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Broger T, Marx FM, Theron G, Marais BJ, Nicol MP, Kerkhoff AD, Nathavitharana R, Huerga H, Gupta-Wright A, Kohli M, Nichols BE, Muyoyeta M, Meintjes G, Ruhwald M, Peeling RW, Pai NP, Pollock NR, Pai M, Cattamanchi A, Dowdy DW, Dewan P, Denkinger CM. Diagnostic yield as an important metric for the evaluation of novel tuberculosis tests: rationale and guidance for future research. Lancet Glob Health 2024; 12:e1184-e1191. [PMID: 38876764 DOI: 10.1016/s2214-109x(24)00148-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 02/11/2024] [Accepted: 03/28/2024] [Indexed: 06/16/2024]
Abstract
Better access to tuberculosis testing is a key priority for fighting tuberculosis, the leading cause of infectious disease deaths in people. Despite the roll-out of molecular WHO-recommended rapid diagnostics to replace sputum smear microscopy over the past decade, a large diagnostic gap remains. Of the estimated 10·6 million people who developed tuberculosis globally in 2022, more than 3·1 million were not diagnosed. An exclusive focus on improving tuberculosis test accuracy alone will not be sufficient to close the diagnostic gap for tuberculosis. Diagnostic yield, which we define as the proportion of people in whom a diagnostic test identifies tuberculosis among all people we attempt to test for tuberculosis, is an important metric not adequately explored. Diagnostic yield is particularly relevant for subpopulations unable to produce sputum such as young children, people living with HIV, and people with subclinical tuberculosis. As more accessible non-sputum specimens (eg, urine, oral swabs, saliva, capillary blood, and breath) are being explored for point-of-care tuberculosis testing, the concept of yield will be of growing importance. Using the example of urine lipoarabinomannan testing, we illustrate how even tests with limited sensitivity can diagnose more people with tuberculosis if they enable increased diagnostic yield. Using tongue swab-based molecular tuberculosis testing as another example, we provide definitions and guidance for the design and conduct of pragmatic studies that assess diagnostic yield. Lastly, we show how diagnostic yield and other important test characteristics, such as cost and implementation feasibility, are essential for increased effective population coverage, which is required for optimal clinical care and transmission impact. We are calling for diagnostic yield to be incorporated into tuberculosis test evaluation processes, including the WHO Grading of Recommendations, Assessment, Development, and Evaluations process, providing a crucial real-life implementation metric that complements traditional accuracy measures.
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Affiliation(s)
- Tobias Broger
- Department of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Florian M Marx
- Department of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany; DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Faculty of Science, Stellenbosch University, Stellenbosch, South Africa
| | - Grant Theron
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Ben J Marais
- The University of Sydney Infectious Diseases Institute, Sydney, NSW, Australia; Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Mark P Nicol
- Division of Infection and Immunity, School of Biomedical Sciences, University of Western Australia, Perth, WA, Australia
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases, and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA; Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | | | - Helena Huerga
- Department of Epidemiology, Epicentre, Paris, France
| | - Ankur Gupta-Wright
- Department of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | | | | | - Monde Muyoyeta
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | - Nitika Pant Pai
- Department of Medicine, Centre for Outcomes Research & Evaluation, McGill University, Montreal, QC, Canada
| | | | - Madhukar Pai
- McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Adithya Cattamanchi
- Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA; Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of California Irvine, Irvine, CA, USA
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Puneet Dewan
- Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Claudia M Denkinger
- Department of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany; German Center for Infection Research, Heidelberg University Hospital, Heidelberg, Germany.
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Chilambi GS, Reiss R, Daivaa N, Banada P, De Vos M, Penn-Nicholson A, Alland D. Optimal processing of tongue swab samples for Mycobacterium tuberculosis detection by the Xpert MTB/RIF Ultra assay. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.06.20.24309244. [PMID: 38947094 PMCID: PMC11213102 DOI: 10.1101/2024.06.20.24309244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Tongue swabs represent a potential alternative to sputum as a sample type for detecting pulmonary tuberculosis (TB) using molecular diagnostic tests. The methods used to process tongue swabs for testing in the WHO-recommended Xpert MTB/RIF Ultra (Xpert Ultra) assay vary greatly. We aimed to identify the optimal method for processing diagnostic tongue swabs for subsequent testing by Xpert Ultra. We compared four methods for treating dry tongue swabs with Xpert Ultra sample reagent (SR) mixed with various concentrations of Tris-EDTA-Tween (TET), to treatment with SR alone or to a commonly used SR-free heat-inactivation protocol. In each condition, swabs obtained from volunteers without TB were placed into test buffer spiked with known amounts of Mycobacterium tuberculosis ( Mtb ) strain H37Rv-mc 2 6230. Swabs processed with 1:1 diluted SR buffer had the lowest Mtb limit of detection (LOD) at 22.7 CFU/700 µl (95% CI 14.2-31.2), followed by 2:1 diluted SR buffer at 30.3 CFU/700 µl (95% CI 19.9-40.7), neat SR at 30.9 CFU/700 µl (95% CI 21.5-40.3) and SR prefilled in the Xpert Ultra at 57.1 CFU/700 µl (95% CI 42.4-71.7). Swabs processed using the heat-based protocol had the highest LOD (77.6 CFU/700 µl; 95% CI 51.2-104.0). Similar findings were observed for LOD of RIF-susceptibility. Assay sensitivity using the 2:1 diluted SR buffer did not vary considerably in the presence of sputum matrix or phosphate buffer saline. Further studies are needed to assess the performance of this processing protocol in a clinical setting. Importance Xpert MTB/RIF Ultra (Xpert Ultra) is approved by the World Health Organization for the diagnosis of tuberculosis (TB). This test is typically performed using sputum specimens obtained from people with presumptive TB. In order to inactivate Mtb and aid liquefaction, sputum must be mixed with Xpert SR prior to transfer into the Xpert Ultra. However, some people under evaluation for TB are unable to produce sputum. Alternative sample types for TB diagnosis would therefore be of value. Oral-swabs, including tongue-swabs have shown promise, but there are technical challenges associated with sample processing. In this study, several new tongue swab processing conditions were evaluated, utilizing SR, either neat or diluted in buffer. The ability of Xpert Ultra to detect TB was improved under these conditions compared with the previously published heat-processing method (1-3), processing steps were simplified, and technical challenges were overcome.
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Zhou L, Zou X, Yong Y, Hu Q. Using cerebrospinal fluid nanopore sequencing assay to diagnose tuberculous meningitis: a retrospective cohort study in China. BMJ Open 2024; 14:e080904. [PMID: 38862231 PMCID: PMC11168130 DOI: 10.1136/bmjopen-2023-080904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 04/30/2024] [Indexed: 06/13/2024] Open
Abstract
OBJECTIVE This study aimed to evaluate the efficiency of nanopore sequencing for the early diagnosis of tuberculous meningitis (TBM) using cerebrospinal fluid and compared it with acid-fast bacilli (AFB) smear, mycobacterial growth indicator tube culture and Xpert Mycobacterium tuberculosis (MTB)/rifampicin (RIF). DESIGN Single-centre retrospective study. SETTING The Tuberculosis Diagnosis and Treatment Center of Zhejiang Chinese and Western Medicine Integrated Hospital. PARTICIPANTS We enrolled 64 adult patients with presumptive TBM admitted to our hospital from August 2021 to August 2023. METHODS We calculated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of AFB smear, culture, Xpert MTB/RIF and nanopore sequencing to evaluate their diagnostic efficacy compared with a composite reference standard for TBM. RESULTS Among these 64 patients, all tested negative for TBM by AFB smear. The sensitivity, specificity, PPV and NPV were 11.11%, 100%, 100% and 32.2% for culture, 13.33%, 100%, 100% and 2.76% for Xpert MTB/RIF, and 77.78%, 100%, 100% and 65.52% for nanopore sequencing, respectively. CONCLUSION The diagnostic accuracy of the nanopore sequencing test was significantly higher than that of conventional testing methods used to detect TBM.
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Affiliation(s)
- Lihong Zhou
- Tuberculosis Diagnosis and Treatment Center, Integrated Traditional Chinese and Western Medicine Hospital of Zhejiang Province, Hangzhou, China
| | - Xingwu Zou
- Tuberculosis Diagnosis and Treatment Center, Integrated Traditional Chinese and Western Medicine Hospital of Zhejiang Province, Hangzhou, China
| | - Yan Yong
- Tuberculosis Diagnosis and Treatment Center, Integrated Traditional Chinese and Western Medicine Hospital of Zhejiang Province, Hangzhou, China
| | - Qin Hu
- Tuberculosis Diagnosis and Treatment Center, Integrated Traditional Chinese and Western Medicine Hospital of Zhejiang Province, Hangzhou, China
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Milburn J, Suresh R, Doyle R, Jarvis JN. The diagnosis of central nervous system infections in resource-limited settings and the use of novel and molecular diagnostic platforms to improve diagnosis. Expert Rev Mol Diagn 2024; 24:219-230. [PMID: 38369939 DOI: 10.1080/14737159.2024.2317414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 02/07/2024] [Indexed: 02/20/2024]
Abstract
INTRODUCTION Central nervous system infections (CNSI) disproportionately affect individuals in low-resource settings where diagnosis is challenging; large proportions of patients never receive a confirmed microbiological diagnosis resulting in inadequate management and high mortality. The epidemiology of CNSI varies globally and conventional diagnostics deployed in resource-limited settings have significant limitations, with an urgent need for improved diagnostic strategies. AREAS COVERED This review describes molecular platforms and other novel diagnostics used in the diagnosis of CNSI that are applicable to resource-limited settings. An extensive literature search of Medline and PubMed was performed. The emphasis is on investigations targeting infections of relevance to resource-limited settings either due to variation in regional CNSI epidemiology or due to increased prevalence in patients with immunosuppression. This includes commercially available multiplex PCR platforms, mycobacterial PCR platforms, and rapid diagnostics tests. To offer a framework for the optimal implementation in clinical settings, existing evidence highlighting the advantages and limitations of available platforms is reviewed. EXPERT OPINION The implementation of molecular platforms and other novel diagnostics has the potential to transform CNSI diagnosis in resource-limited settings, with several examples of successful rollout of novel diagnostics such as Xpert MTB/RIF Ultra and cryptococcal antigen testing.
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Affiliation(s)
- James Milburn
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Rachita Suresh
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Ronan Doyle
- Department of Clinical Research, Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Joseph N Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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Lin BW, Hong JC, Jiang ZJ, Zhang WQ, Fan QC, Yao XP. Performance of metagenomic next-generation sequencing in cerebrospinal fluid for diagnosis of tuberculous meningitis. J Med Microbiol 2024; 73. [PMID: 38506717 DOI: 10.1099/jmm.0.001818] [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] [Indexed: 03/21/2024] Open
Abstract
Purpose. Metagenomic next-generation sequencing (mNGS) has been widely used in the diagnosis of infectious diseases, while its performance in diagnosis of tuberculous meningitis (TBM) is incompletely characterized. The aim of this study was to assess the performance of mNGS in the diagnosis of TBM, and illustrate the sensitivity and specificity of different methods.Methods. We retrospectively recruited TBM patients between January 2021 and March 2023 to evaluate the performance of mNGS on cerebrospinal fluid (CSF) samples, in comparison with conventional microbiological testing, including culturing of Mycobacterium tuberculosis (MTB), acid-fast bacillus (AFB) stain, reverse transcription PCR and Xpert MTB/RIF.Results. Of the 40 enrolled, 34 participants were diagnosed with TBM, including 15(44.12 %) definite and 19(55.88 %) clinical diagnosis based upon clinical manifestations, CSF parameters, brain imaging, pathogen evidence and treatment response. The mNGS method identified sequences of Mycobacterium tuberculosis complex (MTBC) in 11 CSF samples. In patients with definite TBM, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of mNGS were 78.57, 100, 100, 66.67 and 85 %, respectively. Compared to conventional diagnostic methods, the sensitivity of mNGS (78.57 %) was higher than AFB (0 %), culturing (0 %), RT-PCR (60 %) and Xpert MTB/RIF (14.29 %).Conclusions. Our study indicates that mNGS of CSF exhibited an overall improved sensitivity over conventional diagnostic methods for TBM and can be considered a front-line CSF test.
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Affiliation(s)
- Bi-Wei Lin
- Department of Neurology and Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, and Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou 350005, PR China
| | - Jian-Chen Hong
- Department of Gastrointestinal Surgery, the First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, PR China
| | - Zai-Jie Jiang
- Department of Neurology and Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, and Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou 350005, PR China
| | - Wei-Qing Zhang
- Department of Laboratory Medicine, the First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, PR China
| | - Qi-Chao Fan
- Department of Infectious Disease, the First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, PR China
| | - Xiang-Ping Yao
- Department of Neurology and Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, and Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou 350005, PR China
- Department of Neurology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, PR China
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Yang X, Zhou S, Chang Z, Xi X, Li J, Miao M, Chen Y, Chen W, Zhang H, Ding R, Hu Z. Nanopore targeted sequencing-based diagnosis of central nervous system infections in HIV-infected patients. Ann Clin Microbiol Antimicrob 2024; 23:22. [PMID: 38424544 PMCID: PMC10905896 DOI: 10.1186/s12941-024-00682-7] [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: 10/10/2023] [Accepted: 02/19/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Early and accurate etiological diagnosis is very important for improving the prognosis of central nervous system (CNS) infections in human immunodeficiency virus (HIV)-infected patients. The goal is not easily achieved by conventional microbiological tests. We developed a nanopore targeted sequencing (NTS) platform and evaluated the diagnostic performance for CNS infections in HIV-infected patients, with special focus on cryptococcal meningitis (CM). We compared the CM diagnostic performance of NTS with conventional methods and cryptococcal polymerase chain reaction (PCR). METHODS This study included 57 hospitalized HIV-infected patients with suspected CNS infections from September 2018 to March 2022. The diagnosis established during hospitalization includes 27 cases of CM, 13 CNS tuberculosis, 5 toxoplasma encephalitis, 2 cytomegalovirus (CMV) encephalitis and 1 Varicella-zoster virus (VZV) encephalitis. The 2 cases of CMV encephalitis also have co-existing CM. Target-specific PCR amplification was used to enrich pathogen sequences before nanopore sequencing. NTS was performed on stored cerebrospinal fluid (CSF) samples and the results were compared with the diagnosis during hospitalization. RESULTS 53 (93.0%) of the patients were male. The median CD4 cell count was 25.0 (IQR: 14.0-63.0) cells/uL. The sensitivities of CSF culture, India ink staining, cryptococcal PCR and NTS for CM were 70.4% (95%CI: 51.5 - 84.1%), 76.0% (95%CI: 56.6 - 88.5%), 77.8% (59.2 - 89.4%) and 85.2% (95%CI: 67.5 - 94.1%), respectively. All those methods had 100% specificity for CM. Our NTS platform could identify Cryptococcus at species level. Moreover, NTS was also able to identify all the 5 cases of toxoplasma encephalitis, 2 cases of CMV encephalitis and 1 VZV encephalitis. However, only 1 of 13 CNS tuberculosis cases was diagnosed by NTS, and so did Xpert MTB/RIF assay. CONCLUSIONS NTS has a good diagnostic performance for CM in HIV-infected patients and may have the ability of simultaneously detecting other pathogens, including mixed infections. With continuing improving of the NTS platform, it may be a promising alterative microbiological test for assisting with the diagnosis of CNS infections.
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Affiliation(s)
- Xihong Yang
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Shuilian Zhou
- State Key Laboratory of Neurology and Oncology Drug Development, Jiangsu Simcere Pharmaceutical Co.,Ltd, Jiangsu Simcere Diagnostics Co.,Ltd., Nanjing, China
- Nanjing Simcere Medical Laboratory Science Co., Ltd., Nanjing, China
| | - Ziwei Chang
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Xiaotong Xi
- State Key Laboratory of Neurology and Oncology Drug Development, Jiangsu Simcere Pharmaceutical Co.,Ltd, Jiangsu Simcere Diagnostics Co.,Ltd., Nanjing, China
- Nanjing Simcere Medical Laboratory Science Co., Ltd., Nanjing, China
| | - Jiahui Li
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Mengjiao Miao
- Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Yaling Chen
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Wei Chen
- Clinical Research Center, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Hongying Zhang
- Nanjing Center for Disease Control and Prevention, Nanjing Medical University, Nanjing, China.
| | - Ran Ding
- State Key Laboratory of Neurology and Oncology Drug Development, Jiangsu Simcere Pharmaceutical Co.,Ltd, Jiangsu Simcere Diagnostics Co.,Ltd., Nanjing, China.
- Nanjing Simcere Medical Laboratory Science Co., Ltd., Nanjing, China.
| | - Zhiliang Hu
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China.
- Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China.
- Inovention Center for Infectious Disease of Jiangsu Province, Nanjing, China.
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Kamponda M, Bickton FM, Mategula D, Nliwasa M, Kreuels B, Kumwenda J. The diagnostic performance of Xpert MTB/RIF Ultra on Pericardial, Pleural and Ascitic cohort study fluids for diagnosis of extra-pulmonary Tuberculosis at a referral hospital in Malawi. Malawi Med J 2023; 35:201-207. [PMID: 38362570 PMCID: PMC10865050 DOI: 10.4314/mmj.v35i4.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
Background Extra-pulmonary tuberculosis (EPTB) accounts for 15% of the 1.4 million patients with TB notified in 2019. EPTB carries a high risk of mortality and so early diagnosis and treatment are important to reduce this risk. Diagnosis of EPTB in low- and middle-income countries is challenging. This study investigated the diagnostic performance of Xpert MTB Ultra for the diagnosis of EPTB (pericardial, pleural, and ascitic fluid) in adults at a referral hospital in Malawi. Methods Adults with suspected extra-pulmonary TB were screened for evidence of extra-pulmonary fluid and tested for TB using Xpert MTB Ultra, mycobacterial culture, and a Focused Abdominal Sonography in HIV-associated TB (FASH scan). The diagnostic performance of the Xpert MTB Ultra was compared to mycobacterial culture and a composite reference standard defined as a positive FASH scan or a positive mycobacterial culture or a clinical TB diagnosis (constitutional symptoms not otherwise explained with response to empirical TB treatment). Results There were 174 patients recruited: 99/174 (57%) pleural, 70/174 (40%) ascitic and 5/174 (3%) pericardial. Overall, 10/174 (6%) had bacteriologically confirmed TB and 30/174 (17%) were started on TB treatment based on a positive FASH scan or a clinical TB diagnosis. The sensitivity and specificity of Xpert ultra compared to culture was 83% (95%CI:36%-100%) and 98% (95%CI:94%-99%), respectively. Compared to the composite reference standard, the sensitivity of Xpert Ultra was 17% (95%CI:7%-34%) and specificity was 98% (95%CI:94%-100%). Conclusion Xpert MTB Ultra provides good diagnostic performance on pleural, pericardial and ascitic fluid with reference to mycobacterial culture. Improved EPTB diagnostic tests are required to improve patient outcomes. We recommend larger multi-centre studies to corroborate our findings.
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Affiliation(s)
- Martin Kamponda
- Department of Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Fanuel Meckson Bickton
- Department of Rehabilitation Sciences, School of Life Sciences and Allied Health Professions, Kamuzu University of Health Sciences, Blantyre, Malawi
- Lung Health Group, Malawi-Liverpool-Welcome Programme, Blantyre, Malawi
| | - Donnie Mategula
- Lung Health Group, Malawi-Liverpool-Welcome Programme, Blantyre, Malawi
| | - Marriott Nliwasa
- Helse Nord Tuberculosis Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Benno Kreuels
- Department of Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Johnstone Kumwenda
- Department of Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
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Slail MJ, Booq RY, Al-Ahmad IH, Alharbi AA, Alharbi SF, Alotaibi MZ, Aljubran AM, Aldossary AM, Memish ZA, Alyamani EJ, Tawfik EA, Binjomah AZ. Evaluation of Xpert MTB/RIF Ultra for the Diagnosis of Extrapulmonary Tuberculosis: A Retrospective Analysis in Saudi Arabia. J Epidemiol Glob Health 2023; 13:782-793. [PMID: 37707714 PMCID: PMC10686912 DOI: 10.1007/s44197-023-00150-z] [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: 04/11/2023] [Accepted: 08/31/2023] [Indexed: 09/15/2023] Open
Abstract
The incidence of extrapulmonary tuberculosis (EPTB) in low- and middle-income countries, as well as, high-income countries has increased over the last two decades. The acid-fast bacillus (AFB) smear test is easy to perform and cost-effective with a quick turnaround time but the test has low sensitivity. Culture remains the gold standard for detecting TB; however, it has low sensitivity and slow bacterial growth patterns, as it may take up to 6 to 8 weeks to grow. Therefore, a rapid detection tool is crucial for the early initiation of treatment and ensuring an improved therapeutic outcome. Here, the Xpert Ultra system was developed as a nucleic acid amplification technique to accelerate the detection of MTB in paucibacillary clinical samples and endorsed by the World Health Organization. From March 2020 to August 2021, Xpert Ultra was evaluated for its sensitivity and specificity against EPTB and compared with those of the routinely used Xpert, culture, and AFB tests in 845 clinical samples in Saudi Arabia. The results indicate the overall sensitivity and specificity of Xpert Ultra to be 91% and 95%, respectively, compared with the Xpert (82% and 99%, respectively) and AFB smear (18% and 100%, respectively) tests. The results also indicated that despite the low microbial loads that were categorized as trace, very low, or low on Xpert Ultra, yet, complete detection was achieved with some sample types (i.e., 100% detection). Consequently, Xpert Ultra has great potential to replace conventional diagnostic approaches as a standard detection method for EPTB.
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Affiliation(s)
- Mousa J Slail
- Tuberculosis Department, Dammam Regional Laboratory, Ministry of Health, Dammam, Saudi Arabia
| | - Rayan Y Booq
- Wellness and Preventive Medicine Institute, Health Sector, King Abdulaziz City for Science and Technology (KACST), 11442, Riyadh, Saudi Arabia
| | - Ibrahim H Al-Ahmad
- Tuberculosis Department, Dammam Regional Laboratory, Ministry of Health, Dammam, Saudi Arabia
| | - Arwa A Alharbi
- Mycobacteriology Unit, Riyadh Regional Laboratory, Ministry of Health, 12746, Riyadh, Saudi Arabia
| | - Shafi F Alharbi
- Mycobacteriology Unit, Riyadh Regional Laboratory, Ministry of Health, 12746, Riyadh, Saudi Arabia
| | - Mutlaq Z Alotaibi
- Mycobacteriology Unit, Riyadh Regional Laboratory, Ministry of Health, 12746, Riyadh, Saudi Arabia
| | - Abdulaziz M Aljubran
- Mycobacteriology Unit, Riyadh Regional Laboratory, Ministry of Health, 12746, Riyadh, Saudi Arabia
| | - Ahmad M Aldossary
- Wellness and Preventive Medicine Institute, Health Sector, King Abdulaziz City for Science and Technology (KACST), 11442, Riyadh, Saudi Arabia
| | - Ziad A Memish
- College of Medicine, Alfaisal University, 11533, Riyadh, Saudi Arabia
- Research & Innovation Center, King Saud Medical City, Riyadh, Saudi Arabia
- Hubert Department School of Public Health, Emory University, Atlanta, USA
- Division of Infectious Diseases, Kyung Hee University, Seoul, Korea
| | - Essam J Alyamani
- Wellness and Preventive Medicine Institute, Health Sector, King Abdulaziz City for Science and Technology (KACST), 11442, Riyadh, Saudi Arabia
| | - Essam A Tawfik
- Advanced Diagnostics and Therapeutics Institute, Health Sector, King Abdulaziz City for Science and Technology (KACST), 11442, Riyadh, Saudi Arabia.
| | - Abdulwahab Z Binjomah
- Mycobacteriology Unit, Riyadh Regional Laboratory, Ministry of Health, 12746, Riyadh, Saudi Arabia.
- College of Medicine, Alfaisal University, 11533, Riyadh, Saudi Arabia.
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Kimuda S, Kasozi D, Namombwe S, Gakuru J, Mugabi T, Kagimu E, Rutakingirwa MK, Leon KE, Chow F, Wasserman S, Boulware DR, Cresswell FV, Bahr NC. Advancing Diagnosis and Treatment in People Living with HIV and Tuberculosis Meningitis. Curr HIV/AIDS Rep 2023; 20:379-393. [PMID: 37947980 PMCID: PMC10719136 DOI: 10.1007/s11904-023-00678-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE OF REVIEW Tuberculous meningitis (TBM) is the most severe form of tuberculosis. Inadequate diagnostic testing and treatment regimens adapted from pulmonary tuberculosis without consideration of the unique nature of TBM are among the potential drivers. This review focuses on the progress being made in relation to both diagnosis and treatment of TBM, emphasizing promising future directions. RECENT FINDINGS The molecular assay GeneXpert MTB/Rif Ultra has improved sensitivity but has inadequate negative predictive value to "rule-out" TBM. Evaluations of tests focused on the host response and bacterial components are ongoing. Clinical trials are in progress to explore the roles of rifampin, fluoroquinolones, linezolid, and adjunctive aspirin. Though diagnosis has improved, novel modalities are being explored to improve the rapid diagnosis of TBM. Multiple ongoing clinical trials may change current therapies for TBM in the near future.
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Affiliation(s)
- Sarah Kimuda
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Derrick Kasozi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Suzan Namombwe
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Timothy Mugabi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Kristoffer E Leon
- Departments of Neurology and Medicine (Infectious Diseases), University of California San Francisco, San Francisco, CA, USA
| | - Felicia Chow
- Departments of Neurology and Medicine (Infectious Diseases), University of California San Francisco, San Francisco, CA, USA
| | - Sean Wasserman
- Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Fiona V Cresswell
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- HIV Interventions, MRC/UVRI-LSHTM Uganda Research Unit, Entebbe, Uganda
- Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, KS, USA.
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10
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Shi Y, Zhang C, Pan S, Chen Y, Miao X, He G, Wu Y, Ye H, Weng C, Zhang H, Zhou W, Yang X, Liang C, Chen D, Hong L, Su F. The diagnosis of tuberculous meningitis: advancements in new technologies and machine learning algorithms. Front Microbiol 2023; 14:1290746. [PMID: 37942080 PMCID: PMC10628659 DOI: 10.3389/fmicb.2023.1290746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/09/2023] [Indexed: 11/10/2023] Open
Abstract
Tuberculous meningitis (TBM) poses a diagnostic challenge, particularly impacting vulnerable populations such as infants and those with untreated HIV. Given the diagnostic intricacies of TBM, there's a pressing need for rapid and reliable diagnostic tools. This review scrutinizes the efficacy of up-and-coming technologies like machine learning in transforming TBM diagnostics and management. Advanced diagnostic technologies like targeted gene sequencing, real-time polymerase chain reaction (RT-PCR), miRNA assays, and metagenomic next-generation sequencing (mNGS) offer promising avenues for early TBM detection. The capabilities of these technologies are further augmented when paired with mass spectrometry, metabolomics, and proteomics, enriching the pool of disease-specific biomarkers. Machine learning algorithms, adept at sifting through voluminous datasets like medical imaging, genomic profiles, and patient histories, are increasingly revealing nuanced disease pathways, thereby elevating diagnostic accuracy and guiding treatment strategies. While these burgeoning technologies offer hope for more precise TBM diagnosis, hurdles remain in terms of their clinical implementation. Future endeavors should zero in on the validation of these tools through prospective studies, critically evaluating their limitations, and outlining protocols for seamless incorporation into established healthcare frameworks. Through this review, we aim to present an exhaustive snapshot of emerging diagnostic modalities in TBM, the current standing of machine learning in meningitis diagnostics, and the challenges and future prospects of converging these domains.
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Affiliation(s)
- Yi Shi
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
- The First School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Chengxi Zhang
- School of Materials Science and Engineering, Shandong Jianzhu University, Jinan, China
| | - Shuo Pan
- The First School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Yi Chen
- The First School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Xingguo Miao
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
- Department of Infectious Diseases, Wenzhou Sixth People’s Hospital, Wenzhou, China
- Wenzhou Key Laboratory of Diagnosis and Treatment of Emerging and Recurrent Infectious Diseases, Wenzhou, China
| | - Guoqiang He
- Postgraduate Training Base Alliance of Wenzhou Medical University, Wenzhou, China
- Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou, China
| | - Yanchan Wu
- School of Electrical and Information Engineering, Quzhou University, Quzhou, China
| | - Hui Ye
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
- Department of Infectious Diseases, Wenzhou Sixth People’s Hospital, Wenzhou, China
- Wenzhou Key Laboratory of Diagnosis and Treatment of Emerging and Recurrent Infectious Diseases, Wenzhou, China
| | - Chujun Weng
- The Fourth Affiliated Hospital Zhejiang University School of Medicine, Yiwu, China
| | - Huanhuan Zhang
- School and Hospital of Stomatology, Wenzhou Medical University, Wenzhou, China
| | - Wenya Zhou
- School and Hospital of Stomatology, Wenzhou Medical University, Wenzhou, China
| | - Xiaojie Yang
- Wenzhou Medical University Renji College, Wenzhou, China
| | - Chenglong Liang
- The First School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Dong Chen
- Wenzhou Key Laboratory of Diagnosis and Treatment of Emerging and Recurrent Infectious Diseases, Wenzhou, China
- Wenzhou Central Blood Station, Wenzhou, China
| | - Liang Hong
- Department of Infectious Diseases, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Feifei Su
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
- Department of Infectious Diseases, Wenzhou Sixth People’s Hospital, Wenzhou, China
- Wenzhou Key Laboratory of Diagnosis and Treatment of Emerging and Recurrent Infectious Diseases, Wenzhou, China
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11
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Xiang ZB, Leng EL, Cao WF, Liu SM, Zhou YL, Luo CQ, Hu F, Wen A. A systematic review and meta-analysis of the diagnostic accuracy of metagenomic next-generation sequencing for diagnosing tuberculous meningitis. Front Immunol 2023; 14:1223675. [PMID: 37822937 PMCID: PMC10562686 DOI: 10.3389/fimmu.2023.1223675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 09/05/2023] [Indexed: 10/13/2023] Open
Abstract
Objective The utility of metagenomic next-generation sequencing (mNGS) in the diagnosis of tuberculous meningitis (TBM) remains uncertain. We performed a meta-analysis to comprehensively evaluate its diagnostic accuracy for the early diagnosis of TBM. Methods English (PubMed, Medline, Web of Science, Cochrane Library, and Embase) and Chinese (CNKI, Wanfang, and CBM) databases were searched for relevant studies assessing the diagnostic accuracy of mNGS for TBM. Review Manager was used to evaluate the quality of the included studies, and Stata was used to perform the statistical analysis. Results Of 495 relevant articles retrieved, eight studies involving 693 participants (348 with and 345 without TBM) met the inclusion criteria and were included in the meta-analysis. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and area under the summary receiver-operating characteristic curve of mNGS for diagnosing TBM were 62% (95% confidence interval [CI]: 0.46-0.76), 99% (95% CI: 0.94-1.00), 139.08 (95% CI: 8.54-2266), 0.38 (95% CI: 0.25-0.58), 364.89 (95% CI: 18.39-7239), and 0.97 (95% CI: 0.95-0.98), respectively. Conclusions mNGS showed good specificity but moderate sensitivity; therefore, a more sensitive test should be developed to assist in the diagnosis of TBM.
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Affiliation(s)
- Zheng-Bing Xiang
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, Jiangxi, China
- Department of Neurology, Xiangya Hospital, Central South University, Jiangxi Hospital, National Regional Center for Neurological Diseases, Nanchang, Jiangxi, China
| | - Er-Ling Leng
- Department of Pediatrics, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, Jiangxi, China
| | - Wen-Feng Cao
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, Jiangxi, China
- Department of Neurology, Xiangya Hospital, Central South University, Jiangxi Hospital, National Regional Center for Neurological Diseases, Nanchang, Jiangxi, China
| | - Shi-Min Liu
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, Jiangxi, China
- Department of Neurology, Xiangya Hospital, Central South University, Jiangxi Hospital, National Regional Center for Neurological Diseases, Nanchang, Jiangxi, China
| | - Yong-Liang Zhou
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, Jiangxi, China
- Department of Neurology, Xiangya Hospital, Central South University, Jiangxi Hospital, National Regional Center for Neurological Diseases, Nanchang, Jiangxi, China
| | - Chao-Qun Luo
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, Jiangxi, China
- Department of Neurology, Xiangya Hospital, Central South University, Jiangxi Hospital, National Regional Center for Neurological Diseases, Nanchang, Jiangxi, China
| | - Fan Hu
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, Jiangxi, China
- Department of Neurology, Xiangya Hospital, Central South University, Jiangxi Hospital, National Regional Center for Neurological Diseases, Nanchang, Jiangxi, China
| | - An Wen
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, Jiangxi, China
- Department of Neurology, Xiangya Hospital, Central South University, Jiangxi Hospital, National Regional Center for Neurological Diseases, Nanchang, Jiangxi, China
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12
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Chen YL, Zhu MM, Guan CP, Zhang YA, Wang MS. Diagnostic value of the cerebrospinal fluid lipoarabinomannan assay for tuberculous meningitis: a systematic review and meta-analysis. Front Public Health 2023; 11:1228134. [PMID: 37808998 PMCID: PMC10552265 DOI: 10.3389/fpubh.2023.1228134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/16/2023] [Indexed: 10/10/2023] Open
Abstract
Objective This systematic review aims to evaluate the diagnostic accuracy of cerebrospinal fluid (CSF) lipoarabinomannan (LAM) assays in detecting tuberculous meningitis (TBM). Methods A systematic review search was conducted in PubMed and five other databases up to April 2023. Studies that evaluated the diagnostic accuracy of CSF LAM assays were included with either definitive or composite reference standard used as the preferred reference standard. The quality of the included studies was assessed using the QUADAS-2 tool. We performed a bivariate random-effects meta-analysis and calculated the summary diagnostic statistics. Results A total of six studies, including a sample size of 999, were included in the final analysis. The pooled sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) of CSF LAM for diagnosing TBM were determined to be 0.44 (95% CI: 0.31-0.58), 0.89 (95% CI: 0.81-0.93), and 0.76 (95% CI: 0.73-0.80), respectively. Significant heterogeneity was observed in both sensitivity (Q = 73.82, p < 0.01; I2 = 86.45, 95%CI: 79.64-93.27) and specificity (Q = 95.34, p < 0.01; I2 = 89.51, 95% CI: 84.61-94.42). Regression analysis indicated that the study design (retrospective vs. prospective) was associated with the heterogeneity of pooled sensitivity and specificity (all p < 0.05). Conclusion Although more prospective studies are required to validate the role of the CSF LAM assay, current evidence supports that the performance of the CSF LAM assay is unsatisfactory for the TBM diagnosis. Additionally, the optimization of the CSF LAM assay (e.g., improvements in CSF collection and preparation methods) should be considered to improve its performance.
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Affiliation(s)
- Ya-Li Chen
- Department of Lab Medicine, Shandong Public Health Clinical Center, Shandong University, Jinan, China
- Shandong Key Laboratory of Infectious Respiratory Disease, Jinan, China
| | - Meng-Meng Zhu
- Department of Lab Medicine, Shandong Public Health Clinical Center, Shandong University, Jinan, China
| | - Cui-Ping Guan
- Department of Lab Medicine, Shandong Public Health Clinical Center, Shandong University, Jinan, China
- Shandong Key Laboratory of Infectious Respiratory Disease, Jinan, China
| | - Yan-An Zhang
- Shandong Key Laboratory of Infectious Respiratory Disease, Jinan, China
- Department of Cardiovascular Surgery, Shandong Public Health Clinical Center, Shandong University, Jinan, China
| | - Mao-Shui Wang
- Department of Lab Medicine, Shandong Public Health Clinical Center, Shandong University, Jinan, China
- Shandong Key Laboratory of Infectious Respiratory Disease, Jinan, China
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13
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Cao WF, Leng EL, Liu SM, Zhou YL, Luo CQ, Xiang ZB, Cai W, Rao W, Hu F, Zhang P, Wen A. Recent advances in microbiological and molecular biological detection techniques of tuberculous meningitis. Front Microbiol 2023; 14:1202752. [PMID: 37700862 PMCID: PMC10494440 DOI: 10.3389/fmicb.2023.1202752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/21/2023] [Indexed: 09/14/2023] Open
Abstract
Tuberculous meningitis (TBM) is the most common type of central nervous system tuberculosis (TB) and has the highest mortality and disability rate. Early diagnosis is key to improving the prognosis and survival rate of patients. However, laboratory diagnosis of TBM is often difficult due to its paucibacillary nature and sub optimal sensitivity of conventional microbiology and molecular tools which often fails to detect the pathogen. The gold standard for TBM diagnosis is the presence of MTB in the CSF. The recognised methods for the identification of MTB are acid-fast bacilli (AFB) detected under CSF smear microscopy, MTB cultured in CSF, and MTB detected by polymerase chain reaction (PCR). Currently, many studies consider that all diagnostic techniques for TBM are not perfect, and no single technique is considered simple, fast, cheap, and efficient. A definite diagnosis of TBM is still difficult in current clinical practice. In this review, we summarise the current state of microbiological and molecular biological diagnostics for TBM, the latest advances in research, and discuss the advantages of these techniques, as well as the issues and challenges faced in terms of diagnostic effectiveness, laboratory infrastructure, testing costs, and clinical expertise, for clinicians to select appropriate testing methods.
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Affiliation(s)
- Wen-Feng Cao
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, Jiangxi, China
- Department of neurology, Xiangya Hospital, Central South University, Jiangxi Hospital, National Regional Center for Neurological Diseases, Nanchang, Jiangxi, China
| | - Er-Ling Leng
- Department of Pediatrics, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, Jiangxi, China
| | - Shi-Min Liu
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, Jiangxi, China
- Department of neurology, Xiangya Hospital, Central South University, Jiangxi Hospital, National Regional Center for Neurological Diseases, Nanchang, Jiangxi, China
| | - Yong-Liang Zhou
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, Jiangxi, China
- Department of neurology, Xiangya Hospital, Central South University, Jiangxi Hospital, National Regional Center for Neurological Diseases, Nanchang, Jiangxi, China
| | - Chao-Qun Luo
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, Jiangxi, China
- Department of neurology, Xiangya Hospital, Central South University, Jiangxi Hospital, National Regional Center for Neurological Diseases, Nanchang, Jiangxi, China
| | - Zheng-Bing Xiang
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, Jiangxi, China
- Department of neurology, Xiangya Hospital, Central South University, Jiangxi Hospital, National Regional Center for Neurological Diseases, Nanchang, Jiangxi, China
| | - Wen Cai
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, Jiangxi, China
- Department of neurology, Xiangya Hospital, Central South University, Jiangxi Hospital, National Regional Center for Neurological Diseases, Nanchang, Jiangxi, China
| | - Wei Rao
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, Jiangxi, China
- Department of neurology, Xiangya Hospital, Central South University, Jiangxi Hospital, National Regional Center for Neurological Diseases, Nanchang, Jiangxi, China
| | - Fan Hu
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, Jiangxi, China
- Department of neurology, Xiangya Hospital, Central South University, Jiangxi Hospital, National Regional Center for Neurological Diseases, Nanchang, Jiangxi, China
| | - Ping Zhang
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, Jiangxi, China
- Department of neurology, Xiangya Hospital, Central South University, Jiangxi Hospital, National Regional Center for Neurological Diseases, Nanchang, Jiangxi, China
| | - An Wen
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, Jiangxi, China
- Department of neurology, Xiangya Hospital, Central South University, Jiangxi Hospital, National Regional Center for Neurological Diseases, Nanchang, Jiangxi, China
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Weyori EW, Abubakari BB, Nkrumah B, Abdul-Karim A, Abiwu HAK, Kuugbee ED, Yidana A, Ziblim SD, Nuertey B, Weyori BA, Yakubu EB, Azure S, Koyiri VC, Adatsi RK. Predictive signs and symptoms of bacterial meningitis isolates in Northern Ghana. Sci Rep 2023; 13:13400. [PMID: 37591862 PMCID: PMC10435500 DOI: 10.1038/s41598-023-38253-z] [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: 12/30/2022] [Accepted: 07/05/2023] [Indexed: 08/19/2023] Open
Abstract
Cerebrospinal meningitis (CSM) is a public health burden in Ghana that causes up to 10% mortality in confirmed cases annually. About 20% of those who survive the infection suffer permanent sequelae. The study sought to understand the predictive signs and symptoms of bacterial meningitis implicated in its outcomes. Retrospective data from the Public Health Division, Ghana Health Service on bacterial meningitis from 2015 to 2019 was used for this study. A pre-tested data extraction form was used to collect patients' information from case-based forms kept at the Disease Control Unit from 2015 to 2019. Data were transcribed from the case-based forms into a pre-designed Microsoft Excel template. The data was cleaned and imported into SPSS version 26 for analysis. Between 2015 and 2019, a total of 2446 suspected bacterial meningitis cases were included in the study. Out of these, 842 (34.4%) were confirmed. Among the confirmed cases, males constituted majority with 55.3% of the cases. Children below 14 years of age were most affected (51.4%). The pathogens commonly responsible for bacterial meningitis were Neisseria meningitidis (43.7%) and Streptococcus pneumoniae (53.0%) with their respective strains Nm W135 (36.7%), Nm X (5.1%), Spn St. 1 (26.2%), and Spn St. 12F/12A/12B/44/4 (5.3%) accounting for more than 70.0% of the confirmed cases. The presence of neck stiffness (AOR = 1.244; C.I 1.026-1.508), convulsion (AOR = 1.338; C.I 1.083-1.652), altered consciousness (AOR = 1.516; C.I 1.225-1.876), and abdominal pains (AOR = 1.404; C.I 1.011-1.949) or any of these signs and symptoms poses a higher risk for testing positive for bacterial meningitis adjusting for age. Patients presenting one and/or more of these signs and symptoms (neck stiffness, convulsion, altered consciousness, and abdominal pain) have a higher risk of testing positive for bacterial meningitis after statistically adjusting for age.
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Affiliation(s)
| | | | | | - Abass Abdul-Karim
- Ghana Health Service, Northern Regional Health Directorate, Tamale, Ghana
| | | | | | | | | | | | | | - Etowi Boye Yakubu
- Ghana Health Service, Northern Regional Health Directorate, Tamale, Ghana
| | - Stebleson Azure
- Ghana Health Service, Northern Regional Health Directorate, Tamale, Ghana
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Dahiya B, Mehta N, Soni A, Mehta PK. Diagnosis of extrapulmonary tuberculosis by GeneXpert MTB/RIF Ultra assay. Expert Rev Mol Diagn 2023; 23:561-582. [PMID: 37318829 DOI: 10.1080/14737159.2023.2223980] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/06/2023] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Diagnosis of extrapulmonary tuberculosis (EPTB) is an arduous task owing to different anatomical locations, unusual clinical presentations, and sparse bacillary load in clinical specimens. Although GeneXpert® MTB/RIF is a windfall in TB diagnostics including EPTB, it yields low sensitivities but high specificities in many EPTB specimens. To further improve the sensitivity of GeneXpert®, GeneXpert® Ultra, a fully nested real-time PCR targeting IS6110, IS1081 and rpoB (Rv0664) has been endorsed by the WHO (2017), wherein melt curve analysis is utilized to detect rifampicin-resistance (RIF-R). AREA COVERED We described the assay chemistry/work design of Xpert Ultra and evaluated its performance in several EPTB types, that is, TB lymphadenitis, TB pleuritis, TB meningitis, and so on, against the microbiological reference standard or composite reference standard. Notably, Xpert Ultra exhibited better sensitivities than Xpert, but mostly at the compensation of specificity values. Moreover, Xpert Ultra exhibited low false-negative and false-positive RIF-R results, compared with Xpert. We also detailed other molecular tests, that is, Truenat MTBTM/TruPlus, commercial real-time PCR, line probe assay, and so on, for EPTB diagnosis. EXPERT OPINION A combination of clinical features, imaging, histopathological findings, and Xpert Ultra are adequate for definite EPTB diagnosis so as to initiate an early anti-tubercular therapy.
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Affiliation(s)
- Bhawna Dahiya
- Centre for Biotechnology, Maharshi Dayanand University, Rohtak, India
| | - Neeru Mehta
- Department of Medical Electronics, Ambedkar Delhi Skill & Entrepreneurship University, Shakarpur, New Delhi, India
| | - Aishwarya Soni
- Centre for Biotechnology, Maharshi Dayanand University, Rohtak, India
- Department of Biotechnology, Deenbandhu Chhotu Ram University of Science and Technology, Murthal, Sonipat, India
| | - Promod K Mehta
- Centre for Biotechnology, Maharshi Dayanand University, Rohtak, India
- Microbiology Department, Faculty of Allied Health Sciences, SGT University, Budhera, Gurgaon, India
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16
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Kadivarian S, Rostamian M, Kooti S, Abiri R, Alvandi A. Diagnostic accuracy of gold nanoparticle combined with molecular method for detection of Mycobacterium tuberculosis: A systematic review and meta-analysis study. SENSING AND BIO-SENSING RESEARCH 2023. [DOI: 10.1016/j.sbsr.2023.100559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
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17
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Deng L, Li Q, Hu W, Chen X, Chen T, Song S, Mo P, Zou S, Zhang Y, Gao S, Chen L, Zhuang K, Yang R, Xiong Y. Metagenomic next-generation sequencing versus traditional laboratory methods for the diagnosis of central nervous system opportunistic infections in HIV-infected Chinese adults. Sci Rep 2023; 13:4921. [PMID: 36966258 PMCID: PMC10039683 DOI: 10.1038/s41598-023-31974-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/20/2023] [Indexed: 03/27/2023] Open
Abstract
To evaluate clinical value of metagenomic next-generation sequencing (mNGS) in people living with HIV/AIDS (PLWHA) who had CNS disorders. Cerebrospinal fluid (CSF) samples from 48 PLWHA presenting with CNS disorders were sequenced using mNGS and compared with clinical conventional diagnostic methods. In total, 36/48 ss(75%) patients were diagnosed with pathogen(s) infection by mNGS, and the positive detection proportion by mNGS was higher than that by clinical conventional diagnostic methods (75% vs 52.1%, X2 = 5.441, P = 0.020). Thirteen out of 48 patients (27.1%) were detected with 3-7 pathogens by mNGS. Moreover, 77 pathogen strains were detected, of which 94.8% (73/77) by mNGS and 37.0% (30/77) by clinical conventional methods (X2 = 54.206, P < 0.001). The sensitivity and specificity of pathogens detection by mNGS were 63.9% (23/36) and 66.7% (8/12), respectively, which were superior to that by clinical conventional methods (23/36 vs 9/25, X2 = 4.601, P = 0.032; 8/12 vs 5/23, X2 = 5.029, P = 0.009). The application of mNGS was superior for its ability to detect a variety of unknown pathogens and multiple pathogens infection, and relatively higher sensitivity and specificity in diagnosis of CNS disorders in PLWHA.
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Affiliation(s)
- Liping Deng
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Qian Li
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Wenjia Hu
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Xiaoping Chen
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Tielong Chen
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Shihui Song
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Pingzheng Mo
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Shi Zou
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Yongxi Zhang
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Shicheng Gao
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Liangjun Chen
- Department of Laboratory Medicine, Zhongnan Hospital, Wuhan University, Wuhan, Hubei, China
| | - Ke Zhuang
- ABSL-III Laboratory at the Center for Animal Experiment, State Key Laboratory of Virology, Wuhan University, Wuhan, Hubei, China
| | - Rongrong Yang
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China.
| | - Yong Xiong
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China.
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18
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Garg D, Radhakrishnan DM, Agrawal U, Vanjare HA, Gandham EJ, Manesh A. Tuberculosis of the Spinal Cord. Ann Indian Acad Neurol 2023; 26:112-126. [PMID: 37179681 PMCID: PMC10171010 DOI: 10.4103/aian.aian_578_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/21/2022] [Accepted: 09/30/2022] [Indexed: 11/18/2022] Open
Abstract
Tuberculosis involving the spinal cord is associated with high mortality and disabling long-term sequelae. Although tuberculous radiculomyelitis is the most frequent complication, pleomorphic clinical manifestations exist. Diagnosis can be challenging among patients with isolated spinal cord tuberculosis due to diverse clinical and radiological presentations. The principles of management of tuberculosis of the spinal cord are primarily derived from, and dependent upon, trials on tuberculous meningitis (TBM). Although facilitating mycobacterial killing and controlling host inflammatory response within the nervous system remain the primary objectives, several unique features require attention. The paradoxical worsening is more frequent, often with devastating outcomes. The role of anti-inflammatory agents such as steroids in adhesive tuberculous radiculomyelitis remains unclear. Surgical interventions may benefit a small proportion of patients with spinal cord tuberculosis. Currently, the evidence base in the management of spinal cord tuberculosis is limited to uncontrolled small-scale data. Despite the gargantuan burden of tuberculosis, particularly in lower and middle-income countries, large-scale cohesive data are surprisingly sparse. In this review, we highlight the varied clinical and radiological presentations, performance of various diagnostic modalities, summarize data on the efficacy of treatment options, and propose a way forward to improve outcomes in these patients.
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Affiliation(s)
- Divyani Garg
- Department of Neurology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | | | - Umang Agrawal
- Department of Infectious Diseases, PD Hinduja Hospital and MRC, Mumbai, Maharashtra, India
| | | | | | - Abi Manesh
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
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19
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Krishnakumariamma K, Ellappan K, Muthuraj M, Tamilarasu K, Kumar SV, Joseph NM. Diagnostic performance of real time PCR for the detection of Mycobacterium tuberculosis in cerebrospinal fluid samples. Indian J Med Microbiol 2023; 42:7-11. [PMID: 36967219 DOI: 10.1016/j.ijmmb.2022.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 12/10/2022] [Accepted: 12/30/2022] [Indexed: 01/21/2023]
Abstract
PURPOSE We aimed this study to standardize real time - polymerase chain reaction (RT-PCR) for the detection of Mycobacterium tuberculosis (Mtb) in cerebrospinal fluid (CSF) samples and compare its diagnostic performance with GeneXpert (Xpert), Mycobacteria Growth Indicator Tube (MGIT) and Multiplex PCR (MPCR) for tuberculous meningitis (TBM). METHODOLOGY A total of 217 CSF samples were obtained from patients with suspected TBM during the study period between January 2019 and December 2021. The optimal cycle threshold (CT) of RT-PCR was determined by comparing different gene targets of Mtb (IS6110, 16SrRNA, HSP65 and Ag85B). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) was determined for RT-PCR, Xpert, MGIT960 and MPCR. Diagnostic accuracy of these assays was compared by using clinical diagnosis as reference standard. RESULTS IS6110RT-PCR was found to be highly sensitive as compared to other gene targets. Sensitivities of IS6110RT-PCR, MPCR, Xpert and MGIT against a reference standard of definite, probable and possible TBM were 36.7%, 21.1%, 16.7% and 6.7%, respectively; specificities were 97.6%, 100%, 100% and 100%, respectively. Xpert, RT-PCR, MPCR and MGIT960 detected 6.91% (n = 15), 5.99% (n = 13), 5.99% (n = 13) and 2.76% (n = 6) of definite TBM, respectively. RT-PCR detected 6.45% (n = 14) and 2.76% (n = 6) of possible TBM and probable TBM, respectively and MPCR detected 1.38% (n = 3) of possible and probable TBM each. CONCLUSION IS6110RT-PCR is highly sensitive for primary screening of suspected TB cases, which may help clinicians to start appropriate patient's treatment with clinical suspicion of TBM.
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20
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Lin K, Zhang HC, Zhang Y, Zhou Y, Fu ZF, Wang HY, Zhao YH, Qiu C, Fan MX, Song JY, Ai JW, Zhang WH. Clinical application and drug-use-guidance value of metagenomic next-generation sequencing in central nervous system infection. Am J Transl Res 2023; 15:47-62. [PMID: 36777850 PMCID: PMC9908477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/11/2022] [Indexed: 02/14/2023]
Abstract
OBJECTIVE Timely and precise etiology diagnosis is crucial for optimized medication regimens and better prognosis in central nervous system infections (CNS infections). We aimed to analyze the impact of mNGS tests on the management of patients with CNS infections. METHODS We conducted a single-center retrospective cohort study to analyze the value of mNGS in clinical applications. Three hundred sixty-nine patients with a CNS infection diagnosis were enrolled, and their clinical data were collected. CDI and DDI were defined in our study to describe the intensity of drug use in different groups. We used LOH and mRS to evaluate if the application of mNGS can benefit CNS infected patients. RESULTS mNGS reported a 91.67% sensitivity in culture-positive patients and an 88.24% specificity compared with the final diagnoses. Patients who participated with the mNGS test had less drug use, both total (58.77 vs. 81.18) and daily (22.6 vs. 28.12, P < 0.1, McNemar) intensity of drug use, and length of hospitalization (23.14 vs. 24.29). Patients with a consciousness grading 1 and 3 had a decrease in CDI (Grade 1, 86.49 vs. 173.37; Grade 3, 48.18 vs. 68.21), DDI (Grade 1, 1.52 vs. 2.72; Grade 3, 2.3 vs. 2.45), and LOH (Grade 1, 32 vs. 40; Grade 3, 21 vs. 23) with the application of mNGS. Patients infected with bacteria in the CNS had a reduced CDI, DDI, and LOH in the mNGS group. This was compared with the TraE group that had 49% of patients altered medication plans, and 24.7% of patients reduced drug intensity four days after mNGS reports. This was because of the reduction of drug types. CONCLUSION mNGS showed its high sensitivity and specificity characteristics. mNGS may assist clinicians with more rational medication regimens and reduce the drug intensity for patients. The primary way of achieving this is to reduce the variety of drugs, especially for severe patients and bacterial infections. mNGS has the ability of improving the prognosis of CNS infected patients.
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Affiliation(s)
- Ke Lin
- Department of Infectious Disease of Huashan Hospital, National Medical Center for Infectious Diseases and Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Fudan University Shanghai 200040, China
| | - Hao-Cheng Zhang
- Department of Infectious Disease of Huashan Hospital, National Medical Center for Infectious Diseases and Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Fudan University Shanghai 200040, China
| | - Yi Zhang
- Department of Infectious Disease of Huashan Hospital, National Medical Center for Infectious Diseases and Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Fudan University Shanghai 200040, China
| | - Yang Zhou
- Department of Infectious Disease of Huashan Hospital, National Medical Center for Infectious Diseases and Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Fudan University Shanghai 200040, China
| | - Zhang-Fan Fu
- Department of Infectious Disease of Huashan Hospital, National Medical Center for Infectious Diseases and Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Fudan University Shanghai 200040, China
| | - Hong-Yu Wang
- Department of Infectious Disease of Huashan Hospital, National Medical Center for Infectious Diseases and Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Fudan University Shanghai 200040, China
| | - Yuan-Han Zhao
- Department of Infectious Disease of Huashan Hospital, National Medical Center for Infectious Diseases and Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Fudan University Shanghai 200040, China
| | - Chao Qiu
- Department of Infectious Disease of Huashan Hospital, National Medical Center for Infectious Diseases and Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Fudan University Shanghai 200040, China.,Key Laboratory of Medical Molecular Virology (MOE/MOH) and Institutes of Biomedical Sciences, Shanghai Medical College, Fudan University Shanghai 200032, China
| | - Ming-Xiang Fan
- Department of Urology, Tongji Hospital, School of Medicine, Tongji University Shanghai 200065, China
| | - Jie-Yu Song
- Department of Infectious Disease of Huashan Hospital, National Medical Center for Infectious Diseases and Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Fudan University Shanghai 200040, China
| | - Jing-Wen Ai
- Department of Infectious Disease of Huashan Hospital, National Medical Center for Infectious Diseases and Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Fudan University Shanghai 200040, China
| | - Wen-Hong Zhang
- Department of Infectious Disease of Huashan Hospital, National Medical Center for Infectious Diseases and Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Fudan University Shanghai 200040, China.,Key Laboratory of Medical Molecular Virology (MOE/MOH) and Institutes of Biomedical Sciences, Shanghai Medical College, Fudan University Shanghai 200032, China.,State Key Laboratory of Genetic Engineering, School of Life Science, Fudan University Shanghai 200438, China.,National Clinical Research Centre for Aging & Medicine, Huashan Hospital, Fudan University Shanghai 200040, China
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21
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Simmons N, Olsen MA, Buss J, Bailey TC, Mejia-Chew C. Missed Opportunities in the Diagnosis of Tuberculosis Meningitis. Open Forum Infect Dis 2023; 10:ofad050. [PMID: 36861091 PMCID: PMC9969738 DOI: 10.1093/ofid/ofad050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/27/2023] [Indexed: 02/05/2023] Open
Abstract
Background Tuberculosis meningitis (TBM) has high mortality and morbidity. Diagnostic delays can impact TBM outcomes. We aimed to estimate the number of potentially missed opportunities (MOs) to diagnose TBM and determine its impact on 90-day mortality. Methods This is a retrospective cohort of adult patients with a central nervous system (CNS) TB International Classification of Diseases, Ninth/Tenth Revision (ICD-9/10) diagnosis code (013*, A17*) identified in the Healthcare Cost and Utilization Project, State Inpatient and State Emergency Department (ED) Databases from 8 states. Missed opportunity was defined as composite of ICD-9/10 diagnosis/procedure codes that included CNS signs/symptoms, systemic illness, or non-CNS TB diagnosis during a hospital/ED visit 180 days before the index TBM admission. Demographics, comorbidities, admission characteristics, mortality, and admission costs were compared between those with and without a MO, and 90-day in-hospital mortality, using univariate and multivariable analyses. Results Of 893 patients with TBM, median age at diagnosis was 50 years (interquartile range, 37-64), 61.3% were male, and 35.2% had Medicaid as primary payer. Overall, 407 (45.6%) had a prior hospital or ED visit with an MO code. In-hospital 90-day mortality was not different between those with and without an MO, regardless of the MO coded during an ED visit (13.7% vs 15.2%, P = .73) or a hospitalization (28.2% vs 30.9%, P = .74). Independent risk of 90-day in-hospital mortality was associated with older age, hyponatremia (relative risk [RR], 1.62; 95% confidence interval [CI], 1.1-2.4; P = .01), septicemia (RR, 1.6; 95% CI, 1.03-2.45; P = .03), and mechanical ventilation (RR, 3.4; 95% CI, 2.25-5.3; P < .001) during the index admission. Conclusions Approximately half the patients coded for TBM had a hospital or ED visit in the previous 6 months meeting the MO definition. We found no association between having an MO for TBM and 90-day in-hospital mortality.
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Affiliation(s)
- Niamh Simmons
- UCD School of Medicine, University College Dublin, Dublin, Ireland
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, Missouri, USA
| | - Margaret A Olsen
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, Missouri, USA
| | - Joanna Buss
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, Missouri, USA
| | - Thomas C Bailey
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, Missouri, USA
| | - Carlos Mejia-Chew
- Correspondence: Carlos Mejia-Chew, MD, Assistant Professor in Medicine, Infectious Disease, Washington University School of Medicine, 4523 Clayton Ave., Campus Box 8051, St. Louis, MO 63110-0193 (); Margaret Olsen, PhD, MPH, Professor of Medicine and Surgery, Infectious Disease, Washington University School of Medicine, 4523 Clayton Ave., Campus Box 8051, St. Louis, MO 63110-0193 ()
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22
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Nielsen MC, Clarner P, Paroha R, Lee S, Thwe PM, Ren P. Comparison of Analytical Sensitivity (Limit of Detection) of Xpert MTB/RIF and Xpert MTB/RIF Ultra for Non-Sputum Specimens. Pathogens 2023; 12:pathogens12020157. [PMID: 36839429 PMCID: PMC9962446 DOI: 10.3390/pathogens12020157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/15/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
Tuberculosis (TB) is a significant public health threat and has remained a leading cause of death in many parts of the world. Rapid and accurate testing and timely diagnosis can improve treatment efficacy and reduce new exposures. The Cepheid Xpert® MTB/RIF tests have two marketed products (US-IVD and Ultra) that are widely accepted for diagnosis of TB but have not yet been approved for non-sputum specimens. Despite numerous studies in the literature, no data for the analytical sensitivity of these two products on the non-sputum samples are available to date. This is the first study that systematically determined the analytical sensitivities of both US-IVD and Ultra tests on cerebrospinal fluid (CSF), tissue, and bronchoalveolar lavage (BAL). The limits of detection (LoDs) on the US-IVD test for both Mycobacterium tuberculosis and rifampin resistance in CFU/mL, respectively, were as follows: CSF (3.3 and 4.6), tissue (15 and 23), and bronchoalveolar lavage (BAL) (45 and 60), and on the Ultra test: CSF (0.16 and 2.7), tissue (0.11 and 12), and BAL (0.65, and 7.5). Overall, the analytical sensitivities of the Ultra test were substantially better than US-IVD for all sample types tested. This study provided a foundation for using either the US-IVD or Ultra test for the early detection of both pulmonary and extrapulmonary (EP) TB. Furthermore, using Ultra could result in higher TB case detection rates in subjects with paucibacillary TB and EP TB, positively impacting WHO goals to eradicate TB.
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Affiliation(s)
- Marisa C. Nielsen
- Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Paula Clarner
- Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Ruchi Paroha
- Department of Immunology and Microbiology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Sunhee Lee
- Department of Immunology and Microbiology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Phyu M. Thwe
- Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555, USA
- Department of Pathology, Infectious Disease Testing, Montefiore Medical Center, Bronx, NY 10467, USA
- Correspondence: (P.M.T.); (P.R.)
| | - Ping Ren
- Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555, USA
- Correspondence: (P.M.T.); (P.R.)
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23
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Gong X, He Y, Zhou K, Hua Y, Li Y. Efficacy of Xpert in tuberculosis diagnosis based on various specimens: a systematic review and meta-analysis. Front Cell Infect Microbiol 2023; 13:1149741. [PMID: 37201118 PMCID: PMC10185844 DOI: 10.3389/fcimb.2023.1149741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 04/18/2023] [Indexed: 05/20/2023] Open
Abstract
Objective The GeneXpert MTB/RIF assay (Xpert) is a diagnostic tool that has been shown to significantly improve the accuracy of tuberculosis (TB) detection in clinical settings, with advanced sensitivity and specificity. Early detection of TB can be challenging, but Xpert has improved the efficacy of the diagnostic process. Nevertheless, the accuracy of Xpert varies according to different diagnostic specimens and TB infection sites. Therefore, the selection of adequate specimens is critical when using Xpert to identify suspected TB. As such, we have conducted a meta-analysis to evaluate the effectiveness of Xpert for diagnosis of different TB types using several specimens. Methods We conducted a comprehensive search of several electronic databases, including PubMed, Embase, the Cochrane Central Register of Controlled Trials, and the World Health Organization clinical trials registry center, covering studies published from Jan 2008 to July 2022. Data were extracted using an adapted version of the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies. Where appropriate, meta-analysis was performed using random-effects models. The risk of bias and level of evidence was assessed using the Quality in Prognosis Studies tool and a modified version of the Grading of Recommendations Assessment, Development, and Evaluation. RStudio was utilized to analyze the results, employing the meta4diag, robvis, and metafor packages. Results After excluding duplicates, a total of 2163 studies were identified, and ultimately, 144 studies from 107 articles were included in the meta-analysis based on predetermined inclusion and exclusion criteria. Sensitivity, specificity and diagnostic accuracy were estimated for various specimens and TB types. In the case of pulmonary TB, Xpert using sputum (0.95 95%CI 0.91-0.98) and gastric juice (0.94 95%CI 0.84-0.99) demonstrated similarly high sensitivity, surpassing other specimen types. Additionally, Xpert exhibited high specificity for detecting TB across all specimen types. For bone and joint TB, Xpert, based on both biopsy and joint fluid specimens, demonstrated high accuracy in TB detection. Furthermore, Xpert effectively detected unclassified extrapulmonary TB and tuberculosis lymphadenitis. However, the Xpert accuracy was not satisfactory to distinguish TB meningitis, tuberculous pleuritis and unclassified TB. Conclusions Xpert has exhibited satisfactory diagnostic accuracy for most TB infections, but the efficacy of detection may vary depending on the specimens analyzed. Therefore, selecting appropriate specimens for Xpert analysis is essential, as using inadequate specimens can reduce the ability to distinguish TB. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=370111, identifier CRD42022370111.
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Affiliation(s)
| | | | | | - Yimin Hua
- *Correspondence: Yifei Li, ; Yimin Hua,
| | - Yifei Li
- *Correspondence: Yifei Li, ; Yimin Hua,
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24
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Silva GD, Guedes BF, Junqueira IR, Gomes HR, Vidal JE. Diagnostic and therapeutic approach to chronic meningitis in Brazil: a narrative review. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:1167-1177. [PMID: 36577417 PMCID: PMC9797267 DOI: 10.1055/s-0042-1758645] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Chronic meningitis (CM) is characterized by neurological symptoms associated with the evidence of cerebrospinal fluid pleocytosis lasting > 4 weeks. Studies on the management of CM in Brazil are scarce. OBJECTIVE To critically review the literature on CM and propose a rational approach in the Brazilian scenario. METHODS Narrative literature review discussing the epidemiology, clinical evaluation, basic and advanced diagnostic testing, and empirical and targeted therapy for the most relevant causes of CM. The present review was contextualized with the local experience of the authors. In addition, we propose an algorithm for the management of CM in Brazil. RESULTS In Brazil, tuberculosis and cryptococcosis are endemic and should always be considered in CM patients. In addition to these diseases, neurosyphilis and other endemic conditions should be included in the differential diagnosis, including neurocysticercosis, Baggio-Yoshinari syndrome, and endemic mycosis. After infectious etiologies, meningeal carcinomatosis and autoimmune diseases should be considered. Unbiased and targeted methods should be used based on availability and clinical and epidemiological data. CONCLUSION We propose a rational approach to CM in Brazil, considering the epidemiological scenario, systematizing the etiological investigation, and evaluating the timely use of empirical therapies.
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Affiliation(s)
- Guilherme Diogo Silva
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil.,Address for correspondence Guilherme Diogo Silva
| | - Bruno Fukelmann Guedes
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil.
| | - Ióri Rodrigues Junqueira
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil.
| | - Hélio Rodrigues Gomes
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil.
| | - José Ernesto Vidal
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Doenças Infecciosas, São Paulo SP, Brazil.,Instituto de Infectologia Emílio Ribas, Departamento de Neurologia, São Paulo SP, Brazil.
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25
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Wang C, Sun L, Li Q, Lu H. Xpert MTB/RIF Ultra in the auxiliary diagnosis of tuberculosis among people living with human immunodeficiency virus. Drug Discov Ther 2022; 16:305-308. [PMID: 36529510 DOI: 10.5582/ddt.2022.01082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Clinical diagnosis of tuberculosis (TB) in people living with the human immunodeficiency virus (HIV) poses a challenge. The Xpert MTB/RIF Ultra (Ultra) has displayed greater sensitivity at diagnosing tuberculosis and rifampicin resistance compared to the Xpert MTB/RIF (Xpert). However, whether Ultra is able to facilitate an auxiliary diagnosis of TB in patients with an HIV-TB co-infection remains unclear. Accordingly, the current study evaluated the use of Ultra in patients with an HIV-TB co-infection by summarizing relevant studies. The sensitivity and specificity of Ultra and Xpert at diagnosing patients with an HIV-TB co-infection have been summarized and compared. The performance of Ultra in diagnosing extrapulmonary tuberculosis was also summarized. Although a large-cohort, multi-center study needs to be conducted to assess Ultra's ability to detect TB in AIDS patients in the future, the current evidence supports the use of Ultra for the assessment of patients with an HIV-TB co-infection.
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Affiliation(s)
- Cheng Wang
- National Clinical Research Centre for Infectious Diseases, The Third People's Hospital of Shenzhen and The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China.,School of Public Health, Bengbu Medical College, Bengbu, Anhui, China
| | - Liqin Sun
- National Clinical Research Centre for Infectious Diseases, The Third People's Hospital of Shenzhen and The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Qian Li
- National Clinical Research Centre for Infectious Diseases, The Third People's Hospital of Shenzhen and The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Hongzhou Lu
- National Clinical Research Centre for Infectious Diseases, The Third People's Hospital of Shenzhen and The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
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26
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de Almeida SM, Kussen GB, Cogo LL, Nogueira K. Cerebrospinal fluid lactate as a predictive biomarker for tuberculous meningitis diagnosis. Diagnosis (Berl) 2022; 10:130-139. [PMID: 36476307 DOI: 10.1515/dx-2022-0102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022]
Abstract
Abstract
Objectives
The definitive diagnosis of tuberculous meningitis (TBM) is achieved by identifying Mycobacterium tuberculosis (MTb) in cerebrospinal fluid (CSF); however, diagnostic confirmation is difficult due to the inability of current tests for an effective diagnosis. Our objective was to retrospectively assess the characteristics of CSF lactate (CSF-LA) as an adjunct biomarker in the diagnosis of TBM.
Methods
608 CSF laboratory reports were assessed. Of these, 560 had clinically suspected TBM. These were classified as definite (n=36), probable (23), possible (278), or non-TBM (223) according to the international consensus TBM case definitions. An additional 48 CSF samples were negative controls with normal CSF.
Results
Against a reference standard of definite TBM, the cut-off value for CSF-LA was 4.0 mmol/L, the area under the ROC curve was 0.88 (95% CI, 0.82–0.94; p=0.0001), sensitivity was 69%, specificity 90%, negative predictive value 98%. These diagnostic parameters decreased when calculated against those of the other categories of TBM. CSF-LA exhibited high specificity, efficiency, negative predictive value, and clinical utility index in all the groups studied.
Conclusions
CSF-LA is a useful diagnostic marker to rule out TBM when associated with conventional microbiology tests, nucleic acid amplification assays, and clinical algorithms, particularly in endemic areas.
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Affiliation(s)
- Sérgio Monteiro de Almeida
- Virology Section Clinical Pathology Laboratory Hospital De Clínicas , Federal University of Paraná , Curitiba , Brazil
- CSF Section Clinical Pathology Laboratory Hospital De Clínicas , Federal University of Paraná , Curitiba , Brazil
| | - Gislene B. Kussen
- Bacteriology Section, Clinical Pathology Laboratory, Hospital De Clínicas , Federal University of Paraná , Curitiba , Brazil
| | - Laura L. Cogo
- Bacteriology Section, Clinical Pathology Laboratory, Hospital De Clínicas , Federal University of Paraná , Curitiba , Brazil
| | - Keite Nogueira
- Bacteriology Section, Clinical Pathology Laboratory, Hospital De Clínicas , Federal University of Paraná , Curitiba , Brazil
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27
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Yu L, Zhang Y, Zhou J, Zhang Y, Qi X, Bai K, Lou Z, Li Y, Xia H, Bu H. Metagenomic next-generation sequencing of cell-free and whole-cell DNA in diagnosing central nervous system infections. Front Cell Infect Microbiol 2022; 12:951703. [PMID: 36237422 PMCID: PMC9551220 DOI: 10.3389/fcimb.2022.951703] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/29/2022] [Indexed: 11/30/2022] Open
Abstract
Background Central nervous system (CNS) infections pose a fatal risk to patients. However, the limited sample volumes of cerebrospinal fluid (CSF) and low detection efficiency seriously hinder the accurate detection of pathogens using conventional methods. Methods We evaluated the performance of metagenomics next-generation sequencing (mNGS) in diagnosing CNS infections. CSF samples from 390 patients clinically diagnosed with CNS infections were used for the mNGS of cell-free DNA (cfDNA) (n =394) and whole-cell DNA (wcDNA) (n =150). Results The sensitivity of mNGS using cfDNA was 60.2% (237/394, 95% confidence interval [CI] 55.1%–65.0%), higher than that of mNGS using wcDNA (32.0%, 95% [CI] 24.8%–40.2%, 48/150) and conventional methods (20.9%, 95% [CI] 16.2%–26.5%, 54/258) (P < 0.01, respectively). The accuracy of mNGS using cfDNA in positive samples was 82.6%. Most of viral (72.6%) and mycobacterial (68.8%) pathogens were only detected by the mNGS of cfDNA. Meningitis and encephalitis with Streptococcus pneumoniae infection might be more likely to result in critically ill diseases, while Human alphaherpesvirus 3 was prone to cause non-critically ill diseases. Conclusions This is the first report on evaluating and emphasizing the importance of mNGS using CSF cfDNA in diagnosing CNS infections, and its extensive application in diagnosing CNS infections could be expected, especially for viral and mycobacterial CNS infections.
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Affiliation(s)
- Lili Yu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ye Zhang
- Department of Scientific Affairs, Hugobiotech Co., Ltd., Beijing, China
| | - Jiemin Zhou
- Department of Scientific Affairs, Hugobiotech Co., Ltd., Beijing, China
| | - Yu Zhang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xuejiao Qi
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Kaixuan Bai
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zheng Lou
- Department of Scientific Affairs, Hugobiotech Co., Ltd., Beijing, China
| | - Yi Li
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Han Xia
- Department of Scientific Affairs, Hugobiotech Co., Ltd., Beijing, China
- *Correspondence: Hui Bu, ; Han Xia,
| | - Hui Bu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
- *Correspondence: Hui Bu, ; Han Xia,
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28
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Aguilera-Alonso D, Solís-García G, Noguera-Julian A, González-Martín J, Román Cobeña A, Baquero-Artigao F, Toro Rueda C, Rodríguez-Molino P, Bloise Sánchez I, Vallmanya T, Bernet-Sánchez A, Minguell Domingo L, Rubio A, Saavedra-Lozano J, Ruiz-Serrano MJ, Blázquez-Gamero D, López-Roa P, Gomez-Pastrana D, López Prieto MD, López Medina EM, Gil-Brusola A, Martín Nalda A, Soriano-Arandes A, Tórtola T, Falcon-Neyra L, González Galán V, Tebruegge M, Santiago-García B. Accuracy of Xpert Ultra for the diagnosis of paediatric tuberculosis in a low TB burden country: a prospective multicentre study. Thorax 2022; 77:1023-1029. [PMID: 36357344 DOI: 10.1136/thorax-2021-218378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 07/28/2022] [Indexed: 11/04/2022]
Abstract
IntroductionChildhood pulmonary tuberculosis (TB) remains a diagnostic challenge. This study aimed to evaluate the performance of Xpert Ultra for the diagnosis of pulmonary TB in children in a low TB prevalence setting.MethodsProspective, multicentre, diagnostic accuracy study. Children with clinical or radiological suspicion of pulmonary TB were recruited at 11 paediatric units in Spain. Up to three gastric or sputum specimens were taken on 3 consecutive days, and analysed by Xpert MTB/RIF, Xpert Ultra and culture in parallel.Results86 children were included (median age 4.9 years, IQR 2.0–10.0; 51.2% male). The final diagnosis was pulmonary TB in 75 patients (87.2%); 33 (44.0%) were microbiologically confirmed. A total of 219 specimens, comprising gastric aspirates (n=194; 88.6%) and sputum specimens (n=25; 11.4%), were analysed. Using culture as reference standard and comparing individual specimens, the sensitivity was 37.8% (14/37) for Xpert MTB/RIF and 81.1% (30/37) for Xpert Ultra (p<0.001); specificity was 98.4% (179/182) and 93.4% (170/182), respectively (p=0.02). In the per-patient analysis, considering positive results on any specimen, the sensitivity was 42.9% (9/21) for Xpert MTB/RIF and 81.0% for Xpert Ultra (17/21, p=0.01); specificity was 96.9% (63/65) and 87.7% (57/65, p=0.07), respectively.ConclusionsIn children with pulmonary TB in a low burden setting, Xpert Ultra has significantly higher sensitivity than the previous generation of Xpert assay and only marginally lower specificity. Therefore, in children undergoing evaluation for suspected pulmonary TB, Xpert Ultra should be used in preference to Xpert MTB/RIF whenever possible.
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Nandlal L, Perumal R, Naidoo K. Rapid Molecular Assays for the Diagnosis of Drug-Resistant Tuberculosis. Infect Drug Resist 2022; 15:4971-4984. [PMID: 36060232 PMCID: PMC9438776 DOI: 10.2147/idr.s381643] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/20/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Louansha Nandlal
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), South African Medical Research Council (SAMRC)-CAPRISA-TB-HIV Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
| | - Rubeshan Perumal
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), South African Medical Research Council (SAMRC)-CAPRISA-TB-HIV Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
- Correspondence: Rubeshan Perumal, Centre for the AIDS Programme of Research in South Africa (CAPRISA), South African Medical Research Council (SAMRC)-CAPRISA-TB-HIV Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa, Email
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), South African Medical Research Council (SAMRC)-CAPRISA-TB-HIV Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
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Xpert MTB/RIF Ultra outperformed the Xpert assay in tuberculosis lymphadenitis diagnosis: a prospective head-to-head cohort study. Int J Infect Dis 2022; 122:741-746. [PMID: 35872095 DOI: 10.1016/j.ijid.2022.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Xpert MTB/RIF Ultra (Xpert-Ultra) has shown better sensitivity in comparison with Xpert MTB/RIF (Xpert) in extra-pulmonary tuberculosis, while the head-to-head comparison of these methods in tuberculosis lymphadenitis had barely been performed. METHODS Patients with undiagnosed lymphadenopathy were recruited prospectively and consecutively, and fine-needle aspirates biopsy (FNA) or lymph node tissue was collected. The specimen was subjected to smear, culture, Xpert and Xpert-Ultra assays. Culture and/or smear for AFB or AFB observed on histopathology were performed as a reference. RESULTS 106 participants were recruited, including 41 confirmed TB, 33 probableTB and 32 non-TB lymphadenopathy. The head-to-head comparison for Mtb detection showed that Xpert-Ultra produced the highest sensitivity when compared with smear, culture and Xpert (75.7% vs. 5.4 %, 13.5% and 48.7%).When Xpert-Ultra outcomes were integrated for diagnosis, the percentage of confirmed TB lymphadenitis case increased from 55.4% (41/74) to 85.1% (63/74). The sensitivities of Xpert-Ultra and Xpert on tissue were 73.6% (95%CI,59.4-84.3) and 39.6% (95%CI,26.8-54.0), respectively. The sensitiviyt of Xpert-Ultra on FNA samples (81.0%,95%CI 57.4-93.7) was higher than that of Xpert (71.4%,95% CI 47.7-87.8). CONCLUSIONS Xpert-Ultra detected significantly more TB lymphadenitis cases than Xpert or culture. This superiority was particularly distinct using lymph node tissue than FNA detection.
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Kaswala C, Schmiedel Y, Kundu D, George MM, Dayanand D, Devasagayam E, S AM, Kumar SS, Michael JS, Ninan MM, Chacko G, Zachariah A, Sathyendra S, Hansdak SG, Iyadurai R, Christopher DJ, Gupta R, Karthik R, Abraham OC, Varghese GM. Accuracy of Xpert MTB/RIF Ultra for the diagnosis of tuberculosis in adult patients: a retrospective cohort study. Int J Infect Dis 2022; 122:566-568. [PMID: 35811084 DOI: 10.1016/j.ijid.2022.07.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/04/2022] [Accepted: 07/04/2022] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVES The value of the "trace" result in Xpert Ultra for diagnosing active tuberculosis (TB) remains unclear. Our study evaluated the diagnostic accuracy of Xpert MTB/RIF Ultra (Xpert Ultra) (Cepheid, Sunnyvale, USA) over Xpert MTB/RIF (Xpert) (Cepheid, Sunnyvale, USA) and mycobacterial culture when compared with a composite reference standard (CRS). METHODS A retrospective single-center observational study was conducted in a tertiary care hospital in South India. Over three months, patients (aged ≥15 years) data on Xpert Ultra tests and mycobacterial culture of pulmonary and extrapulmonary samples were extracted from their electronic medical records. Patients were defined as TB cases based on the CRS criteria. Sensitivity, specificity, positive and negative predictive values of diagnostic tests were calculated by comparing them to the CRS. RESULTS Xpert Ultra was more sensitive (87.8%) than Xpert (72.1%) and culture (44.1%). The specificity of Xpert Ultra was lower (98.1%) than those of Xpert (100%) and culture (100%). The sensitivity (92%) and specificity (100%) of Xpert Ultra were highest when performed on pus samples. CONCLUSIONS Xpert Ultra with the trace category is superior to the conventional Xpert, and mycobacterial culture in identifying TB.
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Affiliation(s)
- Chintan Kaswala
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | - Yvonne Schmiedel
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | - Debasree Kundu
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | - Mithun Mohan George
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | - Divya Dayanand
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | - Emily Devasagayam
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | - Abi Manesh S
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | - Selwyn Selva Kumar
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | - Joy S Michael
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Marilyn M Ninan
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Geeta Chacko
- Department of Pathology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anand Zachariah
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sowmya Sathyendra
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Ramya Iyadurai
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Richa Gupta
- Department of Respiratory Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Rajiv Karthik
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - George M Varghese
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India.
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Diagnostic and Prognostic Value of Cerebrospinal Fluid Lactate and Glucose in HIV-Associated Tuberculosis Meningitis. Microbiol Spectr 2022; 10:e0161822. [PMID: 35727068 PMCID: PMC9430741 DOI: 10.1128/spectrum.01618-22] [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] [Indexed: 11/20/2022] Open
Abstract
The role of cerebrospinal fluid (CSF) lactate in tuberculosis meningitis (TBM) diagnosis and prognosis is unclear. The aim of this study was to evaluate the performance of CSF lactate alone and in combination with CSF glucose in predicting a diagnosis of TBM and 14-day survival. HIV-positive Ugandan adults were investigated for suspected meningitis. The baseline CSF tests included smear microscopy; Gram stain; cell count; protein; and point-of-care glucose, lactate, and cryptococcal antigen (CrAg) assays. Where CrAg was negative or there was suspicion of TBM, a CSF Xpert MTB/RIF Ultra (Xpert Ultra) test was performed. We recorded baseline demographic and clinical data and 2-week outcomes. Of 667 patients, 25% (n = 166) had TBM, and of these, 49 had definite, 47 probable, and 70 possible TBM. CSF lactate was higher in patients with definite TBM (8.0 mmol/L; interquartile ratio [IQR], 6.1 to 9.8 mmol/L) than in those with probable TBM (3.4 [IQR, 2.5 to 7.0] mmol/L), possible TBM (2.6 [IQR 2.1 to 3.8] mmol/L), and non-TBM disease (3.5 [IQR 2.5 to 5.0] mmol/L). A 2-fold increase in CSF lactate was associated with 8-fold increased odds of definite TBM (odds ratio, 8.3; 95% confidence interval [CI], 3.6 to 19.1; P < 0.01) and 2-fold increased odds of definite/probable TBM (odds ratio, 2.3; 95% CI, 1.4 to 3.7; P < 0.001). At a cut point of >5.5 mmol/L, CSF lactate could be used to diagnose definite TBM with a sensitivity of 87.7%, specificity of 80.7%, and a negative predictive value of 98.8%. CSF lactate was not predictive of 2-week mortality. IMPORTANCE Tuberculosis meningitis (TBM) is the most severe form of tuberculosis, and its fatality is largely due to delays in diagnosis. The role of CSF lactate has not been evaluated in patients with HIV presenting with signs and symptoms of meningitis. In this study, using a point-of-care handheld lactate machine in patients with HIV-associated meningitis, we showed that high baseline CSF lactate (>5.5 mmol) may be used to rapidly identify patients with TBM and shorten the time to initiate treatment with a similar performance to the Xpert Ultra assay for definite TBM. Elevated CSF lactate levels, however, were not associated with increased 2-week mortality in patients with HIV-associated TBM. Due to moderate specificity, other etiologies of meningitis should be investigated.
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Kamra E, Alam D, Singh V, Kumar M, Chauhan M, Mehta PK. Diagnosis of urogenital tuberculosis by multiplex-nested PCR targeting mpt64 (Rv1980c) and IS6110: comparison with multiplex PCR and GeneXpert® MTB/RIF. Lett Appl Microbiol 2022; 75:857-868. [PMID: 35673975 DOI: 10.1111/lam.13758] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 05/23/2022] [Accepted: 06/01/2022] [Indexed: 11/29/2022]
Abstract
A multiplex-nested PCR (M-nested PCR) targeting mpt64 (Rv1980c) + IS6110 was designed to detect Mycobacterium tuberculosis (Mtb) DNA within urine (n = 35), endometrial biopsies (n = 22) and menstrual blood (n = 3) of male/female UGTB patients, and results were compared with M-PCR using the same targets. Detection limit of the purified Mtb DNA was found to be 1 fg by M-nested PCR, which was 106 -fold lower than M-PCR. Moreover, sensitivities of 100% and 81·8% were obtained in confirmed (n = 5) and clinically suspected UGTB (n = 55) cases, respectively, by M-nested PCR, with a specificity of 97·1% (n = 70). Sensitivities attained by M-nested PCR were significantly higher (p < 0·05) than M-PCR in both clinically suspected and total UGTB (n = 60) cases. To confirm the true PCR-negative results, an internal amplification control, that is, human β-globin gene (hbb) was incorporated in the M-nested PCR/M-PCR assays, wherein all the clinical specimens (positive/negative for mpt64/IS6110) were found to be positive for hbb. Some UGTB specimens (n = 35) were also subjected to GeneXpert® MTB/RIF assay that revealed a significantly lower (p < 0·001) sensitivity (17·1 vs 88·6%) than M-nested PCR, although high specificity (100%) was attained with GeneXpert. After validating the results in a higher number of UGTB specimens, our M-nested PCR may be translated into an attractive diagnostic kit.
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Affiliation(s)
- E Kamra
- Centre for Biotechnology, Maharshi Dayanand University, Rohtak, India
| | - D Alam
- Centre for Biotechnology, Maharshi Dayanand University, Rohtak, India
| | - V Singh
- Department of Geriatric Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - M Kumar
- Department of Urology, Pandit Bhagwat Dayal Sharma University of Health Sciences (UHS), Rohtak, India
| | - M Chauhan
- Department of Obstetrics and Gynaecology, UHS, Rohtak, India
| | - P K Mehta
- Centre for Biotechnology, Maharshi Dayanand University, Rohtak, India
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Rindi L. Rapid Molecular Diagnosis of Extra-Pulmonary Tuberculosis by Xpert/RIF Ultra. Front Microbiol 2022; 13:817661. [PMID: 35633667 PMCID: PMC9130774 DOI: 10.3389/fmicb.2022.817661] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 04/11/2022] [Indexed: 11/29/2022] Open
Abstract
Rapid detection of Mycobacterium tuberculosis complex and determination of drug resistance are essential for early diagnosis and treatment of tuberculosis (TB). Xpert MTB/RIF Ultra (Xpert Ultra), a molecular test that can simultaneously identify M. tuberculosis complex and resistance to rifampicin directly on clinical samples, is currently used. Xpert Ultra represents a helpful tool for rapid pulmonary TB diagnosis, especially in patients with paucibacillary infection. The aim of this review is to provide an overview of the diagnostic performance of Xpert Ultra in detection of extra-pulmonary tuberculosis.
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Affiliation(s)
- Laura Rindi
- Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in Medicina e Chirurgia, Università di Pisa, Pisa, Italy
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Sharma V, Singh A, Gaur M, Rawat D, Yadav A, Rajan, Kumar C, Varma-Basil M, Lohiya S, Khanna V, Khanna A, Chaudhry A, Singh Y, Misra R. Evaluating the efficacy of stool sample on Xpert MTB/RIF Ultra and its comparison with other sample types by meta-analysis for TB diagnostics. Eur J Clin Microbiol Infect Dis 2022; 41:893-906. [PMID: 35508741 DOI: 10.1007/s10096-022-04449-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/19/2022] [Indexed: 11/03/2022]
Abstract
Precise and timely detection of tuberculosis (TB) is crucial to reduce transmission. This study aims to assess the accuracy of Xpert MTB/RIF Ultra on stool samples and systematically review the performance of Xpert MTB/RIF Ultra with different sample types by meta-analysis. Stool samples of smear-negative pulmonary TB (PTB), cervical lymph node TB, and abdominal TB patients were tested on the Xpert MTB/RIF Ultra system. Meta-analysis was performed on a set of 44 studies. Data were grouped by sample type, and the pooled sensitivity and specificity of Xpert MTB/RIF Ultra were calculated. The sensitivity of Xpert MTB/RIF Ultra with stool samples was 100% for smear-negative PTB, 27.27% for cervical lymph node TB, and 50% for abdominal TB patients, with 100% specificity for all included TB groups. The summary estimate for all PTB samples showed 84.2% sensitivity and 94.5% specificity, and EPTB samples showed 88.6% sensitivity and 96.4% specificity. Among all sample types included in our meta-analysis, urine showed the best performance for EPTB diagnosis. This pilot study supports the use of stool as an alternative non-invasive sample on Xpert MTB/RIF Ultra for rapid testing, suitable for both PTB and EPTB diagnosis.
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Affiliation(s)
- Vishal Sharma
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Anoop Singh
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Mohita Gaur
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Deepti Rawat
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Anjali Yadav
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Rajan
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Chanchal Kumar
- Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, 110007, India
| | - Mandira Varma-Basil
- Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, 110007, India
| | - Sheelu Lohiya
- Chest Clinic, Lok Nayak Hospital, Delhi, 110002, India
| | - Vishal Khanna
- Chest Clinic, Lok Nayak Hospital, Delhi, 110002, India
| | - Ashwani Khanna
- State TB Officer & In-Charge, Chest Clinic, Lok Nayak Hospital, Delhi, 110002, India
| | - Anil Chaudhry
- Rajan Babu Institute of Pulmonary Medicine and Tuberculosis, Kingsway Camp, Delhi, 110009, India
| | - Yogendra Singh
- Department of Zoology, University of Delhi, Delhi, 110007, India.
| | - Richa Misra
- Department of Zoology, University of Delhi, Delhi, 110007, India. .,Department of Zoology, Sri Venkateswara College, University of Delhi, Delhi, 110021, India.
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Ssebambulidde K, Gakuru J, Ellis J, Cresswell FV, Bahr NC. Improving Technology to Diagnose Tuberculous Meningitis: Are We There Yet? Front Neurol 2022; 13:892224. [PMID: 35711276 PMCID: PMC9195574 DOI: 10.3389/fneur.2022.892224] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/22/2022] [Indexed: 11/23/2022] Open
Abstract
Diagnosis of tuberculous meningitis (TBM) remains challenging due to a paucity of high-performance diagnostics. Even those that have reasonable sensitivity are not adequate to 'rule out' TBM. Therefore, a combination of clinical factors alongside microbiological, molecular, and radiological investigations are utilized, depending on availability. A low threshold for starting empiric therapy in the appropriate clinical scenario remains crucial for good outcomes in many cases. Herein, we review the current TBM diagnostics landscape with a focus on limitations frequently encountered, such as diagnostic test performance, cost, laboratory infrastructure, and clinical expertise. Though molecular technologies, particularly GeneXpert MTB/Rif Ultra, have been a step forward, diagnosis of TBM remains difficult. We also provide an overview of promising technologies, such as cerebrospinal fluid (CSF) lactate, a new lipoarabinomannan test (FujiLAM), metagenomic next-generation sequencing, and transcriptomics that may further improve our TBM diagnostic capacity and lead to better outcomes.
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Affiliation(s)
- Kenneth Ssebambulidde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jane Gakuru
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jayne Ellis
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Fiona V. Cresswell
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Global Health and Infection, Brighton and Sussex Medicine School, Brighton, United Kingdom
| | - Nathan C. Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, KS, United States
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Manyelo CM, Solomons RS, Snyders CI, Kidd M, Kooblal Y, Leukes VN, Claassen C, Roos K, Stanley K, Walzl G, Chegou NN. Validation of host cerebrospinal fluid protein biomarkers for early diagnosis of tuberculous meningitis in children: a replication and new biosignature discovery study. Biomarkers 2022; 27:549-561. [PMID: 35506251 DOI: 10.1080/1354750x.2022.2071991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The diagnosis of tuberculous meningitis (TBM) in children is often delayed due to diagnostic difficulties. New tools are urgently needed to improve the diagnosis of the disease in this vulnerable group. The present study aimed to validate the accuracy of recently identified host cerebrospinal (CSF) biomarkers as candidates for the diagnosis of TBM in children. We collected CSF samples from 87 children aged 3 months to 13 years, that were consecutively admitted at a tertiary hospital in Cape Town, South Africa, on suspicion of having TBM. We evaluated the concentrations of 67 selected host protein biomarkers using a multiplex platform. Previously identified 3-marker (VEGF-A + IFN-γ + MPO) and 4-marker (IFN-γ + MPO + ICAM-1 + IL-8) signatures diagnosed TBM with AUCs of 0.89 (95% CI, 0.81-0.97) and 0.87 (95% CI, 0.79-0.95) respectively; sensitivities of 80.6% (95% CI, 62.5-92.5%) and 81.6% (95% CI, 65.7-92.3%), and specificities of 86.8% (71.9-95.6%) and 83.7% (70.4-92.7%) respectively. Furthermore, a new combination between the analytes (CC4b + CC4 + procalcitonin + CCL1) showed promise, with an AUC of 0.98 (95% CI, 0.94-1.00). We have shown that the accuracies of previously identified candidate CSF biomarkers for childhood TBM was reproducible. Our findings augur well for the future development of a simple bedside test for the rapid diagnosis of TBM in children.
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Affiliation(s)
- Charles M Manyelo
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research; South African Medical Research Council Centre for Tuberculosis Research; Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Regan S Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Candice I Snyders
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research; South African Medical Research Council Centre for Tuberculosis Research; Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Martin Kidd
- Department of Statistics and Actuarial Sciences, Centre for Statistical Consultation, Stellenbosch University, Cape Town, South Africa
| | - Yajna Kooblal
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Vinzeigh N Leukes
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research; South African Medical Research Council Centre for Tuberculosis Research; Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Conita Claassen
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research; South African Medical Research Council Centre for Tuberculosis Research; Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kelly Roos
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research; South African Medical Research Council Centre for Tuberculosis Research; Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kim Stanley
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research; South African Medical Research Council Centre for Tuberculosis Research; Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gerhard Walzl
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research; South African Medical Research Council Centre for Tuberculosis Research; Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Novel N Chegou
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research; South African Medical Research Council Centre for Tuberculosis Research; Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Huynh J, Donovan J, Phu NH, Nghia HDT, Thuong NTT, Thwaites GE. Tuberculous meningitis: progress and remaining questions. Lancet Neurol 2022; 21:450-464. [PMID: 35429482 DOI: 10.1016/s1474-4422(21)00435-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 10/03/2021] [Accepted: 11/25/2021] [Indexed: 12/23/2022]
Abstract
Tuberculous meningitis is a devastating brain infection that is caused by Mycobacterium tuberculosis and is notoriously difficult to diagnose and treat. New technologies characterising the transcriptome, proteome, and metabolome have identified new molecules and pathways associated with tuberculous meningitis severity and poor outcomes that could offer novel diagnostic and therapeutic targets. The next-generation GeneXpert MTB/RIF Ultra assay, when used on CSF, offers diagnostic sensitivity for tuberculous meningitis of approximately 70%, although it is not widely available and a negative result cannot rule out tuberculous meningitis. Small trials indicate that clinical outcomes might be improved with increased doses of rifampicin, the addition of linezolid or fluoroquinolones to standard antituberculosis therapy, or treatment with adjunctive aspirin combined with corticosteroids. Large phase 3 clinical trials are underway worldwide to address these and other questions concerning the optimal management of tuberculous meningitis; these studies also form a platform for studying pathogenesis and identifying novel diagnostic and treatment strategies, by allowing the implementation of new genomic, transcriptomic, proteomic, and metabolomic technologies in nested substudies.
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Affiliation(s)
- Julie Huynh
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK; Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Joseph Donovan
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK; Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Nguyen Hoan Phu
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK; Vietnam National University School of Medicine, Ho Chi Minh City, Vietnam
| | - Ho Dang Trung Nghia
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Nguyen Thuy Thuong Thuong
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK; Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Guy E Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK; Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam.
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Wake RM, Govender NP, Omar SV, Ismail F, Tiemessen CT, Harrison TS, Jarvis JN. Rapid urine-based screening tests increase the yield of same-day tuberculosis diagnoses among patients living with advanced HIV disease. AIDS 2022; 36:839-844. [PMID: 35075041 DOI: 10.1097/qad.0000000000003177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Investigation of the diagnostic yield of urine-based tuberculosis (TB) screening in patients with advanced HIV disease. DESIGN A cross-sectional screening study. SETTING HIV outpatient clinics and wards at two hospitals in Johannesburg, South Africa, between June 2015 and October 2017. PARTICIPANTS Two hundred and one patients living with advanced HIV disease (CD4+ T-lymphocytes <100 cells/μl) attending healthcare facilities following cryptococcal antigen (CrAg) screening. INTERVENTION Screening for TB using sputum for microscopy, culture, and Xpert MTB/Rif and urine for lipoarabinomannan (LAM) and Xpert Ultra. MAIN OUTCOME MEASURES Proportion of positive results using each testing modality, sensitivity, and specificity of urine-based testing compared with culture, and survival outcomes during 6 months follow up. RESULTS Urine was obtained from 177 of 181 (98%) participants and sputum from 91 (50%). Urine-based screening increased same-day diagnostic yield from 7 (4%) to 31 (17%). A positive urine test with either LAM or Xpert Ultra had 100% sensitivity (95% confidence interval, 59-100%) for detecting culture-positive TB at any site. Patients with newly diagnosed TB on urine-based screening were initiated on treatment and did not have excess mortality compared with the remainder of the cohort. CONCLUSION Urine is an easily obtainable sample with utility for detecting TB in patients with advanced HIV disease. Combining urine and sputum-based screening in this population facilitates additional same-day TB diagnoses and early treatment initiation, potentially reducing the risk of TB-related mortality. Urine-based as well as sputum-based screening for TB should be integrated with CrAg screening in patients living with advanced HIV disease.
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Affiliation(s)
- Rachel M Wake
- Institute for Infection and Immunity, St George's University of London
- Clinical Academic Group in Infection and Immunity, St George's University Hospital NHS Foundation Trust, London, UK
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses (CHARM), National Institute for Communicable Diseases, a Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
| | - Nelesh P Govender
- Institute for Infection and Immunity, St George's University of London
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses (CHARM), National Institute for Communicable Diseases, a Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
- Faculty of Health Sciences, University of the Witwatersrand, Witwatersrand
- Division of Medical Microbiology, University of Cape Town, Cape Town
| | - Shaheed V Omar
- Faculty of Health Sciences, University of the Witwatersrand, Witwatersrand
- Department of Medical Microbiology, University of Pretoria, Pretoria
- Centre for Tuberculosis
| | - Farzana Ismail
- Department of Medical Microbiology, University of Pretoria, Pretoria
- Centre for Tuberculosis
| | - Caroline T Tiemessen
- Faculty of Health Sciences, University of the Witwatersrand, Witwatersrand
- Centre for HIV & STIs, National Institute for Communicable Diseases, a Division of the NHLS, Johannesburg, South Africa
| | - Thomas S Harrison
- Institute for Infection and Immunity, St George's University of London
- Clinical Academic Group in Infection and Immunity, St George's University Hospital NHS Foundation Trust, London, UK
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Botswana Harvard AIDS Institute Partnership, Gabarone, Botswana
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Sharma K, Sharma M, Ayyadurai N, Dogra M, Sharma A, Gupta V, Singh R, Gupta A. Comparative Evaluation of GeneXpert MTB/RIF Ultra and GeneXpert MTB/RIF for Detecting Tuberculosis and Identifying Rifampicin Resistance in Pars Plana Vitrectomy Samples of Patients with Ocular Tuberculosis. Ocul Immunol Inflamm 2022:1-7. [PMID: 35442853 DOI: 10.1080/09273948.2022.2064880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Xpert MTB/RIF Ultra (Ultra) was evaluated for the first time on Ocular tuberculosis (OTB) samples and compared with Xpert. METHODS Seventy five vitreous fluid samples (3 confirmed OTB, 47 clinically suspected OTB, and 25 controls) were subjected to Ultra, Xpert and Multiplex-PCR and compared against culture, composite reference standard (CRS), and gene sequencing. RESULTS The sensitivity of Ultra was 50% in diagnosing OTB (100% against culture and 46.8% against CRS). The overall sensitivity of Xpert and MPCR was 16% and 72%, respectively. Xpert missed three culture-positive cases and MPCR detected additional 11. Ultra and Xpert missed two and four cases of RifR, respectively. A total of 13(59%) cases were reported 'trace' by Ultra in which RifR could not be evaluated. CONCLUSION Ultra outperformed Xpert in diagnosing OTB. The advantage of Ultra's simultaneous RifR detection is lost since the trace bacterial loads in the specimens cause indeterminate results of RifR testing.Abbreviations: OTB: Ocular tuberculosis; Ultra: Xpert MTB/RIF Ultra; Xpert: Xpert MTB/RIF, MPCR: multiplex polymerase chain reaction; NAATs: Nucleic acid amplification tests; MLAMP: multitargeted loop-mediated isothermal amplification; PPV: positive predictive value; NPV: negative predictive value; EPTB: extrapulmonary tuberculosis; VF: vitreous fluid; DNA: deoxyribonucleic acid; ATT: antitubercular therapy; RifR: Rifampicin resistance; RifS: Rifampicin susceptible; RifI: Rifampicin indeterminate.
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Affiliation(s)
- Kusum Sharma
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Megha Sharma
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.,Department of Microbiology, All India Institute of Medical Sciences (AIIMS) Bilaspur, Himachal Pradesh, India
| | - Nikitha Ayyadurai
- Department of Ophthalmology, Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mohit Dogra
- Department of Ophthalmology, Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishali Gupta
- Department of Ophthalmology, Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ramandeep Singh
- Department of Ophthalmology, Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amod Gupta
- Department of Ophthalmology, Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Hong JM, Lee H, Menon NV, Lim CT, Lee LP, Ong CWM. Point-of-care diagnostic tests for tuberculosis disease. Sci Transl Med 2022; 14:eabj4124. [PMID: 35385338 DOI: 10.1126/scitranslmed.abj4124] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Rapid diagnosis is one key pillar to end tuberculosis (TB). Point-of-care tests (POCTs) facilitate early detection, immediate treatment, and reduced transmission of TB disease. This Review evaluates current diagnostic assays endorsed by the World Health Organization and identifies the gaps between existing conventional tests and the ideal POCT. We discuss the commercial development of new rapid tests and research studies on nonsputum-based diagnostic biomarkers from both pathogen and host. Last, we highlight advances in integrated microfluidics technology that may aid the development of new POCTs.
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Affiliation(s)
- Jia Mei Hong
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117599, Singapore
| | - Hyeyoung Lee
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117599, Singapore
| | - Nishanth V Menon
- Department of Biomedical Engineering, National University of Singapore, Singapore 117583, Singapore
| | - Chwee Teck Lim
- Department of Biomedical Engineering, National University of Singapore, Singapore 117583, Singapore.,Institute for Health Innovation & Technology (iHealthtech), National University of Singapore, Singapore 117599, Singapore.,Mechanobiology Institute, National University of Singapore, Singapore 117411, Singapore
| | - Luke P Lee
- Department of Bioengineering, University of California, Berkeley, Berkeley, CA 94720, USA.,Berkeley Sensor and Actuator Center, University of California, Berkeley, Berkeley, CA 94720-1764, USA.,Department of Electrical Engineering and Computer Sciences, University of California, Berkeley, Berkeley, CA 94720, USA.,Biophysics Graduate Program, University of California, Berkeley, Berkeley, CA 94720, USA.,Harvard Medical School, Brigham and Women's Hospital, Harvard Institute of Medicine, Harvard University, Boston, MA 02115, USA.,Institute of Quantum Biophysics, Department of Biophysics, Sungkyunkwan University, Suwon, Korea
| | - Catherine W M Ong
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117599, Singapore.,Institute for Health Innovation & Technology (iHealthtech), National University of Singapore, Singapore 117599, Singapore
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Fc-MBL-modified Fe 3O 4 magnetic bead enrichment and fixation in Gram stain for rapid detection of low-concentration bacteria. Mikrochim Acta 2022; 189:169. [PMID: 35364796 DOI: 10.1007/s00604-022-05277-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 03/11/2022] [Indexed: 10/18/2022]
Abstract
Functional bacterial enrichment magnetic beads (Fe3O4@SiO2@Fc-MBL) and Gram staining were combined for the fast diagnosis of infecting bacteria in meningitis. Fe3O4@SiO2@Fc-MBL has excellent microbial binding ability and can be used for bacterial enrichment from cerebrospinal fluid (CSF). The enriched bacteria are recognized by Gram stain at very low concentrations (10 CFU·mL-1). The feasibility of this method was verified by five common bacteria in meningitis infection (Gram-positive: Staphylococcus epidermidis, Staphylococcus haemolyticus, and Staphylococcus capitis; Gram-negative: Klebsiella pneumoniae and Escherichia coli). The extraction efficiency of Fc-MBL-modified Fe3O4 magnetic beads was approximately 90% in artificial CSF for the selected bacteria, with the exception of E. coli (~ 60%). The bacteria were successfully recognized by Gram staining and microscopic observation. Fe3O4@SiO2@Fc-MBL acts by capturing and fixing the bacteria in a magnetic field throughout the experiment. Compared with traditional CSF Gram staining, this new method avoids interference by inflammatory cells and red blood cells during microscopic examination. Furthermore, the sensitivity of this method is much better than the centrifugation smear method. The whole process can be accomplished within 30 min. This novel method may have potential as a clinical tool for analysis of bacteria in the CSF.
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Pradhan NN, Paradkar MS, Kagal A, Valvi C, Kinikar A, Khwaja S, Dhage R, Chandane J, Ithape M, Bendre M, Madewar R, Nadgeri V, Nijampurkar A, Jain D, Gupte N, Gupta A, Mave V, Dooley KE, Thakur KT. Performance of Xpert ® MTB/RIF and Xpert ® Ultra for the diagnosis of tuberculous meningitis in children. Int J Tuberc Lung Dis 2022; 26:317-325. [PMID: 35351236 PMCID: PMC9592112 DOI: 10.5588/ijtld.21.0388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE: To assess Xpert® MTB/RIF (Xpert) and Xpert® MTB/RIF Ultra (Ultra) performance in diagnosing pediatric tuberculous meningitis (TBM).METHODS: We conducted a study among children with suspected meningoencephalitis in Pune, India. Clinical, radiological, laboratory, and treatment data were analyzed to classify disease as definite, probable, possible or no TBM, using microbiologic or composite reference standards. We tested cerebrospinal fluid (CSF) either using Xpert or Ultra and estimated test performance characteristics.RESULTS: Of 341 participants, 149 (43.7%) were tested using Ultra and 192 (56.3%) with Xpert. Ultra had higher sensitivity (50% vs. 18%), lower specificity (91% vs. 99%), poor positive predictive value (PPV) (13% vs. 75%), and higher negative predictive value (NPV) (99% vs. 93%) than Xpert using the composite reference standard, with similar results by the microbiologic reference standard. Of 10 participants with trace positivity on Ultra, none met clinical TBM definitions.CONCLUSION: This is the first study to report on diagnostic performance of Ultra in pediatric TBM, which showed higher sensitivity and NPV than Xpert. For children presenting with nonspecific clinical features, Ultra is a promising diagnostic test. Further studies are required to define its optimal clinical use, including interpretation of trace positive results.
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Affiliation(s)
- N. N. Pradhan
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India;,Johns Hopkins India, Pune, India
| | - M. S. Paradkar
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India;,Johns Hopkins India, Pune, India
| | - A. Kagal
- BJ Government Medical College and Sassoon General Hospitals, Pune, India
| | - C. Valvi
- BJ Government Medical College and Sassoon General Hospitals, Pune, India
| | - A. Kinikar
- BJ Government Medical College and Sassoon General Hospitals, Pune, India
| | - S. Khwaja
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India
| | - R. Dhage
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India
| | - J. Chandane
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India
| | - M. Ithape
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India
| | - M. Bendre
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India
| | - R. Madewar
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India
| | - V. Nadgeri
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India
| | - A. Nijampurkar
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India;,Johns Hopkins India, Pune, India
| | - D. Jain
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India
| | - N. Gupte
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India;,Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A. Gupta
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - V. Mave
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India;,Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - K. E. Dooley
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - K. T. Thakur
- Department of Neurology, Columbia University Irving Medical Center and the New York Presbyterian Hospital, New York, NY, USA
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Integrating central nervous system metagenomics and host response for diagnosis of tuberculosis meningitis and its mimics. Nat Commun 2022; 13:1675. [PMID: 35354815 PMCID: PMC8967864 DOI: 10.1038/s41467-022-29353-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 03/11/2022] [Indexed: 12/13/2022] Open
Abstract
The epidemiology of infectious causes of meningitis in sub-Saharan Africa is not well understood, and a common cause of meningitis in this region, Mycobacterium tuberculosis (TB), is notoriously hard to diagnose. Here we show that integrating cerebrospinal fluid (CSF) metagenomic next-generation sequencing (mNGS) with a host gene expression-based machine learning classifier (MLC) enhances diagnostic accuracy for TB meningitis (TBM) and its mimics. 368 HIV-infected Ugandan adults with subacute meningitis were prospectively enrolled. Total RNA and DNA CSF mNGS libraries were sequenced to identify meningitis pathogens. In parallel, a CSF host transcriptomic MLC to distinguish between TBM and other infections was trained and then evaluated in a blinded fashion on an independent dataset. mNGS identifies an array of infectious TBM mimics (and co-infections), including emerging, treatable, and vaccine-preventable pathogens including Wesselsbron virus, Toxoplasma gondii, Streptococcus pneumoniae, Nocardia brasiliensis, measles virus and cytomegalovirus. By leveraging the specificity of mNGS and the sensitivity of an MLC created from CSF host transcriptomes, the combined assay has high sensitivity (88.9%) and specificity (86.7%) for the detection of TBM and its many mimics. Furthermore, we achieve comparable combined assay performance at sequencing depths more amenable to performing diagnostic mNGS in low resource settings. Tuberculous meningitis is difficult to differentiate from meningitis caused by other pathogens. Here, the authors combine metagenomics-based pathogen detection in cerebrospinal fluid with a host gene expression-based machine learning classifier for diagnosis.
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Tuberculosis Meningitis in People Living with HIV/AIDS in a Health Center in the Brazilian Amazon: A Silent Disease. Case Rep Infect Dis 2022; 2022:8048310. [PMID: 35321086 PMCID: PMC8938075 DOI: 10.1155/2022/8048310] [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: 10/28/2021] [Accepted: 02/07/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Tuberculosis (TB) is one of the ten leading causes of death worldwide and the leading cause of infection in people living with the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (PLWHA). It is a major public health problem in Brazil and worldwide. Methods This was a case series study of five meningeal tuberculosis and PLWHA coinfection patients admitted between June 2019 and June 2020, in a public hospital in the northern region of Brazil. Associated with clinical cases, we propose a discussion of the different laboratory diagnostic methods available in Brazil, with the aim of increasing the diagnosis of this very serious disease, with high mortality. Results The diagnosis of tuberculous meningitis is a challenge in clinical practice; thus, the clinical cases presented help the physician to recognize the signs and symptoms of the disease and improve the confirmatory diagnosis through acid-alcoholic resistant bacilli techniques, molecular testing, and mycobacteria culture in the cerebrospinal fluid. Conclusion Knowing the diagnostic methods of tuberculous meningitis and its characteristics is of paramount importance to increase the correct diagnosis and reduce mortality in delayed treatment.
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Chen Y, Wang Y, Liu X, Li W, Fu H, Liu X, Zhang X, Zhou X, Yang B, Yao J, Ma X, Han L, Li H, Zheng L. Comparative diagnostic utility of metagenomic next-generation sequencing, GeneXpert, modified Ziehl-Neelsen staining, and culture using cerebrospinal fluid for tuberculous meningitis: A multi-center, retrospective study in China. J Clin Lab Anal 2022; 36:e24307. [PMID: 35202495 PMCID: PMC8993600 DOI: 10.1002/jcla.24307] [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: 10/25/2021] [Revised: 01/12/2022] [Accepted: 02/12/2022] [Indexed: 12/03/2022] Open
Abstract
Background Early diagnosis of tuberculosis meningitis (TBM) remains a great challenge during clinical practice. The diagnostic efficacies of cerebrospinal fluid (CSF)‐based mycobacterial growth indicator tube (MGIT) culture, modified Ziehl–Neelsen (ZN) staining, Xpert MTB/RIF, and metagenomic next‐generation sequencing (mNGS) for TBM remained elusive. Methods A total of 216 adult patients with suspicious TBM were retrospectively enrolled in this multi‐cohort study. The diagnostic performances for MGIT, modified ZN staining, Xpert MTB/RIF, and mNGS using CSF samples were evaluated. Results Uniform clinical case definition classified 88 (40.7%) out of 216 patients as the definite TBM, 5 (2.3%) patients as probable TBM cases, and 24 (11.1%) patients as possible TBM cases. The sensitivities of MGIT, modified ZN staining, Xpert MTB/RIF, and mNGS for TBM diagnosis against consensus uniform case definition for definite TBM were 25.0%, 76.1%, 73.9%, and 84.1%, respectively. Negative predictive values (NPVs) were 66.0%, 85.9%, 84.8%, and 90.1%, respectively. The sensitivities of MGIT, modified ZN staining, Xpert MTB/RIF, and mNGS for TBM diagnosis against consensus uniform case definition for definite, probable, and possible TBM were 18.8%, 57.3%, 55.5%, and 63.2%, respectively. Negative predictive values (NPVs) were 51.0%, 66.4%, 65.6%, and 69.7%, respectively. mNGS combined with modified ZN stain and Xpert could cover TBM cases against a composite microbiological reference standard, yielding 100% specificity and 100% NPV. Conclusion Metagenomic next‐generation sequencing detected TBM with higher sensitivity than Xpert, ZN staining and MGIT culture, but mNGS cannot be used as a rule‐out test. mNGS combined with Xpert or modified ZN staining could enhance the sensitivity of diagnostic tests for TBM.
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Affiliation(s)
- Yuxin Chen
- Department of Laboratory Medicine, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Yuqing Wang
- Department of Respiratory Medicine, No. 4 People's Hospital of Qinghai Province, Xining, China
| | - Xiaojin Liu
- Department of Infectious Disease, Hebei Chest Hospital, Hebei, China
| | - Wen Li
- Department of Radiology, Hebei Chest Hospital, Hebei, China
| | - Hongyi Fu
- Department of Tuberculosis, Hebei Chest Hospital, Hebei, China
| | - Xinyan Liu
- Department of Oncology, Hebei Chest Hospital, Hebei, China
| | - Xun Zhang
- Department of Clinical Laboratory, Hebei Chest Hospital, Hebei, China
| | - Xueqin Zhou
- Department of Clinical Laboratory, Hebei Chest Hospital, Hebei, China
| | - Bingzhou Yang
- Department of Clinical Laboratory, Hebei Chest Hospital, Hebei, China
| | - Jie Yao
- Department of Respiratory Medicine, No. 4 People's Hospital of Qinghai Province, Xining, China
| | - Xiaolei Ma
- Department of Respiratory Medicine, No. 4 People's Hospital of Qinghai Province, Xining, China
| | - Lijun Han
- The Center of Tuberculous Meningitis Diagnosis and Treatment, The Infectious Disease Hospital of Changchun, Jilin, China
| | - Huan Li
- The Center of Tuberculous Meningitis Diagnosis and Treatment, The Infectious Disease Hospital of Changchun, Jilin, China
| | - Liheng Zheng
- Department of Clinical Laboratory, Hebei Chest Hospital, Hebei, China
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Wakode P, Siddaiah N, Manjunath N, Bahubali VKH. GeneXpert: A Rapid and Supplementary Diagnostic Tool for Tuberculous Meningitis, Experience from Tertiary Neurocenter. J Neurosci Rural Pract 2022; 13:204-210. [PMID: 35694081 PMCID: PMC9187421 DOI: 10.1055/s-0041-1742138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background
Tuberculous meningitis (TBM) is a highly lethal form of central nervous system tuberculosis (CNS TB) that causes high mortality and morbidity in children and adults. Nonspecific clinical presentation and fewer TB bacilli challenge clinicians resulting in delays in diagnosis and treatment.
Aim
This study aimed to evaluate the utility of GeneXpert alone and in combination with culture using 1 mL of cerebrospinal fluid (CSF) in a volume constraint situation.
Methods
A total of 125 clinically confirmed TBM and 110 non-TBM cases, comprised of both infectious and noninfectious diseases. were included in the study. Patient details including clinical signs and symptoms, CSF, and imaging data were collected from the case records. CSF samples were obtained from all the patients and were tested by the mycobacterial culture method and GeneXpert test. The performance of both the tests was statistically calculated and reported in the form of sensitivity and specificity.
Results
Out of 125 TBM cases, 40 were detected positive by culture and 26 by GeneXpert. All 110 non-TBM cases were identified negative by both methods. The sensitivity and specificity of GeneXpert in comparison with culture were 27 and 100%, respectively. The culture was found to be more sensitive (32%) than GeneXpert. But the assay was able to detect a considerable number of clinically confirmed culture-negative TBM cases.
Conclusion
GeneXpert is a rapid test and including this as an adjunctive test along with the culture in routine clinical practice can improve the diagnosis of TBM in volume constraint scenario.
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Affiliation(s)
- Priyanka Wakode
- Department of Neuromicrobiology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Nagarathna Siddaiah
- Department of Neuromicrobiology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Netravathi Manjunath
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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The diagnostic challenge of atypical tuberculous meningitis in children from rural area. EUR J INFLAMM 2022. [DOI: 10.1177/1721727x221122718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Tuberculous meningitis (TBM) is a severe form of Mycobacterium tuberculosis infection, while its diagnosis is still a challenge in children. Here, six children with atypical TBM were retrospectively reviewed and the main findings were displayed as follows. The enrolled cases exhibited non-specific symptoms on admission, mainly including fever ( n = 5), headache ( n = 3), vomiting ( n = 5), and drowsiness ( n = 3), but no typical symptoms of TB infection. Two of them exhibited progressive symptoms under routine treatment. Cerebrospinal fluid (CSF) examinations revealed increased white blood cells and proteins, as well as decreased glucose and chloride in all cases. Chest imaging identified the possibly of pulmonary tuberculous in 2 cases. Cranial CT and MRI revealed neuroimaging abnormality in 1 and 3 cases, respectively. In addition, next-generation sequencing directly supported the diagnosis of TBM in case 5. To sum up, TBM should be highly suspected in children with central nervous system infection, when there are no improvements under routine treatment and/or the presence of progressive symptoms. Timely rechecking of CSF combined with cranial imaging is feasible and valuable for the diagnosis of TBM.
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Joseph SK, M A A, Thomas S, Nair SC. Nanomedicine as a future therapeutic approach for treating meningitis. J Drug Deliv Sci Technol 2022. [DOI: 10.1016/j.jddst.2021.102968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Biswas S, Uddin MKM, Paul KK, Ather MF, Ahmed S, Nasrin R, Kabir S, Heysell SK, Banu S. Xpert MTB/RIF Ultra assay for the detection of Mycobacterium tuberculosis in people with negative conventional Xpert MTB/RIF but chest imaging suggestive of tuberculosis in Dhaka, Bangladesh: Xpert Ultra for M. tuberculosis detection in Xpert-negative PTB presumptives. Int J Infect Dis 2021; 114:244-251. [PMID: 34774779 DOI: 10.1016/j.ijid.2021.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/03/2021] [Accepted: 11/05/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND World Health Organization is considering substitution of Xpert MTB/RIF (Xpert) by Xpert MTB/RIF Ultra (Ultra) for tuberculosis (TB) diagnosis, but supportive evidence is scarce, particularly among people more likely to have paucibacillary pulmonary TB (PTB). METHODS During January-July 2018, PTB presumptives visiting TB Screening and Treatment Centres of Dhaka for routine chest X-ray (CXR) and conventional Xpert were enrolled. Sputum specimens were additionally tested with microscopy, culture and Ultra. Specimens with "Trace call" by Ultra (Ultra-trace) were retested. Yield and diagnostic accuracy using various approaches to Ultra-trace and concordance of Ultra with bacteriological-positive PTB were assessed. RESULTS 1,083 participants (104 'Xpert-positive'; 979 'Xpert-negative and CXR-suggestive') were enrolled. All Xpert-positives and 900 (92%) Xpert-negatives displayed concordance with Ultra. Seventy-nine (8.1%) Xpert-negative specimens tested positive with Ultra, of which 37 (46.8%) were categorically positives and 42 (53.2%) were Ultra-trace. Sixteen of 42 were retested, of whom eight (50.1%) Ultra-trace turned categorically positive, leading to 45 (4.6%) additionally detected by Ultra. Ultra sensitivity and specificity was 93.9% and 94.6%, and it additionally detected 5.4% more TB patients with concordance 94.6% (kappa, ꓗ=0.78) compared to any bacteriologically positive specimen (microscopy, culture or Xpert). CONCLUSION Ultra exhibited improved detection and accuracy among Xpert-negatives in a cohort with a high likelihood of PTB.
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Affiliation(s)
- Samanta Biswas
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | - Kishor Kumar Paul
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh; The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Md Fahim Ather
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shahriar Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Rumana Nasrin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Senjuti Kabir
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Scott K Heysell
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Sayera Banu
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
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