anatomical Pathology, Tygerberg Hospital, National Health Laboratory Service, Faculty of Medicine and Health Science, Stellenbosch University, Cape Town, South Africa
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Diagnostic Yield of Xpert MTB/RIF Assay Using Bronchoalveolar Lavage Fluid in Detecting Mycobacterium tuberculosis among the Sputum-Scarce Suspected Pulmonary TB Patients. Diagnostics (Basel) 2022; 12:diagnostics12071676. [PMID: 35885580 PMCID: PMC9324532 DOI: 10.3390/diagnostics12071676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/26/2022] [Accepted: 06/27/2022] [Indexed: 11/16/2022] Open
Abstract
Tuberculosis (TB) remains one of the leading causes of death worldwide and is caused by the single infectious agent Mycobacterium tuberculosis (Mtb). Although sputum is the most common specimen for pulmonary TB detection, some other respiratory specimens, such as bronchoalveolar lavage (BAL) fluid, gastric lavage (GL), and induced sputum (IS), are also collected from patients who are unable to deliver sputum. In this study, we aimed to evaluate the diagnostic performances of different test methods for TB diagnosis using BAL fluid specimens from sputum-scarce pulmonary TB patients. In this current study, a total of 210 BAL fluid specimens were collected and subjected to culture on Lowenstein–Jensen (L-J) medium, using an N-acetyl-L-cysteine-Sodium Hydroxide decontamination and digestion method, Xpert MTB/RIF (Xpert, Cepheid, Sunnyvale, CA, USA) assay, and acid-fast bacilli (AFB) microscopy with a Ziehl–Neelsen staining method for the detection of pulmonary TB. The sensitivity and specificity of these methods were then analyzed against the composite reference standard (CRS). Additionally, the receiver operating characteristic (ROC) curve was used to evaluate the diagnostic value of these assays. Among the 210 specimens, 39 (18.6%), 27 (12.8%), and 12 (5.7%) were found positive with Xpert assay, culture, and AFB microscopy, respectively. Considering the CRS, 42 (20%) were positive as the final diagnosis. The Xpert assay had a significantly higher sensitivity (92.9%, 95% CI: 80.5–98.5) compared to culture (64.3%, 95% CI: 48.0–78.4) and AFB microscopy (28.6%, 95% CI: 15.7–44.6) against the CRS. Additionally, the area under the ROC curve (AUC) for the Xpert assay, culture, and AFB microscopy accounted for 0.964, 0.821, and 0.655, respectively, when using CRS as the reference. In conclusion, our study findings demonstrated that the Xpert assay conferred a considerable diagnostic potential compared to other conventional methods for the diagnosis of pulmonary TB from BAL fluid specimens.
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Tian Y, Chen Y. Stroke in Takayasu arteritis with concomitant tuberculosis: an unusual pediatric case report. BMC Pediatr 2022; 22:50. [PMID: 35057771 PMCID: PMC8772212 DOI: 10.1186/s12887-022-03125-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 01/15/2022] [Indexed: 11/25/2022] Open
Abstract
Background Stroke is a lethal complication of polyarteritis in children. Takayasu arteritis is a rare disease with an unknown etiology and is known to mainly affect young women. In this report, we present the case of a Chinese boy diagnosed with TA results in stroke, originally presenting in the context of latent tuberculosis infection and then developing active tuberculosis. Case presentation The patient was a 14-year-old child who developed a latent tuberculosis infection at age 5 after coming in close contact with his grandfather, who had tuberculosis. However, he did not receive any anti-tuberculosis medications at that time. At age 9, he was hospitalized for symptoms of "dizziness and headache" and was diagnosed with Takayasu arteritis and hypertension; however, tuberculosis was not diagnosed. Only antihypertensive drugs were administered without considering the possible pathogenic factors of tuberculosis infection. At age 14, he was rehospitalized for "fever and cough" and was diagnosed with active pulmonary tuberculosis as an analysis of his fiberoptic bronchoscopy sample using the Gene-Xpert assay was positive for Mycobacterium tuberculosis. However, after 2 months of taking oral anti-tuberculosis drugs, his blood pressure continued to rise, and he presented with numbness and weakness of the right limb and a deviation of the right side of his mouth. Computed tomography angiography of his head and neck revealed that the walls of the left subclavian artery and bilateral vertebral arteries were thickened, and the lumen was significantly narrowed. In a recent examination, magnetic resonance imaging and diffusion-weighted imaging of the head showed infarctions in the right basal ganglia area close to the left lateral ventricle. Our patient was treated with methotrexate, tocilizumab and glucocorticoids to control he continued active vasculitis. Conclusions The possible association of tuberculosis and Takayasu arteritis complicated by stroke needs to be considered, especially in children who had prior contact with a family member with tuberculosis infection. The temporal relationship between TA and infection with Mycobacterium tuberculosis in our patient suggests a compelling link that demands further investigation.
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Bai W, Liu L, Wu L, Chen S, Wu S, Wang Z, Xu K, Chi Q, Pan Y, Xu X. Assessing the utility of the Xpert Mycobacterium tuberculosis/rifampin assay for analysis of bronchoalveolar lavage fluid in patients with suspected pulmonary tuberculosis. J Clin Lab Anal 2021; 36:e24154. [PMID: 34850984 PMCID: PMC8761447 DOI: 10.1002/jcla.24154] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 11/09/2021] [Accepted: 11/17/2021] [Indexed: 11/20/2022] Open
Abstract
Background There is limited research assessing the utility of the Xpert Mycobacterium tuberculosis/rifampin (MTB/RIF) assay for the analysis of bronchoalveolar lavage fluid (BALF) in Chinese patients with suspected pulmonary tuberculosis (PTB). Thus, our objective was to determine the diagnostic accuracy of the Xpert MTB/RIF assay and evaluate its utility for the determination of rifampicin resistance. Methods We retrospectively analyzed BALF from 214 patients with suspected PTB between January 2018 and March 2019. Using mycobacterial culture or final clinical diagnosis as the reference standard, the diagnostic accuracy of the smear microscopy (SM), tuberculosis bacillus DNA (TB‐DNA), Xpert MTB/RIF assay, and the determination of rifampicin resistance based on the Xpert MTB/RIF assay were compared. Results As compared to mycobacterial culture, the sensitivity of the Xpert MTB/RIF assay, SM, and TB‐DNA were 85.5% (74.2%–93.1%), 38.7% (26.6%–51.9%), and 67.7% (54.7%–79.1%), respectively. As compared to the final diagnosis, the specificity of the Xpert MTB/RIF assay, SM, and TB‐DNA were 100.0% (95.9%–100.0%), 94.3% (87.1%–98.1%), and 98.9% (93.8%–100.0%), respectively. The sensitivity and specificity of the rifampicin resistance detection using the Xpert MTB/RIF assay were 100% and 98.0%, respectively, with liquid culture as the reference. Conclusions This study demonstrates that the analysis of BALF with the Xpert MTB/RIF assay provides a rapid and accurate tool for the early diagnosis of PTB. The accuracy of diagnosis was superior compared with the SM and TB‐DNA. Moreover, Xpert is a quick and accurate method for the diagnosis of rifampicin‐resistant tuberculosis and can also provide more effective guidance for the treatment of PTB or multidrug‐resistant tuberculosis (MDR‐TB).
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Affiliation(s)
- Wenjing Bai
- Department of Clinical Laboratory Medicine, Wenzhou Central Hospital, Wenzhou, China
| | - Lingling Liu
- Department of Clinical Laboratory Medicine, Wenzhou Longwan First People's Hospital, Wenzhou, China
| | - Lianpeng Wu
- Department of Clinical Laboratory Medicine, Wenzhou Central Hospital, Wenzhou, China
| | - Shanshan Chen
- Department of Blood Transfusion, People's Hospital of Pingyang County, Wenzhou, China
| | - Shuangliao Wu
- Department of Clinical Laboratory Medicine, Wenzhou Central Hospital, Wenzhou, China
| | - Zhihui Wang
- Department of Obstetrics and Gynecology, Wenzhou Central Hospital, Wenzhou, China
| | - Ke Xu
- Department of Clinical Laboratory Medicine, Wenzhou Central Hospital, Wenzhou, China
| | - Qiong Chi
- Department of Respiratory and Critical Care Medicine, Key Laboratory of precision medicine of Wenzhou, Wenzhou Central Hospital, Wenzhou, China
| | - Yong Pan
- Department of Clinical Laboratory Medicine, Key Laboratory of precision medicine of Wenzhou, Wenzhou Central Hospital, Wenzhou, China
| | - Xueqin Xu
- Department of Clinical Laboratory Medicine, Key Laboratory of precision medicine of Wenzhou, Wenzhou Central Hospital, Wenzhou, China
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Geweniger A, Janda A, Eder K, Fressle R, Kannan CV, Fahnenstich H, Elze M, Müller C, Henneke P, Hufnagel M, Elling R. High diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the diagnosis of adolescent pulmonary tuberculosis. BMC Infect Dis 2021; 21:946. [PMID: 34521371 PMCID: PMC8439093 DOI: 10.1186/s12879-021-06413-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 06/25/2021] [Indexed: 11/10/2022] Open
Abstract
Background The microbiological diagnosis of pulmonary tuberculosis (Tb) in a pediatric population is hampered by both low pathogen burden and noncompliance with sputum sampling. Although endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been found useful for the evaluation of mediastinal pathologies in adults, for children, sparse data are available. Here, we have evaluated EBUS-TBNA as a diagnostic procedure in children and adolescents with suspected pulmonary Tb. Methods In this retrospective analysis, we reviewed the charts of unaccompanied refugee minors (URM) who were admitted between January 2016 and July 2018 and who, during their initial medical screening upon arrival in Germany, were found to have abnormal radiological pulmonary and mediastinal findings and/or immunological results indicative of Tb. For each patient, basic sociodemographic data, clinical features and data on diagnostic procedures performed were assessed. These included imaging, immunodiagnostic tests and microbiological data derived from sputum, bronchoalveolar lavage, EBUS-TBNA, bronchoscopy and pleural fluid sampling. All patients who underwent invasive sampling procedures were included in the study. Results Out of 42 URM with suspected Tb, 34 fulfilled the study’s inclusion criteria. Ages ranged from 14 to 17 years. All were of African origin, with 70.0% coming from Somalia, Eritrea and Ethiopia. Among the 21 patients for whom EBUS-TBNA was performed, the diagnostic yield was high: 66.7% positive results (MTb detected either by acid-fast stain, culture or PCR in 4.8, 42.9 and 61.9% of samples, respectively). Multidrug-resistant MTb was found in two patients from Somalia. No complications were associated with the procedure. Overall, pulmonary Tb was diagnosed in 29 patients (85.3%), miliary Tb in two patients (5.9%) and latent Tb in three patients (8.8%). Conclusions EBUS-TBNA is a sensitive and safe method with high diagnostic yield in the evaluation of pediatric patients with mediastinal pathology and suspected Tb. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06413-z.
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Affiliation(s)
- Anne Geweniger
- Department of Pediatrics and Adolescent Medicine, University Medical Center, Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Ales Janda
- Department of Pediatrics and Adolescent Medicine, University Medical Center, Medical Faculty, University of Freiburg, Freiburg, Germany.,Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| | - Kristin Eder
- Department of Pediatrics and Adolescent Medicine, University Medical Center, Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Roland Fressle
- Practice for Pediatric and Adolescent Medicine, Freiburg, Germany
| | | | | | - Mirjam Elze
- Department of Thoracic Surgery, University Medical Center, Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Christoph Müller
- Department of Pediatrics and Adolescent Medicine, University Medical Center, Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Philipp Henneke
- Department of Pediatrics and Adolescent Medicine, University Medical Center, Medical Faculty, University of Freiburg, Freiburg, Germany.,Institute for Immunodeficiency, Center for Chronic Immunodeficiency, University Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Markus Hufnagel
- Department of Pediatrics and Adolescent Medicine, University Medical Center, Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Roland Elling
- Department of Pediatrics and Adolescent Medicine, University Medical Center, Medical Faculty, University of Freiburg, Freiburg, Germany. .,Institute for Immunodeficiency, Center for Chronic Immunodeficiency, University Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany. .,Berta Ottenstein Program, University Medical Center, Medical Faculty, University of Freiburg, Freiburg, Germany.
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11
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Goussard P, Croucamp R, Bosch C, Demers AM, Morrison J, Mfingwana L, Palmer M, van der Zalm MM, Friedrich SO, Janson JT, Whitelaw AC, Andronikou S, Hesseling AC, Walters E, Lopez-Varela E. Diagnostic utility of bronchoalveolar lavage in children with complicated intrathoracic tuberculosis. Pediatr Pulmonol 2021; 56:2186-2194. [PMID: 33818927 DOI: 10.1002/ppul.25405] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 03/23/2021] [Accepted: 03/25/2021] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Bronchoscopy can be a useful tool in children with pulmonary tuberculosis (PTB) with severe disease potentially requiring intervention or in the face of diagnostic dilemmas. The aim of this study was to determine the value of Xpert MTB/RIF assay (Xpert) on bronchoalveolar lavage (BAL) samples in children with complicated PTB. METHODS Retrospective analysis of children with clinically diagnosed PTB, who underwent routine bronchoscopy over a 5-year period at a large referral hospital. BAL and other respiratory samples were tested by microscopy, culture, and Xpert. We explored whether clinical, radiographic and bronchoscopy findings, and duration of antituberculosis treatment were associated with bacteriological confirmation. RESULTS One hundred and twelve out of one hundred and forty-six (76.7%) children (median age 16 months) were on antituberculosis treatment for a median of 10 days at the time of bronchoscopy. Overall, bacteriological confirmation was achieved in 115 (78.7%), with 101 (69.2%) detected on BAL. Of those bacteriologically confirmed on BAL, 61.4% were positive by both Xpert and culture, 34.7% only by Xpert, and 3.9% only by culture. Sensitivity and specificity of Xpert compared with culture on BAL samples for children not on antituberculosis treatment were 94.1% (95% confidence interval [CI]: 71.3, 99.8) and 68.7% (95% CI: 41.3, 89.0), respectively. CONCLUSIONS In children undergoing bronchoscopy for complicated PTB, Xpert testing of BAL had a high diagnostic yield in children already on antituberculosis treatment. Bronchoscopy should be considered if noninvasive respiratory specimens fail to confirm complicated TB.
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Affiliation(s)
- Pierre Goussard
- Paediatric Pulmonology, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Tygerberg Academic Hospital, Stellenbosch University, Cape Town, South Africa
| | - Roland Croucamp
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Corne Bosch
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anne-Marie Demers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Julie Morrison
- Paediatric Pulmonology, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Tygerberg Academic Hospital, Stellenbosch University, Cape Town, South Africa
| | - Lunga Mfingwana
- Paediatric Pulmonology, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Tygerberg Academic Hospital, Stellenbosch University, Cape Town, South Africa
| | - Megan Palmer
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Marieke M van der Zalm
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Sven O Friedrich
- Division of Medical Physiology, MRC Centre for Tuberculosis Research, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Jacques T Janson
- Department of Cardio-Thoracic Surgery, Tygerberg Hospital, Stellenbosch University, Tygerberg, South Africa
| | - Andrew C Whitelaw
- Division of Medical Microbiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Savvas Andronikou
- Department of Pediatric Radiology, The Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Elisabetta Walters
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Elisa Lopez-Varela
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
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12
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Value of Xpert MTB/RIF Using Bronchoalveolar Lavage Fluid for the Diagnosis of Pulmonary Tuberculosis: a Systematic Review and Meta-analysis. J Clin Microbiol 2021; 59:JCM.02170-20. [PMID: 33177121 DOI: 10.1128/jcm.02170-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The performance of Xpert MTB/RIF using bronchoalveolar lavage fluid (BAL) for the diagnosis of pulmonary tuberculosis (PTB) remains unclear. Therefore, a systematic review/meta-analysis was conducted. Studies published before 31 December 2019 were retrieved from the PubMed, Embase, and Web of Science databases using the keywords "pulmonary tuberculosis," "Xpert MTB/RIF," and "BAL." Two independent evaluators extracted the data and assessed the bias risk of the included studies. A random-effects model was used to calculate the overall sensitivity, specificity, positive and negative likelihood ratios (PLR and NLR, respectively), diagnostic odds ratio (DOR), and the area under the curve (AUC), as well as the respective 95% confidence intervals (CIs). Nineteen trials involving 3,019 participants met the inclusion criteria. Compared to the culture method, the pooled sensitivity, specificity, PLR, NLR, DOR, and the AUC with 95% CIs of Xpert MTB/RIF were 0.87 (0.84 to 0.90), 0.92 (0.91 to 0.93), 10.21 (5.78 to 18.02), 0.16 (0.12 to 0.22), 78.95 (38.59 to 161.53), and 0.9467 (0.9462 to 0.9472), respectively. Relative to the composite reference standard, the observed values were 0.69 (0.65 to 0.72), 0.98 (0.98 to 0.99), 37.50 (18.59 to 75.62), 0.30 (0.21 to 0.43), 171.98 (80.82 to 365.96), and 0.9691 (0.9683 to 0.9699), respectively. All subgroups, except children, showed high sensitivity and specificity. In conclusion, the use of Xpert MTB/RIF in the context of BAL samples has a high diagnostic performance for PTB (except for children) and may serve as an alternative rapid diagnostic tool.
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13
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Goussard P, Pohunek P, Eber E, Midulla F, Di Mattia G, Merven M, Janson JT. Pediatric bronchoscopy: recent advances and clinical challenges. Expert Rev Respir Med 2021; 15:453-475. [PMID: 33512252 DOI: 10.1080/17476348.2021.1882854] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: During the last 40 years equipment has been improved with smaller instruments and sufficient size working channels. This has ensured that bronchoscopy offers therapeutic and interventional options.Areas covered: We provide a review of recent advances and clinical challenges in pediatric bronchoscopy. This includes single-use bronchoscopes, endobronchial ultrasound, and cryoprobe. Bronchoscopy in persistent preschool wheezing and asthma is included. The indications for interventional bronchoscopy have amplified and included balloon dilatation, endoscopic intubation, the use of airway stents, whole lung lavage, closing of fistulas and air leak, as well as an update on removal of foreign bodies. Others include the use of laser and microdebrider in airway surgery. Experience with bronchoscope during the COVID-19 pandemic has been included in this review. PubMed was searched for articles on pediatric bronchoscopy, including rigid bronchoscopy as well as interventional bronchoscopy with a focus on reviewing literature in the past 5 years.Expert opinion: As the proficiency of pediatric interventional pulmonologists continues to grow more interventions are being performed. There is a scarcity of published evidence in this field. Courses for pediatric interventional bronchoscopy need to be developed. The COVID-19 experience resulted in safer bronchoscopy practice for all involved.
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Affiliation(s)
- P Goussard
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
| | - P Pohunek
- Division of Pediatric Respiratory Diseases, Pediatric Department, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - E Eber
- Department of Paediatrics and Adolescent Medicine, Head, Division of Paediatric Pulmonology and Allergology, Medical University of Graz, Graz, Austria
| | - F Midulla
- Department of Maternal Infantile and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - G Di Mattia
- Department of Maternal Infantile and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - M Merven
- Department Otorhinolaryngology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
| | - J T Janson
- Department of Surgical Sciences, Division of Cardio-Thoracic Surgery, Stellenbosch University, and Tygerberg Hospital, Tygerberg, South Africa
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14
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Goussard P, Retief F, Burke J, Malherbe A, Janson J. The role of bronchoscopy in the diagnosis and management of pediatric pulmonary tuberculosis. Ther Adv Infect Dis 2021; 8:20499361211037168. [PMID: 34422266 PMCID: PMC8377312 DOI: 10.1177/20499361211037168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/16/2021] [Indexed: 11/16/2022] Open
Abstract
Bronchoscopy is useful as a diagnostic and therapeutic procedure in children with Tuberculosis (TB) disease complicated by airway obstruction. It is needed in children when surgical intervention may be required for airway compression, when drug resistance is suspected, and to rule out an alternative diagnosis for airway obstruction. Bronchoscopy with bronchoalveolar lavage (BAL) should be performed when other, less invasive samples cannot be collected, or when they fail to provide useful diagnostic information. BAL specimens collected at bronchoscopy can be tested using molecular TB assays and mycobacterial culture. The aim of this review is to evaluate the role of bronchoscopy in the diagnosis and management of pulmonary TB in children, and, specifically, to review the role of interventional bronchoscopy. A search of electronic databases was undertaken using the online databases PubMed, Ovid MEDLINE, EMBASE, Google Advanced Scholar, and Web of Science to identify relevant literature. The search was limited to pediatrics, pulmonology, bronchoscopy, and pediatric pulmonary tuberculosis for all articles published in English on pediatric bronchoscopy between 2010 and 2020. Recent advances in pediatric bronchoscopy was included, as well as recent research on improving the diagnosis with the use of interventional bronchoscopy. The role of bronchoscopy in pediatric pulmonary tuberculosis has changed during the last decade, from a simple method of collecting samples for bacteriological conformation to an more sophisticate procedure. New methods are available for collecting samples, which includes the use of Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and also better methods of bacteriological conformation. Interventions are now possible; not only to improve the diagnostic abilities of bronchoscopy but also to diagnose, manage, and follow-up upon airway-related complications. Bronchoscopy services remain limited in resource-limited countries due to the high cost of equipment.
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Affiliation(s)
- Pierre Goussard
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
| | - Francois Retief
- Department of Anaesthesia and Critical Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
| | - Jonathan Burke
- Department of Anaesthesia and Critical Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
| | - Annemie Malherbe
- Department of Anaesthesia and Critical Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
| | - Jacques Janson
- Department of Surgical Sciences, Division of Cardiothoracic Surgery, Stellenbosch University, and Tygerberg Hospital, Tygerberg, South Africa
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15
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Kay AW, González Fernández L, Takwoingi Y, Eisenhut M, Detjen AK, Steingart KR, Mandalakas AM. Xpert MTB/RIF and Xpert MTB/RIF Ultra assays for active tuberculosis and rifampicin resistance in children. Cochrane Database Syst Rev 2020; 8:CD013359. [PMID: 32853411 PMCID: PMC8078611 DOI: 10.1002/14651858.cd013359.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Every year, at least one million children become ill with tuberculosis and around 200,000 children die. Xpert MTB/RIF and Xpert Ultra are World Health Organization (WHO)-recommended rapid molecular tests that simultaneously detect tuberculosis and rifampicin resistance in adults and children with signs and symptoms of tuberculosis, at lower health system levels. To inform updated WHO guidelines on molecular assays, we performed a systematic review on the diagnostic accuracy of these tests in children presumed to have active tuberculosis. OBJECTIVES Primary objectives • To determine the diagnostic accuracy of Xpert MTB/RIF and Xpert Ultra for (a) pulmonary tuberculosis in children presumed to have tuberculosis; (b) tuberculous meningitis in children presumed to have tuberculosis; (c) lymph node tuberculosis in children presumed to have tuberculosis; and (d) rifampicin resistance in children presumed to have tuberculosis - For tuberculosis detection, index tests were used as the initial test, replacing standard practice (i.e. smear microscopy or culture) - For detection of rifampicin resistance, index tests replaced culture-based drug susceptibility testing as the initial test Secondary objectives • To compare the accuracy of Xpert MTB/RIF and Xpert Ultra for each of the four target conditions • To investigate potential sources of heterogeneity in accuracy estimates - For tuberculosis detection, we considered age, disease severity, smear-test status, HIV status, clinical setting, specimen type, high tuberculosis burden, and high tuberculosis/HIV burden - For detection of rifampicin resistance, we considered multi-drug-resistant tuberculosis burden • To compare multiple Xpert MTB/RIF or Xpert Ultra results (repeated testing) with the initial Xpert MTB/RIF or Xpert Ultra result SEARCH METHODS: We searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, Science Citation Index, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, the WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, and the International Standard Randomized Controlled Trials Number (ISRCTN) Registry up to 29 April 2019, without language restrictions. SELECTION CRITERIA Randomized trials, cross-sectional trials, and cohort studies evaluating Xpert MTB/RIF or Xpert Ultra in HIV-positive and HIV-negative children younger than 15 years. Reference standards comprised culture or a composite reference standard for tuberculosis and drug susceptibility testing or MTBDRplus (molecular assay for detection of Mycobacterium tuberculosis and drug resistance) for rifampicin resistance. We included studies evaluating sputum, gastric aspirate, stool, nasopharyngeal or bronchial lavage specimens (pulmonary tuberculosis), cerebrospinal fluid (tuberculous meningitis), fine needle aspirates, or surgical biopsy tissue (lymph node tuberculosis). DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed study quality using the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2). For each target condition, we used the bivariate model to estimate pooled sensitivity and specificity with 95% confidence intervals (CIs). We stratified all analyses by type of reference standard. We assessed certainty of evidence using the GRADE approach. MAIN RESULTS For pulmonary tuberculosis, 299 data sets (68,544 participants) were available for analysis; for tuberculous meningitis, 10 data sets (423 participants) were available; for lymph node tuberculosis, 10 data sets (318 participants) were available; and for rifampicin resistance, 14 data sets (326 participants) were available. Thirty-nine studies (80%) took place in countries with high tuberculosis burden. Risk of bias was low except for the reference standard domain, for which risk of bias was unclear because many studies collected only one specimen for culture. Detection of pulmonary tuberculosis For sputum specimens, Xpert MTB/RIF pooled sensitivity (95% CI) and specificity (95% CI) verified by culture were 64.6% (55.3% to 72.9%) (23 studies, 493 participants; moderate-certainty evidence) and 99.0% (98.1% to 99.5%) (23 studies, 6119 participants; moderate-certainty evidence). For other specimen types (nasopharyngeal aspirate, 4 studies; gastric aspirate, 14 studies; stool, 11 studies), Xpert MTB/RIF pooled sensitivity ranged between 45.7% and 73.0%, and pooled specificity ranged between 98.1% and 99.6%. For sputum specimens, Xpert Ultra pooled sensitivity (95% CI) and specificity (95% CI) verified by culture were 72.8% (64.7% to 79.6%) (3 studies, 136 participants; low-certainty evidence) and 97.5% (95.8% to 98.5%) (3 studies, 551 participants; high-certainty evidence). For nasopharyngeal specimens, Xpert Ultra sensitivity (95% CI) and specificity (95% CI) were 45.7% (28.9% to 63.3%) and 97.5% (93.7% to 99.3%) (1 study, 195 participants). For all specimen types, Xpert MTB/RIF and Xpert Ultra sensitivity were lower against a composite reference standard than against culture. Detection of tuberculous meningitis For cerebrospinal fluid, Xpert MTB/RIF pooled sensitivity and specificity, verified by culture, were 54.0% (95% CI 27.8% to 78.2%) (6 studies, 28 participants; very low-certainty evidence) and 93.8% (95% CI 84.5% to 97.6%) (6 studies, 213 participants; low-certainty evidence). Detection of lymph node tuberculosis For lymph node aspirates or biopsies, Xpert MTB/RIF pooled sensitivity and specificity, verified by culture, were 90.4% (95% CI 55.7% to 98.6%) (6 studies, 68 participants; very low-certainty evidence) and 89.8% (95% CI 71.5% to 96.8%) (6 studies, 142 participants; low-certainty evidence). Detection of rifampicin resistance Xpert MTB/RIF pooled sensitivity and specificity were 90.0% (67.6% to 97.5%) (6 studies, 20 participants; low-certainty evidence) and 98.3% (87.7% to 99.8%) (6 studies, 203 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS We found Xpert MTB/RIF sensitivity to vary by specimen type, with gastric aspirate specimens having the highest sensitivity followed by sputum and stool, and nasopharyngeal specimens the lowest; specificity in all specimens was > 98%. Compared with Xpert MTB/RIF, Xpert Ultra sensitivity in sputum was higher and specificity slightly lower. Xpert MTB/RIF was accurate for detection of rifampicin resistance. Xpert MTB/RIF was sensitive for diagnosing lymph node tuberculosis. For children with presumed tuberculous meningitis, treatment decisions should be based on the entirety of clinical information and treatment should not be withheld based solely on an Xpert MTB/RIF result. The small numbers of studies and participants, particularly for Xpert Ultra, limits our confidence in the precision of these estimates.
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MESH Headings
- Adolescent
- Antibiotics, Antitubercular/therapeutic use
- Bias
- Child
- Feces/microbiology
- Gastrointestinal Contents/microbiology
- Humans
- Molecular Typing/methods
- Molecular Typing/standards
- Mycobacterium tuberculosis/drug effects
- Mycobacterium tuberculosis/isolation & purification
- Rifampin/therapeutic use
- Sensitivity and Specificity
- Sputum/microbiology
- Tuberculosis, Lymph Node/diagnosis
- Tuberculosis, Lymph Node/drug therapy
- Tuberculosis, Lymph Node/microbiology
- Tuberculosis, Meningeal/cerebrospinal fluid
- Tuberculosis, Meningeal/diagnosis
- Tuberculosis, Meningeal/drug therapy
- Tuberculosis, Meningeal/microbiology
- Tuberculosis, Multidrug-Resistant/diagnosis
- Tuberculosis, Multidrug-Resistant/drug therapy
- Tuberculosis, Multidrug-Resistant/microbiology
- Tuberculosis, Pulmonary/diagnosis
- Tuberculosis, Pulmonary/drug therapy
- Tuberculosis, Pulmonary/microbiology
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Affiliation(s)
- Alexander W Kay
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | | | - Yemisi Takwoingi
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Michael Eisenhut
- Paediatric Department, Luton & Dunstable University Hospital NHS Foundation Trust, Luton, UK
| | | | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Anna M Mandalakas
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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Sánchez-Cabral O, Santillán-Díaz C, Flores-Bello ÁP, Herrera-Ortega MI, Sandoval-Gutiérrez JL, Santillán-Doherty P, Martínez-Mendoza D. GeneXpert ® MTB/RIF assay with transbronchial lung cryobiopsy for Mycobacterium tuberculosis diagnosis. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:351. [PMID: 32355795 PMCID: PMC7186622 DOI: 10.21037/atm.2020.02.100] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Early tuberculosis (TB) diagnostic is one of the critical steps to TB control. GeneXpert MTB/RIF has been widely proven for a prompt TB diagnosis. The use of GeneXpert MTB/RIF assay with transbronchial lung cryobiopsy samples may increase diagnostic accuracy. We aim to assess the diagnostic of TB with GeneXpert MTB/RIF assay with transbronchial lung cryobiopsy. Methods Patients with suspected diagnosis of TB and negative smear microscopies, with TB culture and GeneXpert MTB/RIF assay with transbronchial lung cryobiopsy were included in this cross-sectional study. Participants were enrolled from 2016 to 2018 at National Institute of Respiratory Diseases, Mexico. Results We included 54 patients (77.8% males) aged 30 to 65 years. The sensitivity of the GeneXpert MTB/RIF assay with transbronchial lung cryobiopsy was 81.3% (95% CI, 62.1-100%), with a specificity of 100% (95% CI, 100-100%) and a negative predictive value of 92.7% (95% CI, 84.7-100%). Twenty-two patients of the total population have HIV, the sensitivity of the test in these patients was 87.5% (95% CI, 64.6-100%). Also, 28 patients with a peripheral localized lesion which had a solid pattern were identified (51.9%). The sensitivity in patients with peripheral localized lesions was 88.9% (68.4-100%). Conclusions The GeneXpert MTB/RIF assay with transbronchial lung cryobiopsy test is as efficient as broncho alveolar lavage for TB diagnosis. Transbronchial lung cryobiopsy increases a major diagnostic opportunity when the nature of illness is malignant. Transbronchial lung cryobiopsy is efficient in HIV patients, especially in patients with peripheral localized lesion.
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Affiliation(s)
- Olivia Sánchez-Cabral
- Interventional Pulmonology Unit, National Institute of Respiratory Diseases "Ismael Cosío Villegas", Mexico City, Mexico
| | - Cira Santillán-Díaz
- Interventional Pulmonology Unit, National Institute of Respiratory Diseases "Ismael Cosío Villegas", Mexico City, Mexico
| | - Ángel Paul Flores-Bello
- Clinic of Tuberculosis and Pleural Diseases, National Institute of Respiratory Diseases "Ismael Cosío Villegas", Mexico City, Mexico
| | - Mildred Ivannia Herrera-Ortega
- Interventional Pulmonology Unit, National Institute of Respiratory Diseases "Ismael Cosío Villegas", Mexico City, Mexico
| | - José Luis Sandoval-Gutiérrez
- Auxiliary and Diagnostic Services, National Institute of Respiratory Diseases "Ismael Cosío Villegas", Mexico City, Mexico
| | - Patricio Santillán-Doherty
- Medical Direction, National Institute of Respiratory Diseases "Ismael Cosío Villegas", Mexico City, Mexico
| | - Dina Martínez-Mendoza
- Epidemiology Surveillance Unit, National Institute of Respiratory Diseases "Ismael Cosío Villegas", Mexico City, Mexico
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Chiappini E, Matucci T, Lisi C, Petrolini C, Venturini E, Tersigni C, de Martino M, Galli L. Use of Second-line Medications and Treatment Outcomes in Children With Tuberculosis in a Single Center From 2007 to 2018. Pediatr Infect Dis J 2019; 38:1027-1034. [PMID: 31397749 DOI: 10.1097/inf.0000000000002410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The incidence of drug-resistant forms of tuberculosis (DR-TB) and the number of children treated with second-line drugs (SLDs) are increasing. However, limited amount of information is available regarding the use of SLDs in this population. METHODS To describe the treatment of pediatric TB with SLDs and factors associated with use of SLDs in children with and without documented DR-TB, records of pediatric TB patients referred to a center in Italy from 2007 to 2018 were reviewed retrospectively. RESULTS Of 204 children diagnosed with active TB during the study period, 42 were treated with SLDs because of confirmed or probable drug resistance (42.8%), adverse reactions to first-line drugs (7.1%), central nervous system involvement (11.9%) or unconfirmed possible drug resistance (38.1%). There were no deaths or adverse reactions to SLDs reported. Treatment was successful in 85.2% children treated with first-line drugs and 92.9% children treated with SLDs. After adjusting for calendar period, the only factor associated with DR-TB was <2 years old [odds ratio (OR): 5.24 for <2 years vs. 5-18 years; P = 0.008]. Factors associated with treatment with SLDs were TB at 2 or more sites (OR: 11.30; P < 0.001), extrapulmonary TB (OR: 8.48; P < 0.001) or adverse reactions to first-line drugs (OR: 7.48; P = 0.002). No differences were noted in age or region of origin. CONCLUSIONS A substantial proportion of TB children were treated with SLDs. The main reason for using SLDs was failure of a first-line drug regimen, suggesting possible DR-TB and underestimation of DR-TB in children. The use of SLD regimens was associated with a high success rate and good tolerability profile.
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Affiliation(s)
- Elena Chiappini
- From the Department of Health Sciences, Anna Meyer Children University Hospital, University of Florence, Florence, Italy
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18
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Gaensbauer J, Broadhurst R. Recent Innovations in Diagnosis and Treatment of Pediatric Tuberculosis. Curr Infect Dis Rep 2019; 21:4. [PMID: 30767077 DOI: 10.1007/s11908-019-0662-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Tuberculosis is leading cause of global morbidity and mortality and a significant proportion of the burden of disease occurs in children. In the past 5 years, a number of innovations have improved the diagnosis and treatment for children with both latent tuberculosis infection and active disease. RECENT FINDINGS This review discusses three key areas of innovation. First, we assess utilization and performance of interferon-gamma release assays (IGRAs) in different clinical and epidemiologic scenarios. Recent literature has demonstrated good performance of IGRAs for diagnosis of latent tuberculosis infection, particularly in low-incidence settings such as TB control programs in North America. For high-incidence populations, or when testing is done for possible active TB disease, IGRA performance has some important limitations, but IGRA sensitivity when measured against culture proven disease may be better than earlier studies suggested. The second area of innovation is in increased uptake of nucleic acid amplification (NAA) tests and broader application in non-sputum samples for both pediatric pulmonary and extrapulmonary tuberculosis. Finally, recent studies have provided solid evidence in support of shorter treatment courses for pediatric latent tuberculosis infection, such as 12 weeks of weekly isoniazid and rifapentine or 4 months daily rifampin, that improve compliance and may reduce resources required for TB control. Many recent innovations in pediatric tuberculosis relate to an improved understanding of how to optimally use existing tests and treatments. Until diagnostic tests and interventions such as vaccination are developed that can dramatically alter the paradigm of pediatric TB management and control, it is important for stakeholders to have a nuanced understanding of tools currently available.
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Affiliation(s)
- James Gaensbauer
- Denver Metro Tuberculosis Clinic, Pavilion C, Denver Health Medical Center, MC 0590, 777 Bannock Street, Denver, CO, 80204, USA. .,Pediatric Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Richard Broadhurst
- Medicine-Pediatric Residency Training Program, University of Colorado School of Medicine, Aurora, CO, USA
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Saini I, Mukherjee A, Gautam H, Singla M, Jat K, Lodha R, Singh UB, Kabra S. Diagnostic Yield of Xpert MTB/RIF in Bronchoalveolar Lavage in Children with Probable Pulmonary Tuberculosis. Indian Pediatr 2018. [DOI: 10.1007/s13312-018-1443-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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20
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Mitsakakis K, D'Acremont V, Hin S, von Stetten F, Zengerle R. Diagnostic tools for tackling febrile illness and enhancing patient management. MICROELECTRONIC ENGINEERING 2018; 201:26-59. [PMID: 32287568 PMCID: PMC7114275 DOI: 10.1016/j.mee.2018.10.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Most patients with acute infectious diseases develop fever, which is frequently a reason to visit health facilities in resource-limited settings. The symptomatic overlap between febrile diseases impedes their diagnosis on clinical grounds. Therefore, the World Health Organization promotes an integrated management of febrile illness. Along this line, we present an overview of endemic and epidemic etiologies of fever and state-of-the-art diagnostic tools used in the field. It becomes evident that there is an urgent need for the development of novel technologies to fulfill end-users' requirements. This need can be met with point-of-care and near-patient diagnostic platforms, as well as e-Health clinical algorithms, which co-assess test results with key clinical elements and biosensors, assisting clinicians in patient triage and management, thus enhancing disease surveillance and outbreak alerts. This review gives an overview of diagnostic technologies featuring a platform based approach: (i) assay (nucleic acid amplification technologies are examined); (ii) cartridge (microfluidic technologies are presented); (iii) instrument (various detection technologies are discussed); and at the end proposes a way that such technologies can be interfaced with electronic clinical decision-making algorithms towards a broad and complete diagnostic ecosystem.
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Affiliation(s)
- Konstantinos Mitsakakis
- Hahn-Schickard, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
- Laboratory for MEMS Applications, IMTEK – Department of Microsystems Engineering, University of Freiburg, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
- Corresponding author.
| | - Valérie D'Acremont
- Swiss Tropical and Public Health Institute, University of Basel, Socinstrasse 57, 4002 Basel, Switzerland
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Bugnon 44, 1011 Lausanne, Switzerland
| | - Sebastian Hin
- Hahn-Schickard, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
| | - Felix von Stetten
- Hahn-Schickard, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
- Laboratory for MEMS Applications, IMTEK – Department of Microsystems Engineering, University of Freiburg, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
| | - Roland Zengerle
- Hahn-Schickard, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
- Laboratory for MEMS Applications, IMTEK – Department of Microsystems Engineering, University of Freiburg, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
- BIOSS – Centre for Biological Signalling Studies, University of Freiburg, Schaenzlestr. 18, 79104 Freiburg, Germany
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Sánchez-Cabral O, Martínez-Mendoza D, Flores-Bello ÁP, Martínez-Orozco JA, Rivera-Rosales RM, Luna-Rivero C, Santillán-Doherty P, Reyes-Terán G. Diagnostic discrepancy between bronchoalveolar lavage and transbronchial biopsy from bronchoscopies of HIV patients with pneumonia: toward an integral diagnosis. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2018; 10:115-123. [PMID: 30013402 PMCID: PMC6038884 DOI: 10.2147/hiv.s161899] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background The key diagnostic method for the evaluation of lung diseases associated with HIV infection is bronchoscopy, with bronchoalveolar lavage (BAL) being the most commonly used sampling technique. Transbronchial biopsy (TBB) is often complementary. Setting This is a retrospective cross-sectional study to determine the diagnostic usefulness of bronchoscopy with simultaneous samples obtained through BAL and TBB in HIV-infected patients with pneumonia at the National Institute of Respiratory Diseases Ismael Cosío Villegas. Methods In this cross-sectional study (January 2014-December 2015), the diagnostic yield of bronchoscopic samples from all HIV-positive patients with pneumonia aged >18 years, from procedures performed in the Interventional Pulmonology Unit, was analyzed and recorded in its database. The diagnostic yield concordance between BAL and TBB samples was evaluated by kappa index calculation. Results A total of 198 procedures on 189 HIV-infected patients with pneumonia were performed. A total of 167/189 (88.4%) patients were male, and the mean age was 34.7 years (SD ±9.0). Overall, the diagnostic yield for either technique was 87.9% (174/198), but it was higher for TBB, its yield being 78.8% (156/198). In contrast, that of BAL was 62.1% (123/198) (P=0.001). The overall diagnostic yield concordance between TBB and BAL was insignificant (k=0.213, P<0.001). It improved for fungal infections, pneumocystosis, and tuberculosis (k=0.417, 0.583, and 0.462, respectively, all P<0.001). Conclusion Our results show that the simultaneous obtainment of BAL and TBB samples is useful and complementary in the diagnosis of infections and malignancies in HIV-infected patients. Additionally, they are safe procedures in this group of patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Gustavo Reyes-Terán
- Department of Research in Infectious Diseases, National Institute of Respiratory Diseases Ismael Cosío Villegas, Mexico City, Mexico
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Pan X, Yang S, Deighton MA, Qu Y, Hong L, Su F. A Comprehensive Evaluation of Xpert MTB/RIF Assay With Bronchoalveolar Lavage Fluid as a Single Test or Combined With Conventional Assays for Diagnosis of Pulmonary Tuberculosis in China: A Two-Center Prospective Study. Front Microbiol 2018; 9:444. [PMID: 29593688 PMCID: PMC5859353 DOI: 10.3389/fmicb.2018.00444] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 02/26/2018] [Indexed: 11/13/2022] Open
Abstract
Introduction: The Xpert MTB/RIF is recommended by the World Health Organization as a first line rapid test for the diagnosis of pulmonary tuberculosis (TB); however, China does not routinely use this test, partially due to the lack of a sufficient number of systematic evaluations of this assay in local patients. The aims of this study were to comprehensively assess the diagnostic performance of Xpert MTB/RIF, either alone or in combination with conventional assays for the diagnosis of pulmonary TB in adult Chinese patients. Methods: Xpert MTB/RIF tests were performed in 190 adult patients with suspected pulmonary TB, using bronchoalveolar lavage fluid (BALF) as test specimens. In parallel, conventional tests were carried out using the same BALF samples. Using two different reference standards, the performance of Xpert MTB/RIF, conventional assays and their combinations were evaluated. Results: Using mycobacterial culture as the reference comparator, Xpert MTB/RIF was found to be superior to smear-microscopy in detecting Mycobacterium tuberculosis. When final diagnosis, based on clinical criteria, was employed as the reference standard, Xpert MTB/RIF showed an even higher accuracy of 72.1%, supported by a sensitivity of 61.1% and specificity of 96.6%. Xpert MTB/RIF also demonstrated a powerful capability to identify pulmonary TB cases undetected by culture or smear-microscopy. Combining smear-microscopy and Xpert MTB/RIF was found to be the most accurate early predictor for pulmonary TB. Rifampicin resistance reported by Xpert MTB/RIF slightly deviated from that by phenotypic antibiotic susceptibility testing and requires further study with a larger sample size. Conclusion: This two-center prospective study highlights the value of Xpert MTB/RIF with BALF in diagnosing pulmonary TB in adult Chinese patients. These findings might contribute to the optimization of current diagnostic algorithms for pulmonary TB in China.
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Affiliation(s)
- Xiaofu Pan
- Department of Laboratory Medicine, The Third Affiliated Hospital of the Wenzhou Medical University, Rui'an, China
| | - Shoufeng Yang
- Department of Infectious Diseases, Wenzhou Central Hospital, Zhejiang, China
| | | | - Yue Qu
- Department of Laboratory Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Biomedicine Discovery Institute, Department of Microbiology, School of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
| | - Liang Hong
- Department of Infectious Diseases, The Third Affiliated Hospital of Wenzhou Medical University, Rui'an, China
| | - Feifei Su
- Department of Infectious Diseases, Wenzhou Central Hospital, Zhejiang, China
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Evaluating the diagnostic accuracy of the Xpert MTB/RIF assay on bronchoalveolar lavage fluid: A retrospective study. Int J Infect Dis 2018; 71:14-19. [PMID: 29428408 DOI: 10.1016/j.ijid.2018.01.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/29/2018] [Accepted: 01/29/2018] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Limited data on the diagnostic accuracy of the Xpert MTB/RIF assay using bronchoalveolar lavage fluid from patients with suspected pulmonary tuberculosis (PTB) have been reported in China. Therefore, a retrospective study was designed to evaluate the diagnostic accuracy of this assay. METHODS Clinical, radiological, and microbiological characteristics of 238 patients with suspected PTB were reviewed retrospectively. The sensitivity, specificity, positive predictive value, and negative predictive value for the diagnosis of active PTB were calculated for the Xpert MTB/RIF assay using TB culture or final diagnosis based on clinical and radiological evaluation as the reference standard. RESULTS The sensitivity and specificity of the Xpert MTB/RIF assay were 84.5% and 98.9%, respectively, and those for smear microscopy were 36.2% and 100%, respectively, when compared to the culture method. However, compared with the sensitivity and specificity of final diagnosis based on clinical and radiological evaluation, the sensitivity and specificity of the assay were 72.9% and 98.7%, respectively, which were significantly higher than those for smear microscopy. CONCLUSIONS The Xpert MTB/RIF assay on bronchoalveolar lavage fluid could serve as an additional rapid diagnostic tool for PTB in a high TB-burden country and improve the time to TB treatment initiation in patients with PTB.
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Gowda NC, Ray A, Soneja M, Khanna A, Sinha S. Evaluation of Xpert ®Mycobacterium tuberculosis/rifampin in sputum-smear negative and sputum-scarce patients with pulmonary tuberculosis using bronchoalveolar lavage fluid. Lung India 2018; 35:295-300. [PMID: 29970767 PMCID: PMC6034363 DOI: 10.4103/lungindia.lungindia_412_17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Context: Sputum smear-negative and sputum-scarce pulmonary tuberculosis (PTB) is a diagnostic challenge. Xpert®Mycobacterium tuberculosis/rifampin (MTB/RIF) provides a rapid diagnosis on high-quality biological specimen obtained by bronchoscopy. Aims: The aim of this study is to evaluate Xpert® MTB/RIF on bronchoalveolar lavage (BAL) fluid in sputum smear-negative and sputum-scarce PTB patients. Settings: Tertiary care hospital in India. Design: This was prospective observational study. Materials and Methods: Between January 2015 and November 2016, we prospectively recruited sputum-smear negative and sputum-scarce patients under evaluation for PTB and performed BAL. Sensitivity, specificity, positive, and negative predictive values were calculated for the diagnosis of PTB on BAL fluid for acid-fast bacilli smear and Xpert® MTB/RIF using liquid culture as the reference standard and compared to the final diagnosis based on composite reference standard. Sensitivity, specificity, and predictive values were calculated with 95% class intervals. McNemar's test was used for comparison of sensitivities. Results: Of the 60 patients included, 52 (88.3%) had a final diagnosis of PTB and 16 (26.7%) were culture confirmed. Xpert® MTB/RIF had a sensitivity and specificity of 81% (54%–96%) and 73% (56%–85%) in culture confirmed cases; 46% (32%–60%) and 100% (63%–100%) for the final diagnosis; 32% (17%–51%) and 100% (54%–100%) in culture negative cases, respectively. Culture had a sensitivity of 32% (20%–47%) for the final diagnosis. Conclusions: In sputum smear-negative and sputum-scarce patients with clinico-radiological features of PTB Xpert® MTB/RIF has good sensitivity for diagnosis on BAL fluid. It is useful even when cultures are negative.
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Affiliation(s)
- Nikhil C Gowda
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Animesh Ray
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Manish Soneja
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Arjun Khanna
- Department of Pulmonary Medicine and Critical Care Medicine, Yashoda Superspeciality Hospital, Kaushambi, Uttar Pradesh, India
| | - Sanjeev Sinha
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
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Bacteriological diagnosis of childhood TB: a prospective observational study. Sci Rep 2017; 7:11808. [PMID: 28924198 PMCID: PMC5603584 DOI: 10.1038/s41598-017-11969-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 09/01/2017] [Indexed: 12/18/2022] Open
Abstract
Childhood TB diagnosis is challenging. Studies in adults suggest Microscopic Observation Drug Susceptibility (MODS) culture or the Xpert MTB/RIF assay might be used to expand bacteriological diagnosis. However data from children are more limited. We prospectively compared MODS and Xpert MTB/RIF with standard microscopy and culture using the BD MGIT 960 system among 1442 Kenyan children with suspected TB. 97 specimens from 54 children were TB culture-positive: 91 (94%) by MGIT and 74 (76%) by MODS (p = 0.002). 72 (74%) culture-positive and 7 culture-negative specimens were Xpert MTB/RIF positive. Xpert MTB/RIF specificity was 100% (99.7–100%) among 1164 specimens from 892 children in whom TB was excluded, strongly suggesting all Xpert MTB/RIF positives are true positives. The sensitivity of MGIT, MODS and Xpert MTB/RIF was 88%, 71% and 76%, respectively, among all 104 true positive (culture and/or Xpert MTB/RIF positive) specimens. MGIT, MODS and Xpert MTB/RIF on the initial specimen identified 40/51 (78%), 33/51 (65%) and 33/51 (65%) culture-confirmed pulmonary TB cases, respectively; Xpert MTB/RIF detected 5 additional culture-negative cases. The high sensitivity and very high specificity of the Xpert MTB/RIF assay supports its inclusion in the reference standard for bacteriological diagnosis of childhood TB in research and clinical practice.
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Webster I, Goussard P, Gie R, Janson J, Rossouw G. The indications and role of paediatric bronchoscopy in a developing country, with high prevalence of pulmonary tuberculosis and HIV. Expert Rev Respir Med 2017; 11:159-165. [PMID: 28107788 DOI: 10.1080/17476348.2017.1280397] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Bronchoscopy, an important investigation for the diagnosis and management of respiratory diseases, is widely used in high income countries. There is limited information on value of paediatric bronchoscopy in low and middle income countries (LMIC). AIMS AND OBJECTIVES Aim was to describe the indications, findings and complications of bronchoscopy in a middle income country with a high prevalence of tuberculosis and HIV. METHODOLOGY A retrospective analysis of a database over a 3.5 year period. RESULTS A total of 509 bronchoscopies were performed on neonates (2.3%) and children (median age = 18 months) of which 5.1% were HIV-infected. The main indications were: possible large airway compression 40%, complicated pneumonia (25%) and persistent stridor (15%). Pathology was observed in 64% of bronchoscopies. The most findings were lymph node compression of the airways (21%), and upper airway pathology (12%). Interventional procedures were performed in 112 cases (22%), the commonest being foreign bodies removal (30%), endobronchial lymph node enucleation (30%) and transbronchial needle aspiration (20%). No major complications. CONCLUSION The diagnostic yield of paediatric bronchoscopy did not differ from high income countries emphasising the importance of paediatric bronchoscopy in the management of childhood lung disease in LMICs.
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Affiliation(s)
- Irwin Webster
- a Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences , Stellenbosch University and Tygerberg Children's Hospital , Cape Town , South Africa
| | - Pierre Goussard
- a Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences , Stellenbosch University and Tygerberg Children's Hospital , Cape Town , South Africa
| | - Robert Gie
- a Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences , Stellenbosch University and Tygerberg Children's Hospital , Cape Town , South Africa
| | - Jacques Janson
- b Department of Cardio-Thoracic Surgery, Faculty of Medicine and Health Sciences , Stellenbosch University and Tygerberg Children's Hospital , Cape Town , South Africa
| | - Gawie Rossouw
- b Department of Cardio-Thoracic Surgery, Faculty of Medicine and Health Sciences , Stellenbosch University and Tygerberg Children's Hospital , Cape Town , South Africa
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Goussard P, Gie R. The need for bronchoscopic services for children in low and middle-income countries. Expert Rev Respir Med 2016; 10:477-9. [DOI: 10.1586/17476348.2016.1162716] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Detection Yield and Tolerability of String Test for Diagnosis of Childhood Intrathoracic Tuberculosis. Pediatr Infect Dis J 2016; 35:146-51. [PMID: 26517328 DOI: 10.1097/inf.0000000000000956] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Difficulty to obtain sputum in children complicates diagnosis of intrathoracic tuberculosis (TB). The intragastric string test (ST) used for retrieval of enteric pathogens might be an alternative specimen collection method but requires further evaluation of its utility in TB diagnosis. We conducted a cross-sectional study comparing the TB detection yield and the tolerability of ST and sputum induction (SI) in children. METHODS Two ST and SI procedures were performed in children (3-14 years of age) who were clinically suspected of having TB. The string was removed after a 2-hour gastric downtime, and SI was done after a maximum of 20 minutes nebulization with 5% saline solution. LED-fluorescence microscopy and mycobacterial cultures were performed on all specimens, and XpertMTB/RIF assay was performed on stored specimen sediments. Tolerability questionnaires were administered to parents of children. RESULTS Of 137 included children (median age: 8.1 years; 33.3% with HIV infection), 14 (10.2%) were diagnosed with TB, 10 (71.4%) by ST and 12 (85.7%) by SI. Among 105 children with both ST and SI performed, 5 (4.8%) versus 4 (3.8%) were smear positive using ST and SI, respectively (McNemar P = 1.00). Nine (8.6%) in each group had positive cultures (P = 1.00). Of 64 children tested with XpertMTB/RIF, 3 (4.7%) of the ST group versus 4 (6.3%) of the SI group were TB positive (P = 1.00). No adverse serious events were reported. ST could not be performed in 22 of 137 (16.1%) children because they were unable to swallow the capsule. CONCLUSIONS TB detection yield was comparable between ST and SI. The tolerability of ST in young children might be improved by the reduction of the size of the capsule.
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Noah TL, Auten R, Schwarze J, Davis S. Pediatric pulmonology year in review 2014: Part 2. Pediatr Pulmonol 2015; 50:1140-6. [PMID: 26193432 DOI: 10.1002/ppul.23252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 06/22/2015] [Accepted: 06/24/2015] [Indexed: 11/07/2022]
Abstract
To better meet the needs of our readership for updated perspectives on the rapidly expanding knowledge in our field, we here summarize the past year's publications in our major topic areas, as well as selected publications in these areas from the core clinical journal literature outside our own pages. This is Part 2 of a series and covers articles on neonatal lung disease, pulmonary physiology, and respiratory infection.
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Affiliation(s)
- Terry L Noah
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Richard Auten
- Department of Pediatrics, Duke University, Durham, North Carolina
| | - Jurgen Schwarze
- Department of Child Life and Health, The University of Edinburgh, Edinburgh, UK
| | - Stephanie Davis
- Department of Pediatrics, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, Indiana
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Sharma SK, Kohli M, Yadav RN, Chaubey J, Bhasin D, Sreenivas V, Sharma R, Singh BK. Evaluating the Diagnostic Accuracy of Xpert MTB/RIF Assay in Pulmonary Tuberculosis. PLoS One 2015; 10:e0141011. [PMID: 26496123 PMCID: PMC4619889 DOI: 10.1371/journal.pone.0141011] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 10/02/2015] [Indexed: 12/05/2022] Open
Abstract
Pulmonary tuberculosis still remains a major communicable disease worldwide. In 2013, 9 million people developed TB and 1.5 million people died from the disease. India constitutes 24% of the total TB burden. Early detection of TB cases is the key to successful treatment and reduction of disease transmission. Xpert MTB/RIF, an automated cartridge-based molecular technique detects Mycobacterium tuberculosis and rifampicin resistance within two hours has been endorsed by WHO for rapid diagnosis of TB. Our study is the first study from India with a large sample size to evaluate the performance of Xpert MTB/RIF assay in PTB samples. The test showed an overall sensitivity and specificity of 95.7% (430/449) and 99.3% (984/990) respectively. In smear negative-culture positive cases, the test had a sensitivity of 77.7%. The sensitivity and specificity for detecting rifampicin resistance was 94.5% and 97.7% respectively with respect to culture as reference standard. However, after resolving the discrepant samples with gene sequencing, the sensitivity and specificity rose to 99.0% and 99.3% respectively. Hence, while solid culture still forms the foundation of TB diagnosis, Xpert MTB/RIF proposes to be a strong first line diagnostic tool for pulmonary TB cases.
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Affiliation(s)
- Surendra K Sharma
- Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Mikashmi Kohli
- Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Raj Narayan Yadav
- Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Jigyasa Chaubey
- Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Dinkar Bhasin
- Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India
| | | | - Rohini Sharma
- Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Binit K Singh
- Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India
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Singh S, Singh A, Prajapati S, Kabra SK, Lodha R, Mukherjee A, Singh V, Hesseling AC, Grewal HMS. Xpert MTB/RIF assay can be used on archived gastric aspirate and induced sputum samples for sensitive diagnosis of paediatric tuberculosis. BMC Microbiol 2015; 15:191. [PMID: 26420261 PMCID: PMC4589030 DOI: 10.1186/s12866-015-0528-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 09/22/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) in children is neglected, mainly due to lack of sensitive diagnostic tools. Recently Xpert MTB/RIF assay has revolutionized the diagnostic field, but its usefulness in pediatric TB has not been reported from India and no report is available on its use on long term archived samples. METHODS We recruited 130 pediatric patients with probable intrathoracic tuberculosis and their gastric aspirate (GA) and induced sputum (IS) samples on 2 consecutive days were collected between January 2009 and December 2012. All samples (n = 520) were subjected to smear examination, BACTEC-MGIT culture and in-house multiplex PCR. An aliquot of each sample was stored at -80 °C and tested in Xpert MTB/RIF assay in 2013. RESULTS Sample wise and patient wise detection rate of smear microscopy was 4.4 % and 10 %, while for BACTEC-MGIT culture this rate was 24.4 % and 46.9 %, respectively. Of the 130 day 1 GA samples, 31.5 % and 27.7 % day 2 GA samples were culture positive. Only 17.7 % GA samples were positive on both days. Of the 130 IS samples collected on day 1 and day 2, 15.4 % and 23.1 % samples were culture positive. A combination of GA and IS yielded best results. Combining both GA and IS, the overall sensitivity of Xpert MTB/RIF on smear and culture positive samples was 95.6 %. In smear negative and culture positive samples its sensitivity was 62.5 %. The duration of sample storage impacted the Xpert MTB/RIF test performance (p = 0.0001). In smear positive samples stored for 650-849 days, its sensitivity was 85.7 % and 77.1 % for IS and GA samples which dropped to 33.3 % and 50 %, respectively, if stored for more than 1050 days. DISCUSSION Confirmatory diagnosis of tuberculosis particularly in children is a medical challenge. No laboratory or radiological test can reach to a satisfactory level of diagnostic sensitivity. However, in this study we found that combination of multiple samples and multiple diagnostic tests can give much better yield, though not optimum. In present study, combination of 2 gastric aspirates (GA) and 2 induced sputum (IS) samples collected on two consecutive days, and tested on three diagnostic methods yielded a significantly high detection rate. Despite long term storage, the overall sensitivity of Xpert MTB/RIF on smear and -culture positive samples remained very high. But after storing these samples under subfreezing conditions the sensitivity of Xpert MTB/RIF decreased significantly. This is expected because even if the sample is smear and culture positive, the count of surviving mycobacteria goes down, after several years this count can reach to a undetectable level. CONCLUSION This report shows that smear and culture positive samples stored at subfreezing conditions for several years can be used in the Xpert MTB/RIF assay, while maintaining appreciable diagnostic test sensitivity and specificity.
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Affiliation(s)
- Sarman Singh
- Division of Clinical Microbiology and Molecular Medicine, Department of Laboratory Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
| | - Amit Singh
- Division of Clinical Microbiology and Molecular Medicine, Department of Laboratory Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
| | - Suneel Prajapati
- Division of Clinical Microbiology and Molecular Medicine, Department of Laboratory Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
| | - Sushil K Kabra
- Department of Paediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
| | - Rakesh Lodha
- Department of Paediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
| | - Aparna Mukherjee
- Department of Paediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
| | - Varinder Singh
- Department of Paediatrics, Kalawati Saran Children Hospital, New Delhi, 110 001, India.
| | - Anneke C Hesseling
- Paediatric Research, Desmond Tutu TB Centre, University of Stellenbosch, Stellenbosch, South Africa.
| | - Harleen M S Grewal
- Department Clinical Science, Infection, University of Bergen, Bergen, Norway.
- Department of Microbiology, Haukeland University Hospital, Bergen, N-5021, Norway.
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Calligaro GL, Theron G, Khalfey H, Peter J, Meldau R, Matinyenya B, Davids M, Smith L, Pooran A, Lesosky M, Esmail A, Miller MG, Piercy J, Michell L, Dawson R, Raine RI, Joubert I, Dheda K. Burden of tuberculosis in intensive care units in Cape Town, South Africa, and assessment of the accuracy and effect on patient outcomes of the Xpert MTB/RIF test on tracheal aspirate samples for diagnosis of pulmonary tuberculosis: a prospective burden of disease study with a nested randomised controlled trial. THE LANCET RESPIRATORY MEDICINE 2015. [PMID: 26208996 DOI: 10.1016/s2213-2600(15)00198-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND There are few prospective data about the incidence and mortality associated with pulmonary tuberculosis in intensive care units (ICUs), and none on the accuracy and clinical effect of the Xpert-MTB/RIF assay in this setting. We aimed to measure the frequency of culture-positive tuberculosis in ICUs in Cape Town, South Africa and to assess the performance and effect on patient outcomes of Xpert MTB/RIF versus smear microscopy for diagnosis of tuberculosis. METHODS We did a prospective burden of disease study with a randomised controlled substudy at the ICUs of four hospitals in Cape Town. Mechanically ventilated adults (≥18 years) with suspected pulmonary tuberculosis admitted between Aug 1, 2010, and July 31, 2013 (irrespective of the reason for admission), were prospectively investigated by culture, and by Xpert-MTB/RIF testing or smear microscopy, of tracheal aspirate samples. In the substudy, patients were randomly assigned (1:1), via a computer-generated allocation list, to smear microscopy or Xpert MTB/RIF. Participants, caregivers, and outcome assessors were not masked to group assignment. Only the laboratory staff were blinded to the clinical details of the participants. In November, 2012, Xpert MTB/RIF was adopted as the initial diagnostic test for respiratory samples in Western Cape province. Thereafter, patients received Xpert MTB/MIF and culture as standard of care. For the whole study cohort, the primary outcome was the frequency of bacteriologically confirmed tuberculosis. The primary endpoint of the randomised substudy was the proportion of culture-positive patients on treatment at 48 h after enrolment. The randomised substudy is registered with ClinicalTrials.gov, number NCT01530568. FINDINGS We investigated 341 patients for suspected pulmonary tuberculosis out of a total of 2309 ICU admissions. 46 (15%) of 317 patients included in the final analysis had a positive test for tuberculosis (Xpert MTB/RIF or culture). Culture-positive patients who failed to initiate treatment (adjusted HR 4·49, 95% CI 1·45-13·89) or who received inotropes (4·33, 1·49-12·60) were more likely to die. However, tuberculosis status was not associated with 28-day or 90-day mortality. In the substudy, we randomly assigned 115 patients to smear microscopy and 111 to Xpert MTB/RIF. Smear microscopy detected six (43%) of 14 culture-positive patients, and Xpert MTB/RIF detected 11 (100%) of 11 culture-positive patients (p=0·002). The proportion of culture-positive patients on treatment at 48 h was higher in the Xpert MTB/RIF group than in the smear microscopy group (11 [92%] of 12 vs nine [53%] of 17; p=0·043), although use of Xpert MTB/RIF had no effect on mortality or other patient outcomes. INTERPRETATION Tuberculosis is fairly common in ICUs in high-burden settings, and clinicians should screen and test patients for tuberculosis with Xpert MTB/RIF where available. This test improves diagnostic yield and rates of treatment initiation, and reduces unnecessary treatment, but might not increase the total number of patients on treatment when empirical treatment is widely used. A suspected diagnosis of pulmonary tuberculosis should not exclude patients from ICU care in resource-limited settings because mortality is unaffected by the presence of this disease. FUNDING European and Developing Countries Clinical Trials Partnership, South African Medical Research Council, and the Discovery Foundation.
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Affiliation(s)
- Gregory L Calligaro
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Grant Theron
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Hoosain Khalfey
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Jonathan Peter
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Richard Meldau
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Brian Matinyenya
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Malika Davids
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Liezel Smith
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Anil Pooran
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Maia Lesosky
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Aliasgar Esmail
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Malcolm G Miller
- Division of Critical Care, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Jenna Piercy
- Division of Critical Care, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Lancelot Michell
- Division of Critical Care, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Rodney Dawson
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Richard I Raine
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Ivan Joubert
- Division of Critical Care, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.
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Venturini E, Remaschi G, Berti E, Montagnani C, Galli L, de Martino M, Chiappini E. What steps do we need to take to improve diagnosis of tuberculosis in children? Expert Rev Anti Infect Ther 2015; 13:907-22. [PMID: 25938981 DOI: 10.1586/14787210.2015.1040764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Tuberculosis still represents a big global public health challenge. The diagnosis of tuberculosis and the differentiation between active and latent tuberculosis remain difficult, particularly in childhood, because of the lack of a gold standard test for diagnosis. In the last decade, novel diagnostic assays have been developed. Among immunologic tests, new assays based on the measurement of different cytokines released by specific T cells in response to Mycobacterium tuberculosis antigens, other than INF-γ, have been investigated. Promising results rely on nucleic acid amplification techniques, also able to detect drugs resistance. Innovative research fields studied the modifications of CD27 expression in T cells as well as different host gene expression in response to M. tuberculosis. Further studies are needed to assess the diagnostic value and the accuracy of these new assays.
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Affiliation(s)
- Elisabetta Venturini
- Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy
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Detjen AK, DiNardo AR, Leyden J, Steingart KR, Menzies D, Schiller I, Dendukuri N, Mandalakas AM. Xpert MTB/RIF assay for the diagnosis of pulmonary tuberculosis in children: a systematic review and meta-analysis. THE LANCET RESPIRATORY MEDICINE 2015; 3:451-61. [PMID: 25812968 DOI: 10.1016/s2213-2600(15)00095-8] [Citation(s) in RCA: 201] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 02/26/2015] [Accepted: 02/26/2015] [Indexed: 01/22/2023]
Abstract
BACKGROUND Microbiological confirmation of childhood tuberculosis is rare because of the difficulty of collection of specimens, low sensitivity of smear microscopy, and poor access to culture. We aimed to establish summary estimates for sensitivity and specificity of of the Xpert MTB/RIF assay compared with microscopy in the diagnosis of pulmonary tuberculosis in children. METHODS We searched for studies published up to Jan 6, 2015, that used Xpert in any setting in children with and without HIV infection. We systematically reviewed studies that compared the diagnostic accuracy of Xpert MTB/RIF (Xpert) with microscopy for detection of pulmonary tuberculosis and rifampicin resistance in children younger than 16 years against two reference standards-culture results and culture-negative children who were started on anti-tuberculosis therapy. We did meta-analyses using a bivariate random-effects model. FINDINGS We identified 15 studies including 4768 respiratory specimens in 3640 children investigated for pulmonary tuberculosis. Culture tests were positive for tuberculosis in 12% (420 of 3640) of all children assessed and Xpert was positive in 11% (406 of 3640). Compared with culture, the pooled sensitivities and specificities of Xpert for tuberculosis detection were 62% (95% credible interval 51-73) and 98% (97-99), respectively, with use of expectorated or induced sputum samples and 66% (51-81) and 98% (96-99), respectively, with use of samples from gastric lavage. Xpert sensitivity was 36-44% higher than was sensitivity for microscopy. Xpert sensitivity in culture-negative children started on antituberculosis therapy was 2% (1-3) for expectorated or induced sputum. Xpert's pooled sensitivity and specificity to detect rifampicin resistance was 86% (95% credible interval 53-98) and 98% (94-100), respectively. INTERPRETATION Compared with microscopy, Xpert offers better sensitivity for the diagnosis of pulmonary tuberculosis in children and its scale-up will improve access to tuberculosis diagnostics for children. Although Xpert helps to provide rapid confirmation of disease, its sensitivity remains suboptimum compared with culture tests. A negative Xpert result does not rule out tuberculosis. Good clinical acumen is still needed to decide when to start antituberculosis therapy and continued research for better diagnostics is crucial. FUNDING WHO, Global TB Program of Texas Children's Hospital.
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Affiliation(s)
- Anne K Detjen
- The International Union Against Tuberculosis And Lung Disease (The Union), New York, NY, USA.
| | - Andrew R DiNardo
- Infectious Diseases, Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA; The Global Tuberculosis Program, Texas Children's Hospital, Houston, TX, USA
| | - Jacinta Leyden
- Department of Bioengineering, Rice University, Houston, TX, USA; The Global Tuberculosis Program, Texas Children's Hospital, Houston, TX, USA
| | - Karen R Steingart
- Cochrane Infectious Diseases Group, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Dick Menzies
- Respiratory and Epidemiology Clinical Research Unit, Montreal Chest Institute, McGill University, Montreal, QC, Canada
| | - Ian Schiller
- Division of Clinical Epidemiology, McGill University Health Centre, Montreal, QC, Canada
| | - Nandini Dendukuri
- Division of Clinical Epidemiology, McGill University Health Centre, Montreal, QC, Canada
| | - Anna M Mandalakas
- The Global Tuberculosis Program, Texas Children's Hospital, Houston, TX, USA; Retrovirology and Global Health, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
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Rapid diagnosis of childhood pulmonary tuberculosis by Xpert MTB/RIF assay using bronchoalveolar lavage fluid. BIOMED RESEARCH INTERNATIONAL 2014; 2014:310194. [PMID: 25165698 PMCID: PMC4140106 DOI: 10.1155/2014/310194] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 07/15/2014] [Accepted: 07/22/2014] [Indexed: 11/29/2022]
Abstract
In order to evaluate the diagnostic accuracy of the Xpert MTB/RIF assay on childhood pulmonary tuberculosis (PTB) using bronchoalveolar lavage fluid (BALF), we evaluated the sensitivity, specificity, positive predictive value, and negative predictive value of Xpert MTB/RIF assay using BALF in comparison with acid-fast bacilli (AFB) microscopy and Mycobacterium tuberculosis (MTB) culture for diagnosing childhood PTB using Chinese “composite clinical reference standard” (CCRS) as reference standard. Two hundred fifty-five children with suspected PTB were enrolled at Beijing Children's Hospital from September 2010 to July 2013. Compared with Chinese CCRS, the sensitivity of AFB microscopy, MTB culture, and Xpert MTB/RIF assay was 8.4%, 28.9%, and 53.0%, respectively. The specificity of three assays was all 100%. Xpert MTB/RIF assay could detect 33.9% of cases with negative MTB culture, and 48.7% of cases with negative AFB microscopy. Younger age (<3 years), absence of BCG scar, and contact with TB patient were found significantly associated with a positive result of Xpert MTB/RIF assay. In conclusion, Xpert MTB/RIF assay using BALF can assist in diagnosing childhood PTB much faster when fiberoptic bronchoscopy is necessary according to the chest radiograph.
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