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Savage HR, Rickman HM, Burke RM, Odland ML, Savio M, Ringwald B, Cuevas LE, MacPherson P. Accuracy of upper respiratory tract samples to diagnose Mycobacterium tuberculosis: a systematic review and meta-analysis. THE LANCET. MICROBE 2023; 4:e811-e821. [PMID: 37714173 PMCID: PMC10547599 DOI: 10.1016/s2666-5247(23)00190-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Pulmonary tuberculosis due to Mycobacterium tuberculosis can be challenging to diagnose when sputum samples cannot be obtained, which is especially problematic in children and older people. We systematically appraised the performance characteristics and diagnostic accuracy of upper respiratory tract sampling for diagnosing active pulmonary tuberculosis. METHODS In this systematic review and meta-analysis, we searched MEDLINE, Cinahl, Web of Science, Global Health, and Global Health Archive databases for studies published between database inception and Dec 6, 2022 that reported on the accuracy of upper respiratory tract sampling for tuberculosis diagnosis compared with microbiological testing of sputum or gastric aspirate reference standard. We included studies that evaluated the accuracy of upper respiratory tract sampling (laryngeal swabs, nasopharyngeal aspirate, oral swabs, saliva, mouth wash, nasal swabs, plaque samples, and nasopharyngeal swabs) to be tested for microbiological diagnosis of tuberculous (by culture and nucleic acid amplification tests) compared with a reference standard using either sputum or gastric lavage for a microbiological test. We included cohort, case-control, cross-sectional, and randomised controlled studies that recruited participants from any community or clinical setting. We excluded post-mortem studies. We used a random-effects meta-analysis with a bivariate hierarchical model to estimate pooled sensitivity, specificity, and diagnostics odds ratio (DOR; odds of a positive test with disease relative to without), stratified by sampling method. We assessed bias using QUADAS-2 criteria. This study is registered with PROSPERO (CRD42021262392). FINDINGS We screened 10 159 titles for inclusion, reviewed 274 full texts, and included 71, comprising 119 test comparisons published between May 13, 1933, and Dec 19, 2022, in the systematic review (53 in the meta-analysis). For laryngeal swabs, pooled sensitivity was 57·8% (95% CI 50·5-65·0), specificity was 93·8% (88·4-96·8), and DOR was 20·7 (11·1-38·8). Nasopharyngeal aspirate sensitivity was 65·2% (52·0-76·4), specificity was 97·9% (96·0-99·0), and DOR was 91·0 (37·8-218·8). Oral swabs sensitivity was 56·7% (44·3-68·2), specificity was 91·3% (CI 81·0-96·3), and DOR was 13·8 (5·6-34·0). Substantial heterogeneity in diagnostic accuracy was found, probably due to differences in reference and index standards. INTERPRETATION Upper respiratory tract sampling holds promise to expand access to tuberculosis diagnosis. Exploring historical methods using modern microbiological techniques might further increase options for alternative sample types. Prospective studies are needed to optimise accuracy and utility of sampling methods in clinical practice. FUNDING UK Medical Research Council, Wellcome, and UK Foreign, Commonwealth and Development Office.
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Affiliation(s)
- Helen R Savage
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Hannah M Rickman
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK; Public Health Group, Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
| | - Rachael M Burke
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK; Public Health Group, Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
| | - Maria Lisa Odland
- Public Health Group, Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi; Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Martina Savio
- The LIGHT Consortium, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Beate Ringwald
- The LIGHT Consortium, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Luis E Cuevas
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Peter MacPherson
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK; Public Health Group, Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi; School of Health and Wellbeing, University of Glasgow, Glasgow, UK
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Matimba A, Moncho M, Musoke J, Seedat RY. Diagnosis of laryngeal tuberculosis in a high TB burden area. Eur Arch Otorhinolaryngol 2020; 277:2137-2140. [PMID: 32328767 DOI: 10.1007/s00405-020-05976-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 04/10/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The larynx is the second most commonly affected site in the head and neck region in patients with extrapulmonary tuberculosis (TB). Despite this, the prevalence of laryngeal TB is largely unknown, particularly in areas with a high TB burden. The laboratory diagnosis of TB includes microscopy, culture and molecular testing. The aims of this study were to determine the prevalence of laryngeal TB in patients presenting with laryngeal pathology in a region with a high TB burden and to determine the optimal diagnostic methods for the diagnosis of laryngeal TB. METHODS This was a prospective descriptive study of 80 adult patients undergoing direct laryngoscopy and biopsy for laryngeal pathology in the Department of Otorhinolaryngology, Universitas Academic Hospital, Bloemfontein, South Africa over a 1 year period. Histopathological and microbiological investigations (microscopy, Xpert MTB/RIF, and TB culture) were performed on all laryngeal biopsies. RESULTS Five (6.25%) out of 80 patients were diagnosed with laryngeal TB. In one patient, the Xpert MTB/RIF assay was positive on the laryngeal tissue and histology showed granulomas. Two patients had granulomas on histology although the microbiological tests on the tissue were negative. Two patients had only positive tissue cultures for Mycobacterium tuberculosis. None of the biopsies had positive Ziehl-Neelsen stains. CONCLUSION The results suggest that the diagnosis of laryngeal TB required a combination of histopathology, culture and PCR and that the Xpert MTB/RIF assay is not a sensitive test for the diagnosis of laryngeal TB.
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Affiliation(s)
- Abongile Matimba
- Department of Otorhinolaryngology, University of the Free State, P.O. Box 339, Bloemfontein, South Africa. .,Department of Otorhinolaryngology, Universitas Academic Hospital, Bloemfontein, South Africa.
| | - Masego Moncho
- Department of Medical Microbiology, NHLS Bloemfontein, Bloemfontein, South Africa.,Department of Medical Microbiology, University of the Free State, Bloemfontein, South Africa
| | - Jolly Musoke
- Department of Medical Microbiology, NHLS Bloemfontein, Bloemfontein, South Africa.,Department of Medical Microbiology, University of the Free State, Bloemfontein, South Africa
| | - Riaz Y Seedat
- Department of Otorhinolaryngology, University of the Free State, P.O. Box 339, Bloemfontein, South Africa.,Department of Otorhinolaryngology, Universitas Academic Hospital, Bloemfontein, South Africa
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Demirel D, Erkul E, Güngör A, Çekin E, Ramzy I. Laryngeal cytology: A cytological, histological, P16 and human papillomavirus study. Cytopathology 2019; 31:26-34. [PMID: 31630464 DOI: 10.1111/cyt.12779] [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: 12/24/2018] [Revised: 09/29/2019] [Accepted: 10/10/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Invasive diagnostic methods, such as punch biopsies, have a potential to produce undesirable side effects in the larynx, such as scarring and vocal dysfunction. This study is an attempt to assess the diagnostic potential of cytology to efficiently diagnose premalignant and malignant laryngeal lesions, while sparing patients the risk of complications of punch biopsies. METHODS Laryngeal smears, using endocervical-type brushes, and punch biopsies were procured from each patient. Smears were prepared and the brush was cut and put in Surepath preservative solution for cytological analysis and human papillomavirus (HPV) DNA testing. A Real-TM Quant kit that detects 14 HPV types was used for genotyping. Immunohistochemical staining for p16 was performed on cytological and histological specimens. RESULTS Cytological diagnosis was correct in 84.6%, 100% and 100% of cases with a histological diagnosis of squamous cell carcinomas, high-grade squamous intraepithelial lesions and benign lesions, respectively. However, cytological interpretation was correct only in 25% of low-grade squamous intraepithelial lesions. HPV DNA test was positive in only one case, which was a laryngeal polyp. Testing for p16 was negative in all the cytological and histological material. CONCLUSION Laryngeal cytology is a useful diagnostic tool in establishing the diagnosis of high-grade squamous epithelial cell abnormalities. Recognition of low-grade lesions, however, is challenging. HPV genotyping and p16 staining do not seem to be helpful ancillary techniques in cytological material procured from the larynx.
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Affiliation(s)
- Dilaver Demirel
- Department of Pathology, University of Health Sciences, Gaziosmanpasa Health Application and Research Center, Istanbul, Turkey
| | - Evren Erkul
- Department of Otorhinolaryngology, University of Health Sciences, Gulhane School of Medicine, Sultan Abdulhamid Han Health Application and Research Center, Istanbul, Turkey
| | - Atila Güngör
- Department of Otorhinolaryngology, Medical Park Hospital, Istanbul, Turkey
| | - Engin Çekin
- Department of Otorhinolaryngology, University of Health Sciences, Sultan Abdulhamid Han Health Application and Research Center, Istanbul, Turkey
| | - Ibrahim Ramzy
- Department of Pathology and Laboratory Medicine, University of California, Irvine, CA, USA
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Abstract
Upper respiratory tract involvement in cases of tuberculosis (TB) of the head and neck continues to be described in the most recent reports from several different regions, including some from developed countries. Laryngeal TB is the most common of all forms of upper respiratory tract TB (URT-TB). Pulmonary lesions in URT-TB are present in about 20% of adults and about 50 to 60% of children. Systemic manifestations are uncommon. URT-TB is especially seen in patients with a variety of risk factors, such as the presence of human immunodeficiency virus (HIV) infection, diabetes, smoking, alcoholism, drug abuse, malignancies, and use of immunosuppressive drugs. Nodules or ulcerative lesions are seen on morphological examination. Endoscopic examination is required for mucosal lesions. Diagnosis of TB is suspected on an epidemiological basis in high-prevalence countries or from the failure of a patient to respond to routine treatment. Smear and/or histopathological examinations help in establishing the final etiological diagnosis. Treatment includes standard anti-TB chemotherapy for at least 6 months with four primary drugs during the initial intensive phase of 2 months and two or three primary drugs during the remaining maintenance phase of 4 months. Treatment is modified on the basis of culture and sensitivity reports in cases of suspected drug resistance. Surgical intervention may be required for some patients with abscess formation and progressive disease unresponsive to medical therapy. Airway obstruction, although rare, even in fulminant cases may require tracheostomy for relief.
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Kiwanuka J, Graham SM, Coulter JBS, Gondwe JS, Chilewani N, Carty H, Hart CA. Diagnosis of pulmonary tuberculosis in children in an HIV-endemic area, Malawi. ACTA ACUST UNITED AC 2016. [DOI: 10.1080/02724930125056] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Asmar S, Drancourt M. Rapid culture-based diagnosis of pulmonary tuberculosis in developed and developing countries. Front Microbiol 2015; 6:1184. [PMID: 26579092 PMCID: PMC4630581 DOI: 10.3389/fmicb.2015.01184] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 10/12/2015] [Indexed: 12/19/2022] Open
Abstract
Culturing Mycobacterium tuberculosis remains the gold standard for the laboratory diagnosis of pulmonary tuberculosis, with 9 million new cases and 1.5 million deaths mainly in developing countries. Reviewing data reported over 20 years yields a state-of-the-art procedure for the routine culture of M. tuberculosis in both developed and developing countries. Useful specimens include sputum, induced sputum, and stools collected in quaternary ammonium preservative-containing sterile cans. The usefulness of other non-invasive specimens remains to be evaluated. Specimens can be collected in a diagnosis kit also containing sampling materials, instructions, laboratory requests, and informed consent. Automated direct LED fluorescence microscopy after auramine staining precedes inoculation of an egg-lecithin-containing culture solid medium under microaerophilic atmosphere, inverted microscope reading or scanning video-imaging detection of colonies and colonies identification by recent molecular methods. This procedure should result in a diagnosis of pulmonary tuberculosis as fast as 5 days. It may be implemented in both developed and developing countries with automated steps replaceable by manual steps depending on local resources.
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Affiliation(s)
| | - Michel Drancourt
- Faculté de Médecine, URMITE, UM63, Centre National de la Recherche Scientifique 7278, IRD 198, Institut National de la Santé et de la Recherche Médicale 1095, Aix Marseille UniversitéMarseille, France
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Owens S, Abdel-Rahman IE, Balyejusa S, Musoke P, Cooke RPD, Parry CM, Coulter JBS. Nasopharyngeal aspiration for diagnosis of pulmonary tuberculosis. Arch Dis Child 2007; 92:693-6. [PMID: 17185437 PMCID: PMC2083896 DOI: 10.1136/adc.2006.108308] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Confirmation of pulmonary tuberculosis (PTB) in young children is difficult as they seldom expectorate sputum. AIM To compare sputa obtained by nasopharyngeal aspiration and by sputum induction for staining and culture of Mycobacterium tuberculosis. PATIENTS AND METHODS Patients from Mulago Hospital, Kampala with symptoms suggestive of PTB were considered for inclusion in the study. Those with a positive tuberculin test and/or a chest radiograph compatible with tuberculosis were recruited. Infection with human immunodeficiency virus (HIV) was confirmed by duplicate enzyme-labelled immunosorbent assay or in children <15 months by polymerase chain reaction (PCR). Direct PCR was undertaken on 82 nasopharyngeal aspirates. RESULTS Of 438 patients referred, 94 were recruited over a period of 5 months. Median (range) age was 48 (4-144) months. Of 63 patients tested, 69.8% were infected with HIV. Paired and uncontaminated culture results were available for 88 patients and smear results for 94 patients. Nasopharyngeal aspirates were smear-positive in 8.5% and culture-positive in 23.9%. Induced sputa were smear-positive in 9.6% and culture positive in 21.6%. Overall, 10.6% were smear-positive, 25.5% were culture-positive and 26.6% had smear and/or culture confirmed tuberculosis. Direct PCR on nasopharyngeal aspirates had a sensitivity of 62% and specificity of 98% for confirmation of culture-positive tuberculosis. CONCLUSIONS Nasopharyngeal aspiration is a useful, safe and low-technology method for confirmation of PTB and, like sputum induction, can be undertaken in outpatient clinics.
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Affiliation(s)
- S Owens
- Liverpool School of Tropical Medicine, Liverpool, UK
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Harries AD, Graham SM, Weismuller MM, Claessens N, Meijnen S, Hargreaves NJ, Mwansambo C, Kazembe PN, Salaniponi FM. Childhood tuberculosis in Malawi: caseload, diagnostic practices and treatment outcomes. Malawi Med J 2005; 17:119-24. [PMID: 27528998 DOI: 10.4314/mmj.v17i4.10894] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
There were 22,982 cases of TB registered in Malawi in 1998, of which 2739 (11.9%) were children. Children accounted for 11.3% of all case notifications with smear-positive pulmonary TB (PTB), 21.3% with smear-negative PTB and 15.9% with extrapulmonary TB (EPTB). A significantly higher proportion of TB cases were diagnosed in central hospitals. Only 45% of children completed treatment. There were high rates of death (17%), default (13%) and unknown treatment outcomes (21%). Treatment outcomes were worse in younger children and in children with smear-negative PTB. In 2001, all 44 non-private hospitals in Malawi that register and treat children with tuberculosis (TB) were surveyed to determine actual diagnostic practice. This cross sectional study identified 150 children aged 14 years or below in hospital receiving anti-TB treatment, 98 with pulmonary TB (PTB) and 52 with extrapulmonary TB (EPTB). Median duration of illness was 8 weeks. Most patients had fever, no response to anti-malarial treatment and antibiotics, and 40% had a positive family history of TB. Nearly 45% had weight for age < 60%. Diagnosis was mainly based on clinical features and radiography, with less than 10% having tuberculin skin tests or HIV serology, and very few having other sophisticated investigations. Diagnostic difficulties make it difficult to accurately define the actual burden of childhood TB in Malawi. Diagnostic practices are poor and treatment outcomes unsatisfactory.
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Affiliation(s)
- A D Harries
- National Tuberculosis Control Programme, Community Health Science Unit, Private Bag 65, Lilongwe, Malawi (Prof AD Harries FRCP, NJ Hargreaves MRCP, FM Salaniponi PhD)
| | - S M Graham
- Wellcome Trust Research Laboratories and Department of Paediatrics, College of Medicine, Blantyre, Malawi (SM Graham FRACP)
| | - M M Weismuller
- Wellcome Trust Research Laboratories and Department of Paediatrics, College of Medicine, Blantyre, Malawi (SM Graham FRACP)
| | - Njm Claessens
- Wellcome Trust Research Laboratories and Department of Paediatrics, College of Medicine, Blantyre, Malawi (SM Graham FRACP)
| | - S Meijnen
- Wellcome Trust Research Laboratories and Department of Paediatrics, College of Medicine, Blantyre, Malawi (SM Graham FRACP)
| | - N J Hargreaves
- National Tuberculosis Control Programme, Community Health Science Unit, Private Bag 65, Lilongwe, Malawi (Prof AD Harries FRCP, NJ Hargreaves MRCP, FM Salaniponi PhD)
| | - C Mwansambo
- Wellcome Trust Research Laboratories and Department of Paediatrics, College of Medicine, Blantyre, Malawi (SM Graham FRACP)
| | - P N Kazembe
- Wellcome Trust Research Laboratories and Department of Paediatrics, College of Medicine, Blantyre, Malawi (SM Graham FRACP)
| | - F M Salaniponi
- National Tuberculosis Control Programme, Community Health Science Unit, Private Bag 65, Lilongwe, Malawi (Prof AD Harries FRCP, NJ Hargreaves MRCP, FM Salaniponi PhD)
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Abstract
Because of the difficulty of confirming the diagnosis of childhood tuberculosis and because children do not make a significant contribution to the spread of tuberculosis, the burden of childhood tuberculosis in the world is uncertain. Several estimates make use of an arbitrary calculation assigning 10% of the tuberculosis burden to children. Available data linking the incidence of tuberculosis to the proportion of the tuberculosis caseload represented by children suggest an exponential rise in the proportion of the tuberculosis caseload caused by children as the tuberculosis incidence rises so that children may constitute nearly 40% of the caseload in certain high incidence communities. This review discusses the global burden of childhood tuberculosis and attempts to quantify this, the role of HIV/AIDS and tuberculosis in children, the problems this creates for diagnosis, and the occurrence of drug resistant tuberculosis in children. In the developing world, childhood tuberculosis is not under control, and, despite its importance as a child health problem, remains a neglected orphan disease.
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Affiliation(s)
- Peter R Donald
- Department of Pediatrics and Child Health, Tygerberg Children's Hospital and the University of Stellenbosch, Tygerberg, South Africa.
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Abstract
Osteomyelitis of jaws caused by infection with Mycobacterium tuberculosis is uncommon, especially in children. We present a case of tuberculous osteomyelitis in a young child. Its clinical presentation, with features similar to a dento-alveolar abscess, underline the importance of considering it in the differential diagnosis of jaw lesions. We discuss of the diagnostic techniques, management and preventive measures, and stress the importance of history taking during clinical examination.
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Affiliation(s)
- A P Bhatt
- Department of Oral Pathology, Yenepoya Dental College, Rajiv Gandhi University, Karnataka, India
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