Clinical utility of QuantiFERON-TB GOLD In-Tube and tuberculin skin test in patients with tuberculous pleural effusions

Development and validation of a prediction model for tuberculous pleural effusion: a large cohort study and external validation

Background

Distinguishing tuberculous pleural effusion (TPE) from non-tuberculosis (TB) benign pleural effusion (BPE) remains to be a challenge in clinical practice. The aim of the present study was to develop and validate a novel nomogram for diagnosing TPE.

Methods

In this retrospective analysis, a total of 909 consecutive patients with TPE and non-TB BPE from Ningbo First Hospital were divided into the training set and the internal validation set at a ratio of 7:3, respectively. The clinical and laboratory features were collected and analyzed by logistic regression analysis. A diagnostic model incorporating selected variables was developed and was externally validated in a cohort of 110 patients from another hospital.

Results

Six variables including age, effusion lymphocyte, effusion adenosine deaminase (ADA), effusion lactatedehy drogenase (LDH), effusion LDH/effusion ADA, and serum white blood cell (WBC) were identified as valuable parameters used for developing a nomogram. The nomogram showed a good diagnostic performance in the training set. A novel scoring system was then established based on the nomogram to distinguish TPE from non-TB BPE. The scoring system showed good diagnostic performance in the training set [area under the curve (AUC) (95% confidence interval (CI)), 0.937 (0.917–0.957); sensitivity, 89.0%, and specificity, 89.5%], the internal validation set [AUC (95%CI), 0.934 (0.902–0.966); sensitivity, 88.7%, and specificity, 90.3%], and the external validation set [(AUC (95%CI), 0.941 (0.891–0.991); sensitivity, 93.6%, and specificity, 87.5%)], respectively.

Conclusions

The study developed and validated a novel scoring system based on a nomogram originated from six clinical parameters. The novel scoring system showed a good diagnostic performance in distinguishing TPE from non-TB BPE and can be conveniently used in clinical settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02051-4.

Improved early diagnosis of difficult cases of tuberculous pleural effusion by combination of thoracoscopy with immunological tests

INTRODUCTION

Although pleural effusion is a common clinical manifestation, the differential diagnosis of the cause of pleural effusion is often challenging, especially in the early differentiation of tuberculous pleurisy (TP) from other pleural effusion. The aim of this study was to evaluate the performance of commonly used laboratory tests for the early diagnosis of difficult cases of pleural effusion.

METHODS

Patients with undiagnosed pleural effusion were enrolled and subjected to five laboratory tests including thoracoscopy, pleural fluid adenosine deaminase assay (ADA), serum tuberculosis antibody test (TB-antibody), tuberculin skin test (TST), and T-SPOT.TB assay. The diagnosis of TP was established based on pleural histology and mycobacterial culture. The different tests were compared for diagnostic performance.

RESULTS

A total of 106 patients were enrolled; their mean age was 53 years and 70.8% were male. Seventy-two (68%) of them were confirmed to have TP. When used individually, the five laboratory tests showed highly variable performance parameters, including sensitivity ranging from 46% to 92% and specificity ranging from 33% to 82%. When used in different combinations, thoracoscopy combined with TST or TB-antibody showed the optimal performance parameters, with a sensitivity of 80.8% and a specificity of 85.7%.

CONCLUSIONS

The results of this study suggest that the combination of thoracoscopy with TST or TB-antibody test is the best choice for the early diagnosis of difficult cases of TP in high TB burden countries.

A combination of the QuantiFERON-TB Gold In-Tube assay and the detection of adenosine deaminase improves the diagnosis of tuberculous pleural effusion

The differential diagnosis of tuberculous pleural effusion (TPE) and malignant pleural effusion (MPE) remains difficult despite the availability of numerous diagnostic tools. The current study aimed to evaluate the performance of the whole blood QuantiFERON-TB Gold In-Tube (QFT-GIT) assay and conventional laboratory biomarkers in differential diagnosis of TPE and MPE in high tuberculosis prevalence areas. A total of 117 patients with pleural effusions were recruited, including 91 with TPE and 26 with MPE. All of the patients were tested with QFT-GIT, and the conventional biomarkers in both blood and pleural effusion were detected. The level of antigen-stimulated QFT-GIT in the whole blood of TPE patients was significantly higher than that of MPE (2.89 vs 0.33 IU/mL, P<0.0001). The sensitivity and specificity of QFT-GIT for the diagnosis of TPE were 93.0% and 60.0%, respectively. Among the biomarkers in blood and pleural effusion, pleural adenosine deaminase (ADA) was the most prominent biomarker, with a cutoff value of 15.35 IU/L. The sensitivity and specificity for the diagnosis of TPE were 93.4% and 96.2%, respectively. The diagnostic classification tree from the combination of these two biomarkers was 97.8% sensitive and 92.3% specific. Ultimately, the combination of whole blood QFT-GIT with pleural ADA improved both the specificity and positive predictive value to 100%. Thus, QFT-GIT is not superior to pleural ADA in the differential diagnosis of TPE and MPE. Combined whole blood QFT-GIT and pleural ADA detection can improve the diagnosis of TPE.

Interferon-Gamma Release Assays for the Diagnosis of Tuberculosis: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVE

We conducted a systematic review and meta-analysis to compare the accuracy of the interferon-gamma release assays (IGRAs) and the tuberculin skin test (TST) for the diagnosis of Mycobacterium tuberculosis infection.

METHODS

We systematically searched PubMed, Embase, Cochrane library, and Web of Science databases for relevant published studies in recent decades and calculated pooled estimated sensitivities, specificities, DOR, and SROC curve of the QFT-IT, T-SPOT and TST. Random-effects models were used to assess estimates from studies with significant heterogeneity. Moreover, area under the curve was used to evaluate the accuracy of the tests.

RESULTS

Overall, 9 studies for QFT-IT, 12 studies for T-SPOT, and 16 studies for TST involving 3586 participants were included in this analysis. We found that sensitivities of the QFT-IT, T-SPOT, and TST were respectively 0.842 (95 % CI 0.811-0.870), 0.840 (95 % CI 0.814-0.864), and 0.665 (CI 0.635-0.693); specificities were respectively 0.745 (95 % CI 0.715-0.775), 0.658 (95 % CI 0.621-0.693), and 0.633 (CI 0.605-0.661); positive likelihood ratios were respectively 3.652 (95 % CI 2.180-6.117), 2.196 (95 % CI 1.727-2.794), and 1.825 (95 % CI 1.351-2.464); negative likelihood ratios were respectively 0.212 (95 % CI 0.109-0.414), 0.246 (95 % CI 0.161-0.377), and 0.556 (95 % CI 0.385-0.804); the SROC curves were 19.205, 10.397, and 3.810.

CONCLUSIONS

The two IGRAs showed better performance than TST for the diagnosis of the tuberculosis. However, neither of them showed stability in the diagnosis of TB.

Accuracy of the interferon-gamma release assay for the diagnosis of tuberculous pleurisy: an updated meta-analysis

Background and Objectives. The best method for diagnosing tuberculous pleurisy (TP) remains controversial. Since a growing number of publications focus on the interferon-gamma release assay (IGRA), we meta-analyzed the available evidence on the overall diagnostic performance of IGRA applied to pleural fluid and peripheral blood. Materials and Methods. PubMed and Embase were searched for relevant English papers up to October 31, 2014. Statistical analyses were performed using Stata and Meta-DiSc. Pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), positive predictive value (PPV), negative predictive value (NPV) and diagnostic odds ratio (DOR) were count. Summary receiver operating characteristic curves and area under the curve (AUC) were used to summarize the overall diagnostic performance. Results. Fifteen publications met our inclusion criteria and were included in the meta analysis. The following pooled estimates for diagnostic parameters of pleural IGRA were obtained: sensitivity, 0.82 (95% CI [0.79-0.85]); specificity, 0.87 (95% CI [0.84-0.90]); PLR, 4.94 (95% CI [2.60-9.39]); NLR, 0.22 (95% CI [0.13-0.38]); PPV, 0.91 (95% CI [0.85-0.96]); NPV, 0.79 (95% CI [0.71-0.85]); DOR, 28.37 (95% CI [10.53-76.40]); and AUC, 0.91. The corresponding estimates for blood IGRA were as follows: sensitivity, 0.80 (95% CI [0.76-0.83]); specificity, 0.70 (95% CI [0.65-0.75]); PLR, 2.48 (95% CI [1.95-3.17]); NLR, 0.30 (95% CI [0.24-0.37]); PPV, 0.79 (95% CI [0.60-0.87]); NPV, 0.75 (95% CI [0.62-0.83]); DOR, 9.96 (95% CI [6.02-16.48]); and AUC, 0.89. Conclusions. This meta analysis suggested that pleural IGRA has potential for serving as a complementary method for diagnosing TP; however, its cost, high turn around time, and sub-optimal performance make it unsuitable as a stand-alone diagnostic tool. Better tests for the diagnosis of TP are required.

Interferon Gamma Release Assays for Diagnosis of Pleural Tuberculosis: a Systematic Review and Meta-Analysis

The role of interferon gamma release assays (IGRAs), although established for identifying latent tuberculosis, is still evolving in the diagnosis of active extrapulmonary tuberculosis. We systematically evaluated the diagnostic performance of blood- and pleural fluid-based IGRAs in tuberculous pleural effusion (TPE). We searched the PubMed and Embase databases for studies evaluating the use of commercially available IGRAs on blood and/or pleural fluid samples for diagnosing TPE. The quality of the studies included was assessed through the QUADAS-2 tool. The pooled estimates of sensitivity and specificity with 95% confidence intervals (95% CI) were generated using a bivariate random-effects model and examined using forest plots and hierarchical summary receiver operating characteristic (HSROC) curves. Indeterminate IGRA results were included for sensitivity calculations. Heterogeneity was explored through subgroup analysis and meta-regression based on prespecified covariates. We identified 19 studies assessing the T.SPOT.TB and/or QuantiFERON assays. There were 20 and 14 evaluations, respectively, of whole-blood and pleural fluid assays, involving 1,085 and 727 subjects, respectively. There was only one good-quality study, and five studies used nonstandard assay thresholds. The pooled sensitivity and specificity for the blood assays were 0.77 (95% CI, 0.71 to 0.83) and 0.71 (95% CI, 0.65 to 0.76), respectively. The pooled sensitivity and specificity for the pleural fluid assays were 0.72 (95% CI, 0.55 to 0.84) and 0.78 (95% CI, 0.65 to 0.87), respectively. There was considerable heterogeneity; however, multivariate meta-regression did not identify any covariate with significant influence. There was no publication bias for blood assays. We conclude that commercial IGRAs, performed either on whole-blood or pleural fluid samples, have poor diagnostic accuracy in patients suspected to have TPE.

Tuberculin skin test versus interferon-gamma release assays for the diagnosis of tuberculosis infection

OBJECTIVE

Accurate detection of latent tuberculosis infection (LTBI) is becoming increasingly important due to the increasing use of immunosuppressive medications and the human immunodeficiency epidemic, which have increased the risk for reactivation to active tuberculosis (TB) infection. LTBI is detected by tuberculin skin test (TST) and interferon-gamma release assays (IGRAs). The latter include T-SPOT(®).TB (Oxford Immunotec) and QuantiFERON(®)-TB Gold In-Tube (QFT-GIT; Cellestis). We examined the value of TST versus IGRAs in the diagnosis of TB infection by meta-analysis based on data derived from a systematic literature review.

METHODS

PubMed was searched for articles in English published between January 2010 and July 2012 in which TST and IGRA were performed simultaneously in individuals with and without active TB infection. A random effect model meta-analysis was performed to determine pooled sensitivity and specificity values for TST, T-SPOT.TB, and QFT-GIT. Owing to the absence of a gold standard for the diagnosis of LTBI, active TB infection was used as a surrogate for LTBI.

RESULTS

Nineteen studies were included. T-SPOT.TB was significantly more sensitive [90% (95% confidence interval: 85-95) versus 64% (46-81)] than TST. The specificity of T-SPOT.TB was higher than the specificity of TST, but there was overlap between confidence intervals [77% (68-85) versus 57% (41-72)]. QFT-GIT seemed to be more sensitive than TST [75% (61-86) versus 64% (48-78)] but similarly specific [71% (62-86) versus 70% (57-81)].

CONCLUSIONS

IGRAs, especially T-SPOT.TB, are more effective at detecting TB infection than TST. Despite their higher cost, they have added value and can be requested in addition to TST.

Gamma interferon immunospot assay of pleural effusion mononuclear cells for diagnosis of tuberculous pleurisy

Diagnosis of tuberculous pleurisy remains a challenge in the clinic. In this study, we evaluated the usefulness of a previously developed Mycobacterium tuberculosis antigen-specific gamma interferon enzyme-linked immunospot (ELISPOT) assay in the diagnosis of tuberculous pleurisy by testing a cohort of 352 patients with pleural effusion. We found that M. tuberculosis antigen-specific gamma interferon-producing cells were enriched four to five times in pleural fluid compared with their levels in peripheral blood from patients with tuberuclous pleurisy assayed in parallel. The sensitivity, specificity, positive predictive value, and negative predictive value of the pleural fluid mononuclear cell ELISPOT assay for the diagnosis of tuberculous pleurisy were 95.7%, 100%, 100%, and 81.0%, respectively. In comparison, the sensitivity and specificity of the ELISPOT assay using peripheral blood mononuclear cells were 78.3% and 86.3%, respectively. The sensitivity and specificity of the pleural fluid adenosine deaminase activity test were 55.5% and 86.3%, respectively. These results demonstrate that the M. tuberculosis antigen-specific ELISPOT assay performed on pleural fluid mononuclear cells provides an accurate, rapid diagnosis of tuberculous pleurisy.

Psoriatic disease and tuberculosis nowadays

Psoriasis is a chronic, relapsing and remitting inflammatory skin and joint disease that has a prevalence of 2-3% in the world's population, whereas of 1-2% in Europe. The traditional concept of psoriasis as the "healthy people's" disease has been recently revised because of ever-increasing reports of associations with various pathological conditions (hypertension, Crohn's disease, type II diabetes mellitus, obesity, dyslipidemia, metabolic syndrome, infectious conditions). Particularly, advances in psoriasis therapies have introduced biologic agents. All the tumor necrosis factor-alpha inhibitors are associated with an increased risk of developing active disease in patients with latent tuberculosis infection, because of TNF-α key role against Mycobacterium tuberculosis. For this reason, exclusion of active tuberculosis and treatment of latent tuberculosis infection are clinical imperatives prior to starting this therapy. Moreover active surveillance for a history of untreated or partially treated tuberculosis or latent form has already been shown to be effective in reducing the number of incident tuberculosis cases.