Epidemiology and factors associated with Extra-pulmonary tuberculosis in a Low-prevalence area

Peritoneal tuberculosis: the diagnostic challenge must not preclude treatment

Peritoneal tuberculosis (TB) is a rare extrapulmonary infection caused by Mycobacterium tuberculosis It is mainly found in countries with a high burden of TB, so travelling from an endemic area should raise suspicion. Although it is a well-recognised disease, it remains a challenge due to its difficult clinical and microbiological diagnosis. This can lead to a delay, both in diagnosis and treatment with serious prognostic implications. We describe the case of a woman in her mid-50s who presented with fever, abdominal pain, vomiting, breathlessness, anorexia and weight loss. On physical examination, she had decreased breath sounds at the right lung and clinical ascites. Blood tests revealed elevated inflammatory markers and anaemia. Imaging showed ascites, enhanced peritoneal thickening, densification of the mesenteric fat and right pleural effusion. After paracentesis, diagnostic thoracotomy and laparoscopy were undertaken. Based on a presumptive diagnosis, treatment was started. M. tuberculosis was lastly isolated in ascitic fluid culture after 6 weeks. The patient completed a 6-month course of anti-TB drugs with a favourable outcome.

Tuberculous Pericarditis in an Immunocompromised Patient: A Case Report

This case report details the presentation, diagnostic process, and management of tuberculous pericarditis (TBP) in a 43-year-old male with a history of chronic severe pericarditis, right-sided heart failure, and rheumatoid arthritis. The patient exhibited symptoms of chest pain and dyspnea and showed signs of ascites and mild lower limb edema. Our patient was found to have significant pericardial thickening and effusion, as well as necrotic lymph nodes. Diagnostic tests, including a positive QuantiFERON-TB test (QIAGEN, Hilden, Germany) and imaging studies, supported the diagnosis of TBP. Management involved a combination of anti-tuberculosis therapy and eventually, a radical pericardiectomy. This report underscores the importance of timely diagnosis and treatment in improving outcomes for patients with TBP.

Tuberculosis-Associated Respiratory Disability in Children, Adolescents, and Adults: Protocol for a Systematic Review and Individual Participant Data Meta-Analysis

Background

Approximately 2% of the global population has survived tuberculosis (TB). Increasing evidence indicates that a significant proportion of pulmonary TB survivors develop TB-associated respiratory disability, commonly referred to as post-TB lung disease (PLTD) and marked by impaired respiratory function, persistent symptoms, and activity limitations. However, the prevalence, risk factors, and progression of TB-associated respiratory disability throughout the life course are not well understood. To address these gaps, we will undertake a systematic review and individual participant-level data meta-analysis (IPD-MA) focusing on TB-associated respiratory disability in children, adolescents, and adults successfully treated for pulmonary TB.

Methods and analysis

We will systematically search MEDLINE, Embase, CENTRAL, Global Index Medicus, and medRxiv for original studies investigating TB-associated respiratory disability in people of all ages who have completed treatment for microbiologically confirmed or clinically diagnosed pulmonary TB. Authors of eligible studies will be invited to contribute de-identified data and form a collaborative group. Primary outcomes will be (1) abnormal lung function based on spirometry parameters and (2) chronic respiratory symptoms. We will estimate the overall and subgroup-specific prevalence of each outcome through IPD meta-analysis. Next, we will develop clinical prediction tools assessing the risk of future TB-associated respiratory disability at (i) the start of TB treatment and (ii) end of TB treatment for those without existing signs of disability. Finally, we will use stepwise hierarchical modelling to identify epidemiological determinants of respiratory disability.

Ethics and dissemination

This study has been approved by the ethics review boards at the Rhode Island Hospital (2138217-2) and the Research Institute of the McGill University Health Centre (2024-10345). Individual study authors will be required to obtain institutional approval prior to sharing data. Results will be disseminated through open-access, peer-reviewed publications and conference presentations.

Prospero registration number

CRD42024529906.

Molecular diagnosis of an unusual aetiology of chronic abdominal pain with ascites

An immigrant woman in her 60s with a complex medical history and remote occupational exposure to patients with tuberculosis (TB) presented with abdominal pain, early satiety, bloating and weight loss. Physical exam showed abdominal distention and ascites. Diagnostic paracentesis revealed low serum ascites albumin gradient and elevated ascitic lymphocytic count. However, fluid cytology, bacterial and mycobacterial cultures were negative. An interferon-gamma release assay for TB was indeterminate. MRI of the abdomen and pelvis showed a thickened endometrial stripe. Endometrial biopsy demonstrated non-caseating granulomatous endometritis. No organisms were identified on Grocott methenamine silver or acid-fast bacilli special stains. A tissue block from the endometrial biopsy submitted for DNA sequencing was positive for mycobacterium tuberculosis (MTB) complex Urine mycobacterial cultures were obtained and the patient was started on isoniazid, rifampin, ethambutol and pyrazinamide, with significant improvement in her symptoms. Urine mycobacterial cultures were eventually positive for pansusceptible MTB.

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

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

Single Cell Analysis of Peripheral TB-Associated Granulomatous Lymphadenitis

We successfully employed a single cell RNA sequencing (scRNA-seq) approach to describe the cells and the communication networks characterizing granulomatous lymph nodes of TB patients. When mapping cells from individual patient samples, clustered based on their transcriptome similarities, we uniformly identify several cell types that known to characterize human and non-human primate granulomas. Whether high or low Mtb burden, we find the T cell cluster to be one of the most abundant. Many cells expressing T cell markers are clearly quantifiable within this CD3 expressing cluster. Other cell clusters that are uniformly detected, but that vary dramatically in abundance amongst the individual patient samples, are the B cell, plasma cell and macrophage/dendrocyte and NK cell clusters. When we combine all our scRNA-seq data from our current 23 patients (in order to add power to cell cluster identification in patient samples with fewer cells), we distinguish T, macrophage, dendrocyte and plasma cell subclusters, each with distinct signaling activities. The sizes of these subclusters also varies dramatically amongst the individual patients. In comparing FNA composition we noted trends in which T cell populations and macrophage/dendrocyte populations were negatively correlated with NK cell populations. In addition, we also discovered that the scRNA-seq pipeline, designed for quantification of human cell mRNA, also detects Mtb RNA transcripts and associates them with their host cell's transcriptome, thus identifying individual infected cells. We hypothesize that the number of detected bacterial transcript reads provides a measure of Mtb burden, as does the number of Mtb-infected cells. The number of infected cells also varies dramatically in abundance amongst the patient samples. CellChat analysis identified predominating signaling pathways amongst the cells comprising the various granulomas, including many interactions between stromal or endothelial cells and the other component cells, such as Collagen, FN1 and Laminin,. In addition, other more selective communications pathways, including MIF, MHC-1, MHC-2, APP, CD 22, CD45, and others, are identified as originating or being received by individual immune cell components.

Quadriplegia Following Prevertebral/Retropharyngeal Collection Secondary to Extrapulmonary Spinal Tuberculosis (Pott's Disease)

Tuberculous retropharyngeal abscess, though rare, poses significant diagnostic and therapeutic challenges due to its atypical presentation. We present the case of a 51-year-old male with a history of drug abuse and inhalational burn injury presented with generalized weakness, sensory deficits, and neurological symptoms. Despite initial negative investigations, subsequent MRI and microbiological studies confirmed a rare case of tuberculous retropharyngeal abscess. The patient underwent urgent drainage and anti-tubercular therapy, experiencing complications such as Candida infection that required prolonged hospitalization and multidisciplinary care. This case underscores the importance of considering tuberculosis in differential diagnosis, especially in patients with unusual presentations and predisposing factors. It highlights the need for comprehensive evaluation, early intervention, and multidisciplinary management to prevent complications and improve outcomes. The case serves to raise awareness among clinicians about this uncommon presentation, emphasizing the need for a high index of suspicion in high-risk individuals and the importance of long-term follow-up and adherence to anti-tubercular therapy.

Occurrence of multidrug-resistant Mycobacterium tuberculosis in upper Southern Thailand

Background and Aim

Mycobacterium tuberculosis causes global concern with tuberculosis (TB). Multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) pose additional challenges, as they resist to multiple first-line drugs. This study investigated the occurrence of TB, antibiotic resistance due to inhA and katG gene mutations, and multidrug resistance in M. tuberculosis during fiscal years 2020-2022.

Materials and Methods

Samples were gathered from hospitals in seven provinces of upper Southern Thailand. The study investigated the correlation between inhA and katG gene mutations in M. tuberculosis and the development of antimicrobial resistance and isoniazid resistance.

Results

A total of 19,186 samples were sent to the Office of Disease Prevention and Control Region 11st, Nakhon Si Thammarat, Thailand. The results showed that 51% of the samples were obtained from patients located in Nakhon Si Thammarat, followed by Surat Thani provinces. Regarding the spatial distribution of TB-infected cases, the incidence of TB was high in the province, which has a moderate to high population density. The highest average occurrence of TB in this study was found in Phuket province (9.75/100,000 risk person-year). The detected isoniazid resistance was 394, 255, and 179 cases in 2020, 2021, and 2022, respectively. A total of 99 isolates were MDR, whereas four isolates were XDR. The antimicrobial resistance associated with the inhA mutation was 192, 142, and 105 isolates, respectively, whereas the resistance associated with the katG mutation was 249, 182, and 120 cases in 2020, 2021, and 2022, respectively.

Conclusion

These findings contribute to the understanding of the occurrence of antibiotic-resistant TB that could lead to use as data for preventing MDR-TB.

Colliding Challenges: An Analysis of SARS-CoV-2 Infection in Patients with Pulmonary Tuberculosis versus SARS-CoV-2 Infection Alone

Background and Objectives: The concurrent occurrence of tuberculosis and COVID-19 coinfection poses significant clinical complexities, warranting a nuanced approach to diagnosis, management, and patient care. Materials and Methods: A retrospective, cross-sectional study was conducted on two groups: one comprising 32 patients with pulmonary TB (PTB) and COVID-19 co-infection, and one including 100 patients with COVID-19 alone. Data was collected from medical records, including patient history, clinical parameters, laboratory, imaging results, and patient outcome. Results: A lower BMI emerges as a significant marker suggesting underlying PTB in patients with SARS-CoV-2 co-infection. Type 2 diabetes mellitus increases the risk of death in PTB-SARS-CoV-2 co-infection. Co-infected patients show lymphocytopenia and higher neutrophil levels, CRP, transaminases, and D-dimer levels. Elevated CRP and ALT levels are linked to increased co-infection likelihood. Certain parameters like SpO2, CRP, ALT, AST, and D-dimer effectively differentiate between co-infected and COVID-19 patients. Platelet-to-lymphocyte ratio is notably higher in co-infected individuals. Lesion severity on imaging is significantly associated with co-infection, highlighting imaging's diagnostic importance. Longer hospital stays are linked to co-infection but not significantly to death risk. Conclusions: Certain clinical and biological factors may serve as potential indicators of PTB co-infection in patients with SARS-CoV-2.

Management of postinfectious inflammatory arthritis

PURPOSE OF REVIEW

Postinfectious inflammatory arthritis can result from various pathogens, including bacteria, viruses, fungi, and parasites. Prompt identification and treatment of acute infection is vital, but some cases progress to chronic arthritis despite successful treatment of infection. Postinfectious inflammatory arthritis varies from mild, self-limited arthralgia to severe, refractory arthritis, necessitating ongoing disease-modifying treatment. This review explores the spectrum of postinfectious inflammatory arthritis to provide insights into effective management.

RECENT FINDINGS

Research continues regarding the benefit of antimicrobial therapy, beyond treatment of the acute infection, to diminish the severity of postinfectious inflammatory arthritis. Following treatment of acute infection, most cases are self-limited so treatment is symptomatic. However, a difficult-to-predict fraction of cases develop chronic postinfectious inflammatory arthritis that can be challenging to manage. Recently, as more biologic, and targeted synthetic DMARDs have become available, treatment options have expanded.

SUMMARY

In this article, we use the term 'postinfectious inflammatory arthritis' rather than 'reactive arthritis' because it describes a broader spectrum of diseases and emphasizes the common pathogenesis of a postinfectious inflammatory process. We summarize the conventional therapies and recent management developments for the most frequently encountered postinfectious inflammatory arthritides.

Tuberculous pleuritis: clinical presentations and diagnostic challenges

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Concomitant bedaquiline and delamanid therapy in patients with drug-resistant extra-pulmonary tuberculosis in Mumbai, India

Background

World Health Organization suggests concurrent bedaquiline-delamanid (BDQ-DLM) as part of individualised regimens for eligible patients with pulmonary drug-resistant tuberculosis (DR-TB); however, data for patients with drug-resistant extrapulmonary tuberculosis (EPTB) is extremely limited. This study documents the treatment outcomes and adverse events associated with concurrent BDQ-DLM-based regimens in patients with drug-resistant EPTB at a Médecins Sans Frontières clinic in Mumbai, India.

Methods

Retrospective cohort study based on routinely collected programmatic data. Individualised regimens were based on drug-susceptibility testing and previous drug exposure. Drug-resistant EPTB patients initiated on regimens containing concurrent BDQ and DLM from April 2016 to October 2019 were included. Patients who completed treatment were followed up at 12 months.

Results

Of 17 patients, median age was 23 years (IQR = 21-30 years) and 12/17 (71 %) were female. Pre-extensively drug-resistant tuberculosis and extensively drug-resistant TB was reported in 13/17 (76.4 %) and 2/17 (11.7 %) patients respectively. Microbiological reports were unavailable for two patients with central nervous system TB. Lymph node TB was the commonest form of EPTB in 9/17 (53 %) of patients. Median duration of treatment was 18.9 months. At least one grade three or four severe adverse event (SAE) was reported by 13/17 (76.4 %) patients. Thirteen (76.4 %) patients had favourable outcomes. None of the patients relapsed or died in the one-year period of post-treatment follow-up.

Conclusion

Concurrent BDQ-DLM-based regimens in drug-resistant EPTB were effective and associated with manageable adverse events.

Multidrug-Resistant Moderate Tubercular Pleural Effusion: A Rare Case Presentation

Tuberculosis (TB) is among the most predominant infectious illnesses in developing areas around the globe. As stated by the World Health Organization (WHO), the number of instances of drug-resistant tuberculosis (DR-TB) has increased lately. This case report describes the effective diagnosis and customized treatment for primary extra-pulmonary multidrug-resistant tubercular pleural effusion, a disease which is difficult to identify due to relatively low bacterial count as well as frequently negative staining on Ziehl Neelsen (ZN) for acid-fast bacilli (AFB). The bacteria causing multidrug-resistant tuberculosis (MDR-TB) is resistant to a minimum of two drugs, isoniazid and rifampicin, the most effective TB medications. We are going to present the case of a 60-year-old male who complained of breathlessness, cough, and loss of weight for one month and chest pain and fever for 12 days. The patient's pleural fluid examination was carried out, which showed exudative fluid (according to Light's criteria) with adenosine deaminase (ADA) positive. Cartridge-based nucleic acid amplification test (CBNAAT) and line probe assays (LPAs) were carried out, which suggested mycobacterium tuberculosis (MTB) with rifampicin and isoniazid resistance. The patient was started an oral regimen with bedaquiline in accordance with WHO standards, leading to significant improvement. This case reveals that to promptly diagnose and treat DR-TB, pleural effusions, and pleural biopsies need to be exposed early to investigations such as Xpert (MTB)/resistance to rifampicin assay, culturing, and genotype drug sensitivity testing (DST).

Tubercular Mediastinal Lymphadenopathy Presenting as an Isolated Unilateral Vocal Cord Palsy and the "Sail" Sign

Tuberculosis continues to remain a major public health challenge, especially in low- and middle-income countries. Unilateral vocal cord palsy in adults as the sole manifestation of tubercular mediastinal lymphadenopathy has been rarely reported. A 22-year-old lady presented with a history of hoarseness of voice for the past month. The general physical examination revealed palpable lymph nodes in the left axilla. Axial CT sections at the level of the vocal cords demonstrated dilation of the right laryngeal ventricle and mild anteromedial deviation of the ipsilateral arytenoid cartilage ("sail" sign) suggestive of a right vocal cord palsy. Contrast-enhanced CT chest revealed right paratracheal, right hilar, and subcarinal lymph nodes with areas of central necrosis. She was started on anti-tubercular therapy and her voice completely improved after three months of treatment. The "Sail" sign on axial CT scans is a useful radiological sign for diagnosing unilateral vocal cord palsy. Rarely, compression of the recurrent laryngeal nerve by enlarged mediastinal lymph nodes due to tuberculosis can present with unilateral vocal cord palsy as the sole manifestation in adults.

Basal Ganglia Ischemic Stroke: The Unforeseen Progression of Tuberculosis Epididymo-Orchitis

Tuberculosis is an infectious disease with broad pulmonary and extrapulmonary clinical manifestations. Central nervous system tuberculosis (CNS-TB) is a complex extrapulmonary infection known for its diverse clinical features including meningitis, tuberculoma, and spinal arachnoiditis. Particularly, tuberculosis meningitis can further lead to complications such as ischemic stroke.  This article presents a challenging case of a 35-year-old male patient initially diagnosed with epididymo-orchitis, followed by viral-like central nervous system symptoms, ultimately complicated by tuberculosis meningitis and basal ganglia ischemic stroke.  This case presentation underscores the diagnostic complexities associated with CNS-TB and emphasizes on the critical need for heightened awareness of the wide-ranging clinical presentations that can potentially delay early disease recognition and management.