Differential diagnosis of tuberculous and malignant pleurisy using pleural fluid adenosine deaminase and interferon gamma in Taiwan

A meta-analysis of Th1 and Th2 cytokine profiles differentiating tuberculous from malignant pleural effusion

To clarify the predominance of Th1 or Th2 immune responses in malignant and tuberculous pleural effusion (MPE and TPE, respectively), we performed a meta-analysis of previously published results of the levels of Th1/Th2 cytokines associated with these two types of pleural effusion to evaluate the use of Th1/Th2 cytokine profiles in distinguishing TPE from MPE. We searched the PubMed and EMBASE databases for studies indexed from 2000 to March 2021. We included studies that (a) diagnosed TPE and MPE based on culture or pleural tissue biopsy and that (b) compared levels of Th1/Th2 cytokines between TPE and MPE. Pooled data based on a random-effects model or fixed-effects model and standardized mean differences (SMDs) across studies were used to compare TPE and MPE. We also performed Egger’s test to assess publication bias. Of 917 identified studies, a total of 42 studies were selected for the meta-analysis. Compared with MPE subjects, TPE subjects had a significantly higher level of TNF-α [2.22, (1.60–2.84)], an elevated level of IFN-γ [3.30, (2.57–4.40)] in pleural effusion, a situation where the Th1 immune response dominated. Conversely, the levels of interleukin-4 (IL-4) and IL-10 (Th2 cytokines) were higher in the MPE subjects than in the TPE subjects, showing statistically nonsignificant tiny effects [−0.15, (−0.94 to 0.63) and −0.04, (−0.21 to 0.12), respectively]. We confirmed that TPE, a situation in which the Th1 cytokines are predominant. The slight preponderance of Th2 cytokines in MPE, which is not convincing enough to prove.

Comparative accuracy of pleural fluid unstimulated interferon-gamma and adenosine deaminase for diagnosing pleural tuberculosis: A systematic review and meta-analysis

Objective

We compared diagnostic accuracy of pleural fluid adenosine deaminase (ADA) and interferon-gamma (IFN-γ) in diagnosing tuberculous pleural effusion (TPE) through systematic review and comparative meta-analysis.

Methods

We queried PubMed and Embase databases to identify studies providing paired data for sensitivity and specificity of both pleural fluid ADA and IFN-γ for diagnosing TPE. We used hierarchical summary receiver operating characteristic (HSROC) plots and HSROC meta-regression to model individual and comparative diagnostic performance of the two tests.

Results

We retrieved 376 citations and included 45 datasets from 44 publications (4974 patients) in our review. Summary estimates for sensitivity and specificity for ADA were 0.88 (95% CI 0.85–0.91) and 0.91 (95% CI 0.89–0.92), while for IFN-γ they were 0.91 (95% CI 0.89–0.94) and 0.96 (95% CI 0.94–0.97), respectively. HSROC plots showed consistently greater diagnostic accuracy for IFN-γ over ADA across the entire range of observations. HSROC meta-regression using test-type as covariate yielded a relative diagnostic odds ratio of 2.22 (95% CI 1.68–2.94) in favour of IFN-γ, along with better summary sensitivity and specificity figures. No prespecified subgroup variable significantly influenced the summary diagnostic accuracy estimates.

Conclusion

Pleural fluid IFN-γ estimation has better diagnostic accuracy than ADA estimation for diagnosis of TPE.

Application of NGS in Diagnosis of Tuberculous Pleurisy with Multiple Negative Tests: A Case Report

Background

Tuberculous pleurisy is inflammation caused by direct infection of Mycobacterium tuberculosis (MTB) and/or delayed allergic reaction of the pleura to MTB thallus components. The diagnosis of tuberculous pleurisy is mainly confirmed by bacterial culture, smear staining or histopathology, but has some clinical limitations. Next-generation sequencing (NGS), as a new diagnostic technology, has good application prospects in the diagnosis of tuberculous pleurisy.

Case Presentation

A patient admitted with right pleural effusion and pneumonia was actively treated with anti-infection, anti-inflammatory and symptomatic support while various etiological tests of right pleural effusion were improved. However, all the etiological tests for MTB infection were negative. At this time, the patient’s condition worsened and pleural effusion also appeared on the left side. In order to clarify the cause of the disease as soon as possible and prevent the disease from worsening again, the left and right pleural effusions of the patient were sent for NGS testing. The test results suggested MTB infection, which finally clarified the diagnosis of tuberculous pleurisy, and the next treatment plan of the patient was timely adjusted.

Conclusion

NGS is instructive in the diagnosis of tuberculous pleurisy when various conventional tests and imaging methods fail.

The clinical utility of joined detection of cancer ratio, cancer ratio plus, Interferon gamma (IFN-ϒ) & Carcinoembryonic antigen (CEA) in differentiating lymphocytic pleural effusions

Background

The differentiation between malignant (MPE) and tuberculous (TPE) pleural effusions should be considered in any patient with an exudative lymphocytic pleural effusion. A rapid precise diagnosis is valuable as the treatment and prognosis are totally different. The histopathological proof may shorten the time to differential diagnosis. But it may be invasive and costly. The aim of this study is to validate the clinical reliability of joined detection of cancer ratio (serum LDH to pleural ADA), cancer ratio plus (cancer ratio to percentage of pleural fluid lymphocytic count), pleural interferon gamma (pIFN-ϒ), and pleural carcinoembryonic antigen (pCEA) values to differentiate between lymphocytic pleural effusions.

Results

Seventy-eight patients were included with mean age ± SD 53.09 ± 9.56 years old, 49 males and 29 females, diagnosed as 47 MPE, 24 TPE, and 7 others. Cancer ratio at cutoff value of ≥ 22 and cancer ration plus at cutoff value of ≥ 41 can discriminate MPE from any other cause with sensitivity (91.5%, 93.6%), specificity (87.5%, 91.7%), and diagnostic accuracy (90.1%, 92.9%) respectively. When the levels of pCEA and pIFN-ϒ were combined with cutoff value of cancer ratio, there were powerful diagnostic differentiating results.

Conclusions

Cancer ratio and cancer ratio plus offered valid, efficient, non-invasive, and easy measuring diagnostic tools. On diagnostic uncertainty, the add-on of pCEA in cases of suspected MPE, and pIFN-ϒ in cases of suspected TPE has a trustable diagnostic efficacy with no need for further investigations.

Identification of differentially expressed miRNAs in differentiating benign from malignant pleural effusion

Background

Tuberculosis pleural effusion (TPE) and malignant pleural effusion (MPE) are very common clinical complications. Considering the totally different prognosis and clinical treatment of TPE and MPE, the accurate and non-invasive diagnosis are very critical for patients with pleural effusion to initiate efficient management and treatment. However, effective clinical biomarkers were rarely explored to distinguish benign from MPE. The purpose of this study is to identify potential miRNAs which can probably be used to differentiate malignant pleural effusion from TPE.

Results

A total of 23 significantly differentially expressed miRNAs were identified in MPE, with 18 up-expressed and 5 down-expressed. And the target genes of the miRNAs mainly involved in the biology process of nervous system, cancer, immune system and metabolic process etc. Three high confident target genes, AGO4, FGF9 and LEF1 can be regulated by miR-195-5p, miR-182-5p and miR-34a-5p respectively. And these genes participate in the canonical pathway of regulation of the Epithelial-Mesenchymal and the biological functions of apoptosis, growth of tumor and cell proliferation of tumor cell lines. Further, RT-PCR validation results based on 64 collected individuals showed that the expression levels of the three miRNAs were 2–5 times higher in MPE samples, which were consistent with the microarray results. In addition, ROC curve analysis demonstrated that the combination of the three miRNAs can achieve higher AUC of 0.93 (p-value< 0.0001) to differentiate MPE from TPE.

Conclusions

The identified miR-195-5p, miR-182-5p and miR-34a-5p can become potential diagnostic biomarkers for MPE with further evidences.

The diagnostic effect of sequential detection of ADA screening and T-SPOT assay in pleural effusion patients

Purpose: To evaluate the diagnostic effect of sequential detection of Adenosine deaminase (ADA) screening and T-SPOT assay on tuberculosis (TB) pleurisy in pleural effusion patients. Materials and methods: 248 pleural effusion patients (172 TB and 76 non-TB) were retrospectively analyzed in the study. The concentrations of ADA and lactate dehydrogenase (LDH) were measured in pleural fluids and serum samples of the patients. T-SPOTT assays were performed in pleural fluids. The relationship between ADA, T-SPOT and the occurrence of TB pleurisy was evaluated using logistic regression analysis. Results: The level of pleural ADA and positive rate of T-SPOT were all higher in TB pleurisy group than non-TB pleurisy group (p < .001). The positive rate of T-SPOT detection reached 98.83% in the TB pleurisy group while only 40.7% in non-TB pleurisy group (p < .001). Additionally, 8 patients (4.65%) in the TB pleurisy group showed the level of pleurisy ADA exceeded 40 IU/L while only one patient (1.31%) in the non-TB pleurisy group. Conclusion: The sequential detection of ADA screening and T-SPOT assay was found to be an accurate and rapid method for identifying TB pleurisy from pleural effusion, which would promote effective treatment.

Same-Day Tools, Including Xpert Ultra and IRISA-TB, for Rapid Diagnosis of Pleural Tuberculosis: a Prospective Observational Study

The diagnosis of pleural tuberculosis (TB) is problematic. The comparative performance of newer same-day tools for pleural TB, including Xpert MTB/RIF Ultra (ULTRA), has hitherto not been comprehensively studied. Adenosine deaminase (ADA), IRISA-TB (interferon gamma ultrasensitive rapid immunosuspension assay), Xpert MTB/RIF, and ULTRA performance outcomes were evaluated in pleural fluid samples from 149 patients with suspected pleural TB.

The diagnosis of pleural tuberculosis (TB) is problematic. The comparative performance of newer same-day tools for pleural TB, including Xpert MTB/RIF Ultra (ULTRA), has hitherto not been comprehensively studied. Adenosine deaminase (ADA), IRISA-TB (interferon gamma ultrasensitive rapid immunosuspension assay), Xpert MTB/RIF, and ULTRA performance outcomes were evaluated in pleural fluid samples from 149 patients with suspected pleural TB. The reference standard was culture positivity (fluid, biopsy specimen, or sputum) and/or pleural biopsy histopathology (termed definite TB). Those designated as having non-TB were negative by microbiological testing and were not initiated on anti-TB treatment. To determine the effect of sample concentration, 65 samples underwent pelleting by centrifugation, followed by conventional Xpert MTB/RIF and ULTRA. Of the 149 patients, 49 had definite TB, 16 had probable TB (not definite but treated for TB), and 84 had non-TB. ULTRA sensitivity and specificity (95% confidence intervals [CI]) were similar to those of Xpert MTB/RIF [sensitivity, 37.5% (25.3 to 51.2) versus 28.6% (15.9 to 41.2), respectively; specificity, 98.8% (96.5 to 100) versus 98.8% (96.5 to 100), respectively]. Centrifugation did not significantly improve ULTRA sensitivity (29.5% versus 31.3%, respectively). Adenosine deaminase and IRISA-TB sensitivity were 84.4% (73.9 to 95.0) and 89.8% (81.3 to 98.3), respectively. However, IRISA-TB demonstrated significantly better specificity (96.4% versus 87.5% [P = 0.034]), positive predictive value (93.6% versus 80.9 [P = 0.028]), and positive likelihood ratio (25.1 versus 6.8 [P = 0.032]) than ADA. In summary, Xpert ULTRA has poor sensitivity for the diagnosis of pleural TB. Alternative assays (ADA and IRISA-TB) are significantly more sensitive, with IRISA-TB demonstrating a higher specificity and rule-in value than ADA in this high-TB-burden setting where HIV is endemic.

Application of Venn's diagram in the diagnosis of pleural tuberculosis using IFN-γ, IP-10 and adenosine deaminase

BACKGROUND

Pleural tuberculosis (PlTB) is the most common extrapulmonary manifestation of this infectious disease which still presents high mortality rates worldwide. Conventional diagnostic tests for PlTB register multiple limitations, including the lack of sensitivity of microbiological methods on pleural specimens and the need of invasive procedures such as pleural biopsy performance. In this scenario, the search for biological markers on pleural fluid (PF) has been the target of several studies as a strategy to overcome the limitations of PlTB diagnosis. This study aims to evaluate the use either isolated or in combination with adenosine deaminase (ADA), interferon-gamma (IFN-γ), interferon-gamma inducible protein of 10-kD (IP-10) levels on PF in order to guide an accurate anti-TB treatment in microbiologically non-confirmed cases.

METHODS AND FINDINGS

Eighty patients presenting pleural effusion under investigation were enrolled in a cross-sectional study conducted at Pedro Ernesto University Hospital, Rio de Janeiro, RJ, Brazil. Peripheral blood (PB) and PF samples collected from all patients were applied to the commercial IFN-γ release assay, QuantiFERON-TB Gold In-Tube, and samples were analyzed for IFN-γ and IP-10 by immunoassays. ADA activity was determined on PF by the colorimetric method. Based on microbiological and histological criteria, patients were categorized as follow: confirmed PlTB (n = 16), non-confirmed PlTB (n = 17) and non-PlTB (n = 47). The Mycobacterium tuberculosis antigen-specific production of IFN-γ and IP-10 on PB or PF did not show significant differences. However, the basal levels of these biomarkers, as well as the ADA activity on PF, were significantly increased in confirmed PlTB in comparison to non-PlTB group. Receiver operating characteristics curves were performed and the best cut-off points of these three biomarkers were estimated. Their either isolated or combined performances (sensitivity [Se], specificity [Sp], positive predictive value [PPV], negative predictive value [NPV] and accuracy [Acc]) were determined and applied to Venn's diagrams among the groups. Based on the confirmed PlTB cases, IFN-γ showed the best performance of them at a cut-off point of 2.33 IU/mL (Se = 93.8% and Sp = 97.9%) followed by ADA at a cut-off of 25.80 IU/L (Se = 100% and Sp = 84.8%) and IP-10 (Cut-point = 4,361.90 pg/mL, Se = 75% and Sp = 82.6%). IFN-γ plus ADA (cut-point: 25.80 IU/L) represent the most accurate biomarker combination (98.4%), showing Se = 93.7%, Sp = 100%, PPV = 100% and NPV = 97.9%. When this analysis was applied in non-confirmed PlTB, 15/17 (88.2%) presented at least two positive biomarkers in combination.

CONCLUSION

IFN-γ, IP-10, and ADA in PlTB effusions are significantly higher than in non-PlTB cases. IFN-γ is an excellent rule-in and rule-out test compared to IP-10 and ADA. The combination of IFN-γ and ADA, in a reviewed cut-off point, showed to be particularly useful to clinicians as their positive results combined prompts immediate treatment for TB while both negative results suggest further investigation.

Vascular endothelial growth factor and protein level in pleural effusion for differentiating malignant from benign pleural effusion

Pleural effusion is associated with multiple benign and malignant conditions. Currently no biomarkers differentiate malignant pleural effusion (MPE) and benign pleural effusion (BPE) sensitively and specifically. The present study identified a novel combination of biomarkers in pleural effusion for differentiating MPE from BPE by enrolling 75 patients, 34 with BPE and 41 with MPE. The levels of lactate dehydrogenase, glucose, protein, and total cell, neutrophil, monocyte and lymphocyte counts in the pleural effusion were measured. The concentrations of interleukin (IL)-1β, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12, tumor necrosis factor-α, interferon γ, transforming growth factor-β1, colony stimulating factor 2, monocyte chemoattractant protein-1 and vascular endothelial growth factor (VEGF) were detected using cytometric bead arrays. Protein and VEGF levels differed significantly between patients with BPE and those with MPE. The optimal cutoff value of VEGF and protein was 214 pg/ml and 3.35 g/dl respectively, according to the receiver operating characteristic curve. A combination of VEGF >214 pg/ml and protein >3.35 g/dl in pleural effusion presented a sensitivity of 92.6% and an accuracy of 78.6% for MPE, but was not associated with a decreased survival rate. These results suggested that this novel combination strategy may provide useful biomarkers for predicting MPE and facilitating early diagnosis.

Increased soluble and membrane-bound PD-L1 contributes to immune regulation and disease progression in patients with tuberculous pleural effusion

Soluble and membrane-bound programmed death ligand-1 (sPD-L1 and mPD-L1, respectively) have been demonstrated to participate in the immune suppression of non-small cell lung cancer. However, the contribution of sPD-L1 and mPD-L1 to immune regulation and disease progression in patients with pleural effusions remains unknown. The present study evaluated the levels of sPD-L1 and membrane-bound PD-1/PD-L1 in the peripheral blood and pleural effusions of patients with tuberculous pleural effusion (TPE), malignant pleural effusion (MPE) and non-tuberculous non-malignant pleural effusion (n-TB n-M). Furthermore, selected T lymphocytes and cluster of differentiation (CD)14⁺ monocytes were co-cultured to investigate the potential effect of the PD-1/PD-L1 pathway in TPE. Levels of sPD-L1 and PD-L1 on CD14⁺ monocytes were increased in the TPE group, as compared with the MPE and n-TB n-M groups. Furthermore, sPD-L1 levels and the expression levels of PD-L1 on CD14⁺ monocytes were demonstrated to be positively correlated with interferon (IFN)-γ concentration in pleural effusions. Therefore, IFN-γ may increase the expression of PD-L1 on CD14⁺ monocytes in vitro. Cell counting kit-8 analysis demonstrated that anti-PD-L1 antibody was able to partially reverse the proliferation of T lymphocytes in the co-culture system. The results of the present study indicated that sPD-L1 or mPD-L1 are associated with the immune regulation and disease progression of TPE, and may serve as possible biomarkers of TPE. Furthermore, sPD-L1 and the PD-1/PD-L1 pathway of TPE may be associated with the Th1 immune response; therefore, an anti-PD-1/PD-L1 pathway suggests a potential immune therapy strategy for the treatment of TPE.

Novel biomarker analysis of pleural effusion enhances differentiation of tuberculous from malignant pleural effusion

Lymphocytic pleurisy is commonly observed in tuberculosis and cancer. Noninvasive biomarkers are needed to distinguish tuberculous pleural effusion (TPE) from malignant pleural effusion (MPE) because current clinical diagnostic procedures are often invasive. We identified immune response biomarkers that can discriminate between TPE and MPE. Fourteen pleural effusion biomarkers were compared in 22 MPE patients and five TPE patients. Of the innate immunity biomarkers, the median levels of interleukin (IL)-1β and interferon-induced protein-10 (IP-10) were higher in TPE patients than in MPE patients (P<0.05 and P<0.01, respectively). Of the adaptive immunity biomarkers, the median levels of IL-13 and interferon-γ (IFN-γ) were higher in TPE patients than in MPE patients (P<0.05). In addition, the levels of basic fibroblast growth factor were higher in MPE patients than in TPE patients (P<0.05). Receiver operator characteristic analysis of these biomarkers was performed, resulting in the highest area under the curve (AUC) for IP-10 (AUC =0.95, 95% confidence interval, P<0.01), followed by IL-13 (AUC =0.86, 95% confidence interval, P<0.05). Our study shows that five biomarkers (IL-1β, IP-10, IFN-γ, IL-13, and basic fibroblast growth factor) have a potential diagnostic role in differentiating TPE from MPE, particularly in lung cancer-related MPE.

Adenosine deaminase is a useful biomarker to diagnose pleural tuberculosis in low to medium prevalence settings

Adenosine deaminase (ADA) activity measurement in pleural fluid is a relevant test to diagnose pleural tuberculosis (pTB) in high tuberculosis prevalence settings. We investigated the diagnostic utility of pleural ADA using a retrospective analysis of patients admitted with newly diagnosed pleural effusion without identified etiology between 2001 and 2008 in Paris suburb, a low to medium tuberculosis prevalence area. 104 adults (mean age 55 years; 34 with pTB, 70 with other diagnoses) were analyzed. Median follow-up was 15.6 months. Mean [interquartile range] pleural ADA was 119 U/L [IQR: 83-143] in pTB and 24 U/L [IQR: 15-31] in non-tuberculous effusions (P<0.001). With an optimal pleural ADA cut-off value of 41.5 U/L for pTB diagnosis, sensitivity and specificity were 97.1% and 92.9%, while positive and negative predictive values were 86.8% and 98.5%, respectively. We conclude that pleural ADA activity could be integrated in the diagnostic procedures of pTB in low to medium tuberculosis prevalence settings.

Age and sex distribution in malignant and tuberculous serous effusions: A study of 127 patients and review of the literature

AIM

Tuberculosis and carcinomatosis are the two most frequent causes of pleural effusion and exudative ascites, and both are characterized by lymphocyte-rich effusion. We attempted to discover if there is any significant difference in the age and sex distribution between patients presenting with these two conditions.

METHODS

A total of 161 serous effusion samples from 127 patients (89 with pleural effusion and 38 with ascites) having follow-up biopsy and histopathological examination were included in the present study. Three groups - malignancy (47 patients), tuberculosis (47) and non-tuberculous benign lesions (26) as per histopathological diagnoses - were compared in respect to age and sex distribution.

RESULTS

A total of 29 (61.7%) patients with malignancy were aged ≥50 years as compared with three (6.4%) tuberculosis patients with serous effusions (P = 0.00000). A similar trend was observed in the ≥60 years age group (18 or 38.3% malignancy vs none with tuberculosis, P = 0.00000). A total of 36 (76.6%) tuberculous effusion patients were aged less than 40 years as opposed to eight (17.0%) patients with malignant effusions (P = 0.00000). There was also s significant difference between tuberculous and non-tuberculous benign lesions in the ≥50 years age group (6.4% vs 69.2%, P = 0.00000), but no significant difference between malignancy and non-tuberculous benign lesions (P = 0.61385). There were 31 female (66.0%) patients with malignancy, which was significantly higher than that of patients with tuberculosis (16, [34%], P = 0.00365) and non-specific inflammation/benign lesions (23.1%, P = 0.00059). However, the difference between tuberculosis and non-tuberculous benign lesions was not significant (P = 0.42756).

CONCLUSION

Whereas malignancy in serous effusions is found in older and middle-aged people, tuberculous effusion is a disease of younger people.

Myelomatous pleural effusion as an initial sign of multiple myeloma-a case report and review of literature

OBJECTIVE

Discuss and improve the understanding of the clinical characters and diagnostic methods of myelomatous pleurisy, particularly of the patients with pleural effusion as an initial manifestation.

BACKGROUND

A 53-year-old male, who had been misdiagnosed as tuberculous pleurisy in a local hospital, was diagnosed as multiple myeloma (MM) with pleural infiltration. We reviewed the literature on clinical manifestations, serum and pleural effusion characters, treatment and diagnostic options of this exceptionally rare presentation of MM.

METHODS

We conducted a search of the published medical literature since 2000 in MEDLINE and PubMed using search criteria [("pleural effusion" and "MM") or "myelomatous pleural effusions"]. The search led to 64 case reports, and 16 cases with pleural effusion as an initial manifestation were included in this review. We have also searched for recent advances in diagnosis.

RESULTS AND CONCLUSIONS

Myelomatous pleurisy is a rare complication of MM. Its clinical and laboratory findings are non-specific. Definitive diagnosis relies on the histopathology of pleural biopsy or pleural effusion. Thoracoscopic pleural biopsy is reliable, safe and effective. Chemotherapy is the mainstay of treatment for myelomatous pleural effusion. However, the response rate is low with an overall median survival time of 4 months.

Comparison of same day diagnostic tools including Gene Xpert and unstimulated IFN-γ for the evaluation of pleural tuberculosis: a prospective cohort study

BACKGROUND

The accuracy of currently available same-day diagnostic tools (smear microscopy and conventional nucleic acid amplification tests) for pleural tuberculosis (TB) is sub-optimal. Newer technologies may offer improved detection.

METHODS

Smear-microscopy, adenosine deaminase (ADA), interferon gamma (IFN-γ), and Xpert MTB/RIF [using an unprocessed (1 ml) and centrifuged (~20 ml) sample] test accuracy was evaluated in pleural fluid from 103 consecutive patients with suspected pleural TB. Culture for M.tuberculosis and/or histopathology (pleural biopsy) served as the reference standard. Patients were followed prospectively to determine their diagnostic categorisation.

RESULTS

Of 93 evaluable participants, 40 had definite-TB (reference positive), 5 probable-TB (not definite but treated for TB) and 48 non-TB (culture and histology negative, and not treated for TB). Xpert MTB/RIF sensitivity and specificity (95% CI) was 22.5% (12.4 - 37.6) and 98% (89.2 - 99.7), respectively, and centrifugation did not improve sensitivity (23.7%). The Xpert MTB/RIF internal positive control showed no evidence of inhibition. Biomarker specific sensitivity, specificity, PPV, and NPVs were: ADA (48.85 IU/L; rule-in cut-point) 55.3% (39.8 - 69.9), 95.2% (83.9 - 98.7), 91.4 (73.4 - 95.4), 69.7% (56.7 - 80.1); ADA (30 IU/L; clinically used cut-point) 79% (63.7 - 89), 92.7% (80.6 - 97.5), 91.0 (73.4 - 95.4), 82.7% (69.3 - 90.1); and IFN-γ (107.7 pg/ml; rule-in cut-point) 92.5% (80.2 - 97.5), 95.9% (86.1 - 98.9), 94.9% (83.2 - 98.6), 93.9% (83.5 - 97.9), respectively (IFN-γ sensitivity and NPV better than Xpert [p < 0.05] and rule-in ADA [p < 0.05]).

CONCLUSION

The usefulness of Xpert MTB/RIF to diagnose pleural TB is limited by its poor sensitivity. IFN-γ is an excellent rule-in test and, compared to ADA, has significantly better sensitivity and rule-out value in a TB-endemic setting.

Impact of molecular diagnosis on treating Mendelian susceptibility to mycobacterial diseases

BACKGROUND/OBJECTIVE

The IL-12-IFN-γ axis is critical for immune defense against mycobacterial infections. Inherited mutations that affect normal activation of this self-amplifying cytokine reaction lead to increased chances of mycobacterial infections, known as Mendelian susceptibility to mycobacterial diseases (MSMD). Delayed diagnosis and difficulty in identifying pathogenic mycobacteria hinder proper treatment of patients, so the aim of this study was to facilitate the diagnosis of mycobacterial infections in MSMD patients using an oligonucleotide array method.

METHODS

Peripheral blood mononuclear cells (PBMCs) were isolated from three MSMD patients in the same family. A series of immunologic studies, including testing for cytokine secretion after leukocyte stimulation, cell-surface marker analysis, and cDNA sequencing, were then performed. An oligonucleotide array was used to rapidly identify pathogens.

RESULTS

Cytokine secretion testing showed normal IFN-γ secretion after IL-12 stimulation but low IL-12 secretion after IFN-γ stimulation, which indicates a defect in the IFN-γ receptor or its intracellular signaling. Cell-surface receptor analysis showed IFN-γ receptor 1 overexpression, suggesting an autosomal dominant IFN-γ receptor 1 deficiency. cDNA sequencing identified the IFNGR1 818del4 mutation in three members of the family with known MSMD, and an oligonucleotide array identified Mycobacterium tuberculosis complex and Mycobacterium abscessus as pathogens.

CONCLUSIONS

Patients with suspected MSMD should undergo molecular diagnosis of the primary immunodeficiency. Oligonucleotide array methods may be a tool for rapid identification of pathogens and for guiding antimicrobial treatment in immunodeficient patients.

Otitis media and otomastoiditis caused by Mycobacterium massiliense (Mycobacterium abscessus subsp. bolletii)

We describe two patients with otologic infections caused by Mycobacterium massiliense (M. abscessus subsp. bolletti) which were identified using erm(41) PCR, 23S rRNA, and rpoB gene sequence analysis. They were middle-aged adults with underlying otologic diseases and were treated successfully with clarithromycin-based combination regimens for 3 and 9 months, respectively.

Performance assessment of the DR. TBDR/NTM IVD kit for direct detection of Mycobacterium tuberculosis isolates, including rifampin-resistant isolates, and nontuberculous Mycobacteria

We evaluated the performance of the DR. TBDR/NTM IVD kit, which was designed to detect Mycobacterium tuberculosis, rifampin-resistant M. tuberculosis, and nontuberculous mycobacteria, for detecting 110 positive and 50 negative cultures in Mycobacterium Growth Indicator Tubes. The accuracy rate of this kit for identification of Mycobacterium species was 95.5% (105/110).