A high-resolution computed tomography-based scoring system to differentiate the most infectious active pulmonary tuberculosis from community-acquired pneumonia in elderly and non-elderly patients

High-resolution computed tomography features associated with differentiation of tuberculosis among elderly patients with community-acquired pneumonia: a multi-institutional propensity-score matched study

While high-resolution computed tomography (HRCT) is increasingly performed, its role in diagnosing pulmonary tuberculosis (TB) among elderly patients with community-acquired pneumonia (CAP) has not been fully elucidated. This study aimed to determine HRCT features that can differentiate pulmonary TB from non-TB CAP in elderly patients. This study included consecutive elderly patients (age > 65 years) admitted to two teaching hospitals for pulmonary TB or non-TB pneumonia who met the CAP criteria of the American Thoracic Society/Infectious Diseases Society of America guidelines. After propensity score matching for clinical background between patients with pulmonary TB and those with non-TB CAP, their HRCT features were compared. This study included 151 patients with pulmonary TB and 238 patients with non-TB CAP. The presence of centrilobular nodules, air bronchograms, and cavities and the absence of ground-glass opacities and bronchial wall thickening were significantly associated with pulmonary TB. The negative predictive values of centrilobular nodules, air bronchograms, and cavities for pulmonary TB were moderate (70.6%, 67.9%, and 63.0%, respectively), whereas the positive predictive value of cavities was high (96.6%). In elderly patients, although some HRCT features could differentiate pulmonary TB from non-TB CAP, no useful findings could rule out pulmonary TB with certainty.

Absence of Association between Previous Mycoplasma pneumoniae Infection and Subsequent Myasthenia Gravis: A Nationwide Population-Based Matched Cohort Study

Mycoplasma pneumoniae (M. pneumoniae) is not only one of the most common pathogenic bacteria for respiratory infection but also a trigger for many autoimmune diseases. Its infection process shared many similarities with the pathogenesis of myasthenia gravis (MG) at cellular and cytokine levels. Recent case reports demonstrated patients present with MG after M. pneumoniae infection. However, no epidemiological studies ever looked into the association between the two. Our study aimed to investigate the relationship between M. pneumoniae infection and subsequent development of MG. In this population-based retrospective cohort study, the risk of MG was analyzed in patients who were newly diagnosed with M. pneumoniae infection between 2000 and 2013. A total of 2428 M. pneumoniae patients were included and matched with the non-M. pneumoniae control cohort at a 1:4 ratio by age, sex, and index date. Cox proportional hazards regression analysis was applied to analyze the risk of MG development after adjusting for sex, age, and comorbidities, with hazard ratios and 95% confidence intervals. The incidence rates of MG in the non-M. pneumoniae and M. pneumoniae cohorts were 0.96 and 1.97 per 10,000 person-years, respectively. Another case-control study of patients with MG (n = 515) was conducted to analyze the impact of M. pneumoniae on MG occurrence as a sensitivity analysis. The analysis yielded consistent absence of a link between M. pneumoniae and MG. Although previous studies have reported that M. pneumoniae infection and MG may share associated immunologic pathways, we found no statistical significance between M. pneumoniae infection and subsequent development of MG in this study.

How radiology can help pulmonary tuberculosis diagnosis: analysis of 49 patients

PURPOSE

To identify the most frequent radiological findings of pulmonary tuberculosis using CT of the chest, to determine those with the highest degree of correlation, and, if possible, to identify the most suggestive radiological findings for acid-fast bacilli (AFB) positive disease.

MATERIALS AND METHODS

The radiological and clinical data of 49 patients submitted to CT during diagnosis were retrospectively analysed. The association between findings was assessed using Fisher's exact test, while correlation at CT scan was evaluated with the Spearman analysis.

RESULTS

Bronchiectasis/bronchioloectasis (89.8%), nodule(s) (81.6%), tree-in-bud (TIB), and consolidation (79.6% each) figured among the most common parenchymal findings. Lymphadenopathy (26.5%) was the most common nodal finding. TIB and cavity showed the highest correlation (r = 0.577), followed by TIB and bronchi(olo)ectasis (r = 0.498), TIB and consolidation (r = 0.497), nodule(s), and ground glass opacity (r = 0.488). High correlation was found in only the seven most frequent parenchymal findings. Consolidation, TIB, and cavity were useful to predict the AFB stain positivity.

CONCLUSIONS

Our series confirms the extreme heterogeneity of pulmonary tuberculosis. It also proves there are couple of findings which can drive us to the right diagnosis. While a triad of findings predicts AFB positivity, we have not found any predictive sign of AFB negativity; consequently, all patients with suspected imaging and clinical findings for TB should be isolated.

High-resolution computed tomography findings of pulmonary tuberculosis in lung transplant recipients

OBJECTIVE

Respiratory infections constitute a major cause of morbidity and mortality in solid organ transplant recipients. The incidence of pulmonary tuberculosis is high among such patients. On imaging, tuberculosis has various presentations. Greater understanding of those presentations could reduce the impact of the disease by facilitating early diagnosis. Therefore, we attempted to describe the HRCT patterns of pulmonary tuberculosis in lung transplant recipients.

METHODS

From two hospitals in southern Brazil, we collected the following data on lung transplant recipients who developed pulmonary tuberculosis: gender; age; symptoms; the lung disease that led to transplantation; HRCT pattern; distribution of findings; time from transplantation to pulmonary tuberculosis; and mortality rate. The HRCT findings were classified as miliary nodules; cavitation and centrilobular nodules with a tree-in-bud pattern; ground-glass attenuation with consolidation; mediastinal lymph node enlargement; or pleural effusion.

RESULTS

We evaluated 402 lung transplant recipients, 19 of whom developed pulmonary tuberculosis after transplantation. Among those 19 patients, the most common HRCT patterns were ground-glass attenuation with consolidation (in 42%); cavitation and centrilobular nodules with a tree-in-bud pattern (in 31.5%); and mediastinal lymph node enlargement (in 15.7%). Among the patients with cavitation and centrilobular nodules with a tree-in-bud pattern, the distribution was within the upper lobes in 66.6%. No pleural effusion was observed. Despite treatment, one-year mortality was 47.3%.

CONCLUSIONS

The predominant HRCT pattern was ground-glass attenuation with consolidation, followed by cavitation and centrilobular nodules with a tree-in-bud pattern. These findings are similar to those reported for immunocompetent patients with pulmonary tuberculosis and considerably different from those reported for AIDS patients with the same disease.

Statin for Tuberculosis and Pneumonia in Patients with Asthma⁻Chronic Pulmonary Disease Overlap Syndrome: A Time-Dependent Population-Based Cohort Study

We investigated the effects of statins on tuberculosis (TB) and pneumonia risks in asthma⁻chronic pulmonary disease overlap syndrome (ACOS) patients. We extracted data of patients diagnosed as having ACOS during 2000⁻2010 from the Taiwan National Health Insurance Research Database and divided them into statin users and nonusers. All study participants were followed up from the index date until death, withdrawal from insurance, or TB and pneumonia occurred (31 December 2011). The cumulative TB and pneumonia incidence was analyzed using Cox proportional regression analysis with time-dependent variables. After adjustments for multiple confounding factors including age, sex, comorbidities, and use of medications [statins, inhaled corticosteroids (ICSs), or oral steroids (OSs)], statin use was associated with significantly lower TB [adjusted hazard ratio (aHR) 0.49, 95% confidence interval (CI) 0.34⁻0.70] and pneumonia (aHR 0.52, 95% CI 0.41⁻0.65) risks. Moreover, aHRs (95% CIs) for statins combined with ICSs and OSs were respectively 0.60 (0.31⁻1.16) and 0.58 (0.40⁻0.85) for TB and 0.61 (0.39⁻0.95) and 0.57 (0.45⁻0.74) for pneumonia. Thus, statin users had lower TB and pneumonia risks than did nonusers, regardless of age, sex, comorbidities, and ICS or OS use. Pneumonia risk was lower among users of statins combined with ICSs or Oss and TB risk was lower among the users of statins combined with OSs.

Correlation of microbiological yield with radiographic activity on chest computed tomography in cases of suspected pulmonary tuberculosis

BACKGROUND

Little is known about the correlation between microbiological yield and radiographic activity, on chest computed tomography (CT), in suspected pulmonary tuberculosis (PTB) cases, despite CT being widely used, clinically.

METHODS

We used multicenter retrospective data, obtained from medical records, focusing on the diagnostic performance for definite PTB. We categorized patients into four groups, by radiographic activity: definitely active, probably active, indeterminate activity, and probably inactive.

RESULTS

Of the 650 patients included, 316 had culture-confirmed PTB; 190 (29.2%), 323 (49.7%), 70 (10.8%), and 67 (10.3%) were classified into the definitely active, probably active, indeterminate activity, and probably inactive groups, respectively. The corresponding observed culture rates for CT radiographic activity were 61.6%, 60.7%, 4.3% and 0%, respectively. When not only culture rates but TB-PCR and histological results were taken into consideration as definite PTB, it showed 66.6%, 67.2%, 14.3%, and 0% of each CT radiographic activity, respectively. Regarding the diagnostic performance for definite PTB, radiographic activity displayed high sensitivity (97.1%, 95% confidence interval (CI), 94.6-98.5) and negative predictive values (92.7%, 95% CI, 86.6-96.2), considered definitely and probably active PTB. Apart from PTB, other etiologies, according to radiographic activity, were predominantly respiratory infections such as bacterial pneumonia and non-tuberculous mycobacterial infection.

CONCLUSIONS

Radiographic activity showed good diagnostic performance, and can be used easily in clinical practice. However, clinicians should consider other possibilities, because radiologic images do not confirm microbiological PTB.

Diagnostic Imaging in Sepsis of Pulmonary Origin

Lung infections (community- or hospital-acquired) represent the most common cause for sepsis. Diagnostic imaging plays a crucial role in the initial evaluation of patients with criteria for sepsis and suspected pulmonary infection. In patients with clinical signs and symptoms of respiratory infection, the chest X-ray allows confirming the diagnosis of pneumonia. On the other hand, the chest X-ray can be useful to assess response to treatment (in some patients), define a pattern suggesting specific germs (particularly TB), identify complications (empyema and ARDS), and propose a differential diagnosis.

Asthma-Chronic Obstructive Pulmonary Diseases Overlap Syndrome Increases the Risk of Incident Tuberculosis: A National Cohort Study

Purpose

The association between asthma–chronic obstructive pulmonary diseases (COPD) overlap syndrome (ACOS) and tuberculosis (TB) has yet to be studied.

Methods

The newly diagnosed TB patients (age > 20 y) treated from January 2000 to December 2008 were included (ACOS cohort, n = 10 751; non-ACOS cohort, n = 42 966). The non-ACOS cohort involved patients with confirmed absence of ACOS. We calculated incidence rate ratios (IRRs) for TB in the ACOS and non-ACOS cohorts by using poisson regression analysis. Cox proportional hazards regression models were used to determine the adjusted HR (aHR) for TB in the ACOS cohort compared with the non-ACOS cohort.

Results

The aHR for TB was 2.41 (95% confidence interval [CI], 2.19–2.66) in the ACOS cohort. The TB risk was significantly higher in the ACOS cohort than in the non-ACOS cohort when stratified by age, sex, comorbidities, and atopy. Within the ACOS cohort, the aHR was higher among patients receiving SABAs+SAMAs, LABAs+LAMAs, and ICSs (aHR [95% CI]: 3.06 [2.75–3.41], 3.68 [2.93–4.61], and 2.79 [1.25–6.22], respectively; all P < .05). Furthermore, patients with more than 15 outpatient visits and hospitalizations per year demonstrated the highest aHR (8.09; 95% CI, 6.85–9.56).

Conclusions

ACOS cohort potentially develop incident TB, regardless of the age,sex, comorbidities and atopy; even without receiving the inhalers.This risk is higher, especially in the ACOS cohort have a high frequency of medical services or receiving the inhalers such as SABAs+SAMAs, LABAs+LAMAs and ICSs.

Incident asthma and Mycoplasma pneumoniae: A nationwide cohort study

BACKGROUND

Previous studies investigating the relationship between Mycoplasma pneumoniae and incident asthma in the general population have been inconclusive.

OBJECTIVE

We conducted a nationwide cohort study to clarify this relationship.

METHODS

Using the National Health Insurance Research Database of Taiwan, we identified 1591 patients with M pneumoniae infection (International Classification of Diseases, Ninth Revision, Clinical Modification code 4830) given diagnoses between 2000 and 2008. We then frequency matched 6364 patients without M pneumoniae infection from the general population according to age, sex, and index year. Cox proportional hazards regression analysis was performed to determine the adjusted hazard ratio (aHR) of the occurrence of asthma in the M pneumoniae cohort compared with that in the non-M pneumoniae cohort.

RESULTS

Regardless of comorbidities and the use of antibiotic or steroid therapies, patients with M pneumonia infection had a higher risk of incident asthma than those without it. The aHR of asthma was 3.35 (95% CI, 2.71-4.15) for the M pneumoniae cohort, with a significantly higher risk when patients were stratified by age, sex, follow-up time, and comorbidities, including allergic rhinitis, atopic dermatitis, or allergic conjunctivitis. Patients with M pneumoniae infection had a higher risk of having early-onset (age, <12 years; aHR, 2.87) and late-onset (age, ≥12 years; aHR, 3.95) asthma. The aHR was also higher within the less than 2-year follow-up in the M pneumoniae cohort (aHR, 4.41; 95% CI, 3.40-5.74) than in the cohort without the infection.

CONCLUSION

This study found that incident cases of early-onset and late-onset asthma are closely related to M pneumoniae infection, even in nonatopic patients.

Chest tuberculosis: Radiological review and imaging recommendations

Chest tuberculosis (CTB) is a widespread problem, especially in our country where it is one of the leading causes of mortality. The article reviews the imaging findings in CTB on various modalities. We also attempt to categorize the findings into those definitive for active TB, indeterminate for disease activity, and those indicating healed TB. Though various radiological modalities are widely used in evaluation of such patients, no imaging guidelines exist for the use of these modalities in diagnosis and follow-up. Consequently, imaging is not optimally utilized and patients are often unnecessarily subjected to repeated CT examinations, which is undesirable. Based on the available literature and our experience, we propose certain recommendations delineating the role of imaging in the diagnosis and follow-up of such patients. The authors recognize that this is an evolving field and there may be future revisions depending on emergence of new evidence.

Imaging of Pulmonary Infections

Pulmonary infection is one of the most frequent causes of morbidity and mortality throughout the world. Many infections occur in individuals with concomitant intrapulmonary or extrathoracic diseases; however, they commonly develop in otherwise healthy people. In the non-immunocompromised population, pneumonia is the most prevalent community-acquired infection and the second most common nosocomial infectious disorder. In immunocompromised patients, in children, and in the elderly, pneumonia, as well as other pulmonary infections, may develop into a life-threatening condition.

Rheumatoid arthritis increases the risk of nontuberculosis mycobacterial disease and active pulmonary tuberculosis

Background

Few studies have examined the association of rheumatoid arthritis (RA) with nontuberculosis mycobacterium (NTM) disease and pulmonary tuberculosis (PTB).

Methods

We identified 29 131 patients with RA from the catastrophic illness registry who were diagnosed from 1998–2008; 116 524 patients without RA from inpatient data files were randomly frequency matched according to sex, age, and index year and used as a comparison group. Both groups were followed-up until the end of 2010 to measure the incidence of NTM disease and active PTB. We analyzed the risk of NTM disease and active PTB using the Cox proportional hazards regression models, controlling for sex, age, and Charlson comorbidity index (CCI).

Results

The incidence of NTM disease was 4.22 times greater in the RA group than in the non-RA group (1.91 vs 0.45 per 10,000 person-years). The incidence of PTB was 2.99 times greater in the RA group than in the non-RA group (25.3 vs 8.46 per 10,000 person-years). After adjusting for age, sex, and CCI, the adjusted hazard ratios (HRs) of NTM disease and active PTB for the RA group were 4.17 (95% CI = 2.61–6.65) and 2.87 (95% CI = 2.55–3.23), respectively, compared with the non-RA group. In the first 2 years of follow-up, the RA group yielded corresponding adjusted HRs of 4.98 and 3.39 compared with the non-RA group. The follow-up time-specific RA group to the non-RA group HR of both the NTM disease and active PTB varied.

Conclusion

This study can serve as a reference for clinical physicians to increase awareness regarding the detection of NTM disease and active PTB in RA patients among the any stage of the clinical course even without CCI.