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Kabra SK. New advances in diagnosis in pulmonary tuberculosis. Pediatr Pulmonol 2024. [PMID: 39315742 DOI: 10.1002/ppul.27270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2024] [Revised: 09/03/2024] [Accepted: 09/07/2024] [Indexed: 09/25/2024]
Affiliation(s)
- S K Kabra
- Department of Pediatrics, AIIMS, New Delhi, India
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2
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Nicol MP, Zar HJ. Advances in the diagnosis of pulmonary tuberculosis in children. Paediatr Respir Rev 2020; 36:52-56. [PMID: 32624357 PMCID: PMC7686111 DOI: 10.1016/j.prrv.2020.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/19/2020] [Indexed: 10/24/2022]
Abstract
Major challenges still exist in the accurate diagnosis of tuberculosis in children. Algorithms based on clinical and radiological features remain in widespread use despite poor performance. Newer molecular diagnostics allow for rapid identification of TB and detection of drug-resistance in a subset of children, but lack sensitivity. Molecular testing of multiple specimens, including non-traditional specimen types, such as nasopharyngeal aspirates and stool and urine, may improve sensitivity, but the optimal combination of specimens requires further research. Novel tests under development or evaluation include a urine lipoarabinomannan test with improved sensitivity and a range of biomarkers measured from stimulated or unstimulated peripheral blood.
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Affiliation(s)
- Mark P Nicol
- Division of Infection and Immunity, School of Biomedical Sciences, University of Western Australia, Perth, Australia.
| | - Heather J Zar
- Department of Paediatrics and Child Health, and SA-MRC Unit on Child & Adolescent Health, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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Evaluation of Xpert MTB/RIF Ultra Assay for Diagnosis of Childhood Tuberculosis: a Multicenter Accuracy Study. J Clin Microbiol 2020; 58:JCM.00702-20. [PMID: 32522831 PMCID: PMC7448660 DOI: 10.1128/jcm.00702-20] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 06/04/2020] [Indexed: 02/07/2023] Open
Abstract
A multicenter study was performed to evaluate the value of testing gastric aspirate (GA) with Xpert MTB/RIF Ultra assay (Ultra) for childhood tuberculosis (TB) detection in China. In total, 129 children with active TB and 173 children without TB were enrolled. The sensitivity of Ultra in bacteriologically confirmed TB and probable TB cases was 87.5% (42/48) and 44.4% (36/81), respectively. The specificity of Ultra was high (99.4%, 172/173). When Ultra, culture, and acid-fast bacilli outcomes were integrated as a composite reference standard, the percentage of children with definite TB increased from 37. A multicenter study was performed to evaluate the value of testing gastric aspirate (GA) with Xpert MTB/RIF Ultra assay (Ultra) for childhood tuberculosis (TB) detection in China. In total, 129 children with active TB and 173 children without TB were enrolled. The sensitivity of Ultra in bacteriologically confirmed TB and probable TB cases was 87.5% (42/48) and 44.4% (36/81), respectively. The specificity of Ultra was high (99.4%, 172/173). When Ultra, culture, and acid-fast bacilli outcomes were integrated as a composite reference standard, the percentage of children with definite TB increased from 37.2% (48/129) to 67.4% (87/129). The sensitivity of Ultra is 80.0% (40/50) in children aged <4 years, which is significantly higher than that in older children (48.1%, 38/79) (P < 0.001). Ultra conducted using GA samples can provide faster results, allowing an early and accurate TB diagnosis, especially in younger children with difficulty producing sputum.
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Combining host-derived biomarkers with patient characteristics improves signature performance in predicting tuberculosis treatment outcomes. Commun Biol 2020; 3:359. [PMID: 32647325 PMCID: PMC7347567 DOI: 10.1038/s42003-020-1087-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 06/18/2020] [Indexed: 11/08/2022] Open
Abstract
Tuberculosis (TB) is a global health concern. Treatment is prolonged, and patients on anti-TB therapy (ATT) often experience treatment failure for various reasons. There is an urgent need to identify signatures for early detection of failure and initiation of a treatment switch. We investigated how gene biomarkers and/or basic patient characteristics could be used to define signatures for treatment outcomes in Indian adult pulmonary-TB patients treated with standard ATT. Using blood samples at baseline, a 12-gene signature combined with information on gender, previously-diagnosed TB, severe thinness, smoking and alcohol consumption was highly predictive of treatment failure at 6 months. Likewise a 4-protein biomarker signature combined with the same patient characteristics was almost as highly predictive of treatment failure. Combining biomarkers and basic patient characteristics may be useful for predicting and hence identification of treatment failure at an early stage of TB therapy. Sivakumaran et al. show that a 12-gene signature combined with gender, previously diagnosed tuberculosis (TB), severe thinness, smoking, and alcohol consumption predict the treatment outcome at 6 months. This study suggests that the combination of biomarkers and basic patient characteristics may better predict the treatment failure at an early stage of TB therapy.
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Mesman AW, Rodriguez C, Ager E, Coit J, Trevisi L, Franke MF. Diagnostic accuracy of molecular detection of Mycobacterium tuberculosis in pediatric stool samples: A systematic review and meta-analysis. Tuberculosis (Edinb) 2019; 119:101878. [PMID: 31670064 DOI: 10.1016/j.tube.2019.101878] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 10/18/2019] [Accepted: 10/19/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Stool is a promising specimen option to diagnose pediatric tuberculosis (TB), but studies have reported a wide range of test sensitivities. We conducted a meta-analysis to assess the accuracy of Xpert MTB/RIF or 'in-house' molecular tests on stool samples against culture or Xpert MTB/RIF on respiratory samples or clinically-diagnosed unconfirmed TB and aimed to identify factors that contribute to the heterogeneity of reported sensitivity. METHODS We searched EMBASE and Pubmed databases and conference abstract books for studies reporting molecular stool testing against a clinical or microbiological reference standard among children. RESULTS We identified 16 studies that included 2,481 children in stool test analyses. Pooled specificity was 98% [95%CI: 96-99], pooled sensitivity was 57% [95%CI: 40-72] against culture and 3% [95%CI: 2-6] among children with clinically-diagnosed, unconfirmed TB. There was much heterogeneity. Sensitivity was higher among children with a smear-positive sputum test. Rifampin resistance in stool was reported in two studies and detected in 5/14 children (36%). CONCLUSION Our results suggest molecular stool tests have potential as diagnostic rule-in tests, but it is challenging to optimize sensitivity due to between-study variation in methodology and test procedures. Therefore, we recommend future research with rigorous study design and standardized results reporting.
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Affiliation(s)
- Annelies W Mesman
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA
| | - Carly Rodriguez
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA
| | - Emily Ager
- Harvard TH Chan School of Public Health, Department of Social and Behavioral Sciences, Boston, MA, USA
| | - Julia Coit
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA
| | - Letizia Trevisi
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA
| | - Molly F Franke
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA.
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Ioos V, Cordel H, Bonnet M. Alternative sputum collection methods for diagnosis of childhood intrathoracic tuberculosis: a systematic literature review. Arch Dis Child 2019; 104:629-635. [PMID: 30127061 DOI: 10.1136/archdischild-2018-315453] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/03/2018] [Accepted: 07/08/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Diagnosis of intrathoracic tuberculosis (ITB) is limited in children partly by their difficulty to produce sputum specimen. OBJECTIVE To systematically review the detection yields of mycobacterial culture and Xpert MTB/RIF from induced sputum (IS), nasopharyngeal aspirate (NPA) and gastric aspirate (GA) in children with presumptive ITB. DESIGN Pubmed, Embase and Biosis databases and grey literature were searched. Randomised controlled trials, cohort, cross-sectional or case control studies using IS, GA and NPA for diagnosis of ITB published between January 1990 and January 2018 were included. Data were extracted on study design, case definition of presumptive ITB, sample collection methods, outcome measures and results. RESULTS 30 studies were selected, including 11 554 children. Detection yields for culture ranged between 1% and 30% for IS, 1% and 45% for GA and 4% and 24% for NPA. For Xpert MTB/RIF, it was between 2% and 17% for IS, 5% and 51% for GA and 3% and 8% for NPA. There was a tendency of better yields with IS when the pretest probability of ITB was low to moderate and with GA when it was high. Sampling a second specimen contributed for 6%-33% of the cumulative yield and combination of different methods significantly increase the detection yields. CONCLUSIONS Despite the important study heterogeneity, any of the specimen collection methods offers good potential to confirm childhood ITB. However, their operational challenges were poorly evaluated. In the absence of a sensitive non-sputum based test, only a minority of children with ITB can be confirmed.
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Affiliation(s)
- Vincent Ioos
- Département Médical, Médecins Sans Frontières, Paris, Paris, France
| | - Hugues Cordel
- Infectious disease department, Avicenne Hospital, Bobigny, Seine-Saint-Denis, France
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Tafur KT, Coit J, Leon SR, Pinedo C, Chiang SS, Contreras C, Calderon R, Mendoza MJ, Lecca L, Franke MF. Feasibility of the string test for tuberculosis diagnosis in children between 4 and 14 years old. BMC Infect Dis 2018; 18:574. [PMID: 30442105 PMCID: PMC6238308 DOI: 10.1186/s12879-018-3483-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 10/31/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The enteric string test can be used to obtain a specimen for microbiological confirmation of tuberculosis in children, but it is not widely used for this. The aim of this analysis to evaluate this approach in children with tuberculosis symptoms. METHODS We conducted a cross-sectional study to assess children's ability to complete the test (feasibility), and self-reported pain (tolerability). We examined caregivers' and children's willingness to repeat the procedure (acceptability) and described the diagnostic yield of cultures for diagnostic tools. We stratified estimates by age and compared metrics to those derived for gastric aspirate (GA). RESULTS Among 148 children who attempted the string test, 34% successfully swallowed the capsule. Feasibility was higher among children aged 11-14 than in children 4-10 years (83% vs 22% respectively, p < 0.0001). The string test was better tolerated than GA in both age groups; however, guardians and older children reported higher rates of willingness to repeat GA than the string test (86% vs. 58% in children; 100% vs. 83% in guardians). In 9 children with a positive sputum culture, 6 had a positive string culture. The one children with a positive gastric aspirate culture also had a positive string culture. CONCLUSION Although the string test was generally tolerable and accepted by children and caregivers; feasibility in young children was low. Reducing the capsule size may improve test success rates in younger children.
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Affiliation(s)
- Karla T. Tafur
- Socios En Salud Sucursal Perú, Av. Túpac Amaru 4480, Comas, Lima, Peru
| | - Julia Coit
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
| | - Segundo R. Leon
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
| | - Cynthia Pinedo
- Socios En Salud Sucursal Perú, Av. Túpac Amaru 4480, Comas, Lima, Peru
| | - Silvia S. Chiang
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, RI USA
- Center for International Health Research. Rhode Island Hospital, Providence, RI USA
| | - Carmen Contreras
- Socios En Salud Sucursal Perú, Av. Túpac Amaru 4480, Comas, Lima, Peru
| | - Roger Calderon
- Socios En Salud Sucursal Perú, Av. Túpac Amaru 4480, Comas, Lima, Peru
| | | | - Leonid Lecca
- Socios En Salud Sucursal Perú, Av. Túpac Amaru 4480, Comas, Lima, Peru
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
| | - Molly F. Franke
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
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Predictors of Microbiologically Confirmed Intrathoracic Tuberculosis. Indian J Pediatr 2017; 84:843-847. [PMID: 28924924 DOI: 10.1007/s12098-017-2467-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 08/28/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To identify risk factors for microbiologically confirmed intrathoracic tuberculosis in children. METHODS Children, 6 mo to 15 y of age, attending the out-patient department of a tertiary care centre in India, with probable intrathoracic tuberculosis were enrolled. Microbiological confirmation of tuberculosis was defined as positivity on smear (Ziehl-Neelsen staining) and/or Xpert MTB/RIF and/or MGIT-960 culture. Association of various factors with microbiological confirmation were assessed by univariate and multivariate analysis. RESULTS Microbiologic confirmation was documented in 39 (25%) of 153 patients enrolled. On univariate analysis, microbiological positivity was associated with female gender, higher mean (SD) age [136.6 (31.8) vs. 117.3 (41.4) mo], parenchymal lesion on chest radiograph, low body mass index for age, having symptoms of cough and weight loss, lower mean (SD) hemoglobin [10.4 (1.37) g/dl vs. 11(1.52) g/dl; p = 0.04], and higher mean (SD) monocyte: lymphocyte ratio [0.38 (0.30) vs. 0.24 (0.02); p = 0.37]. Higher proportion of microbiologically negative children were BCG vaccinated (95% vs. 79%; p = 0.002). On multivariate analysis, microbiological positivity showed significant association with low body mass index for age (p = 0.033) and higher monocyte: lymphocyte ratio (p = 0.037). CONCLUSIONS Low body mass index for age and higher monocyte: lymphocyte ratios were associated with microbiological confirmation in children with intrathoracic tuberculosis.
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Jenum S, Bakken R, Dhanasekaran S, Mukherjee A, Lodha R, Singh S, Singh V, Haks MC, Ottenhoff THM, Kabra SK, Doherty TM, Ritz C, Grewal HMS. BLR1 and FCGR1A transcripts in peripheral blood associate with the extent of intrathoracic tuberculosis in children and predict treatment outcome. Sci Rep 2016; 6:38841. [PMID: 27941850 PMCID: PMC5150239 DOI: 10.1038/srep38841] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 11/08/2016] [Indexed: 02/07/2023] Open
Abstract
Biomarkers reflecting the extent of Mycobacterium tuberculosis-induced pathology and normalization during anti-tuberculosis treatment (ATT) would considerably facilitate trials of new treatment regimens and the identification of patients with treatment failure. Therefore, in a cohort of 99 Indian children with intrathoracic tuberculosis (TB), we performed blood transcriptome kinetic analysis during ATT to explore 1) the association between transcriptional biomarkers in whole blood (WB) and the extent of TB disease at diagnosis and treatment outcomes at 2 and 6 months, and 2) the potential of the biomarkers to predict treatment response at 2 and 6 months. We present the first data on the association between transcriptional biomarkers and the extent of TB disease as well as outcome of ATT in children: Expression of three genes down-regulated on ATT (FCGR1A, FPR1 and MMP9) exhibited a positive correlation with the extent of TB disease, whereas expression of eight up-regulated genes (BCL, BLR1, CASP8, CD3E, CD4, CD19, IL7R and TGFBR2) exhibited a negative correlation with the extent of disease. Baseline levels of these transcripts displayed an individual capacity >70% to predict the six-month treatment outcome. In particular, BLR1 and FCGR1A seem to have a potential in monitoring and perhaps tailoring future antituberculosis therapy.
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Affiliation(s)
- Synne Jenum
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
- Department of Infectious Diseases, Oslo University Hospital, Oslo, Norway
| | - Rasmus Bakken
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - S. Dhanasekaran
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Aparna Mukherjee
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Sarman Singh
- Division of Clinical Microbiology & Molecular Medicine, Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Varinder Singh
- Department of Pediatrics, Kalawati Saran Children Hospital, New Delhi, India
| | - Marielle C. Haks
- Department of Infectious Diseases Group, Immunology and Immunogenetics of Bacterial Infectious Disease, Leiden University Medical Center, The Netherland
| | - Tom H. M. Ottenhoff
- Department of Infectious Diseases Group, Immunology and Immunogenetics of Bacterial Infectious Disease, Leiden University Medical Center, The Netherland
| | - S. K. Kabra
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Christian Ritz
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark
| | - Harleen M. S. Grewal
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
- Department of Microbiology, Haukeland university hospital, University of Bergen, N-5021, Norway
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Chiappini E, Lo Vecchio A, Garazzino S, Marseglia GL, Bernardi F, Castagnola E, Tomà P, Cirillo D, Russo C, Gabiano C, Ciofi D, Losurdo G, Bocchino M, Tortoli E, Tadolini M, Villani A, Guarino A, Esposito S. Recommendations for the diagnosis of pediatric tuberculosis. Eur J Clin Microbiol Infect Dis 2016; 35:1-18. [PMID: 26476550 DOI: 10.1007/s10096-015-2507-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 10/07/2015] [Indexed: 01/10/2023]
Abstract
Tuberculosis (TB) is still the world's second most frequent cause of death due to infectious diseases after HIV infection, and this has aroused greater interest in identifying and managing exposed subjects, whether they are simply infected or have developed one of the clinical variants of the disease. Unfortunately, not even the latest laboratory techniques are always successful in identifying affected children because they are more likely to have negative cultures and tuberculin skin test results, equivocal chest X-ray findings, and atypical clinical manifestations than adults. Furthermore, they are at greater risk of progressing from infection to active disease, particularly if they are very young. Consequently, pediatricians have to use different diagnostic strategies that specifically address the needs of children. This document describes the recommendations of a group of scientific societies concerning the signs and symptoms suggesting pediatric TB, and the diagnostic approach towards children with suspected disease.
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Prajapati S, Upadhyay K, Mukherjee A, Kabra SK, Lodha R, Singh V, Grewal HMS, Singh S. High prevalence of primary drug resistance in children with intrathoracic tuberculosis in India. Paediatr Int Child Health 2016; 36:214-8. [PMID: 26052730 DOI: 10.1179/2046905515y.0000000041] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Drug susceptibility testing (DST) of Mycobacterium tuberculosis (Mtb) isolates is crucial for the effective treatment of tuberculosis. Data on DST patterns in Mtb isolates in childhood tuberculosis are scanty. AIMS To determine drug resistance patterns in Mtb isolates from a paediatric TB cohort in North India. METHODS 403 children aged 6 months to14 year with probable intrathoracic tuberculosis were enrolled prospectively. All were treatment-naïve. 802 ambulatory-induced sputa (IS) and 787 gastric aspirate (GA) samples were cultured in BACTEC-MGIT960 system, and DST of the Mtb isolates was undertaken using the automated BACTEC-MGIT960 SIRE kit. RESULTS Of the 403 children, 147 (36.4%) were culture-confirmed: 132 (89.8%) isolates were Mtb and 15 (10.2%) non-tuberculous mycobacteria (NTM). Five Mtb isolates were contaminated and the remaining 127 were subjected to in-vitro drug susceptibility testing against streptomycin, isoniazid, rifampicin and ethambutol. Twenty-six (20.47%) isolates were resistant to one or more drugs, seven (5.5%) were resistant to rifampicin singly or in combination, and 11 (8.7%) were resistant to isoniazid singly or in combination. Mono-resistance to isoniazid, rifampicin, streptomycin and ethambutol was detected in four (3.1%), one (0.8%), four (3.1%) and two (1.6%), respectively. Five children (3.9%) had MDR-TB; 101 (79.9%) children had Mtb isolates which were sensitive to all four drugs. CONCLUSIONS The rifampicin and isoniazid resistance rates were much higher than those in the adult TB population in India.
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Affiliation(s)
- Suneel Prajapati
- a Division of Clinical Microbiology and Molecular Medicine , Department of Laboratory Medicine
| | - Kriti Upadhyay
- a Division of Clinical Microbiology and Molecular Medicine , Department of Laboratory Medicine
| | - Aparna Mukherjee
- b Department of Paediatrics , All India Institute of Medical Sciences
| | - S K Kabra
- b Department of Paediatrics , All India Institute of Medical Sciences
| | - Rakesh Lodha
- b Department of Paediatrics , All India Institute of Medical Sciences
| | - Varinder Singh
- c Department of Paediatrics , Kalawati Saran Children Hospital , New Delhi , India
| | - Harleen M S Grewal
- d Section of Microbiology and Immunology, The Gade Institute, University of Bergen and Department of Microbiology , Haukeland University Hospital , Bergen , Norway
| | - Sarman Singh
- a Division of Clinical Microbiology and Molecular Medicine , Department of Laboratory Medicine
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Laboratory Diagnosis of Mycobacterium tuberculosis Infection and Disease in Children. J Clin Microbiol 2016; 54:1434-1441. [PMID: 26984977 DOI: 10.1128/jcm.03043-15] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Diagnosis of tuberculosis in children is challenging; even with advanced technologies, the diagnosis is often difficult to confirm microbiologically in part due to the paucibacillary nature of the disease. Clinical diagnosis lacks standardization, and traditional and molecular microbiologic methods lack sensitivity, particularly in children. Immunodiagnostic tests may improve sensitivity, but these tests cannot distinguish tuberculosis disease from latent infection and some lack specificity. While molecular tools like Xpert MTB/RIF have advanced our ability to detect Mycobacterium tuberculosis and to determine antimicrobial resistance, decades old technologies remain the standard in most locales. Today, the battle against this ancient disease still poses one of the primary diagnostic challenges in pediatric laboratory medicine.
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13
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Detection Yield and Tolerability of String Test for Diagnosis of Childhood Intrathoracic Tuberculosis. Pediatr Infect Dis J 2016; 35:146-51. [PMID: 26517328 DOI: 10.1097/inf.0000000000000956] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Difficulty to obtain sputum in children complicates diagnosis of intrathoracic tuberculosis (TB). The intragastric string test (ST) used for retrieval of enteric pathogens might be an alternative specimen collection method but requires further evaluation of its utility in TB diagnosis. We conducted a cross-sectional study comparing the TB detection yield and the tolerability of ST and sputum induction (SI) in children. METHODS Two ST and SI procedures were performed in children (3-14 years of age) who were clinically suspected of having TB. The string was removed after a 2-hour gastric downtime, and SI was done after a maximum of 20 minutes nebulization with 5% saline solution. LED-fluorescence microscopy and mycobacterial cultures were performed on all specimens, and XpertMTB/RIF assay was performed on stored specimen sediments. Tolerability questionnaires were administered to parents of children. RESULTS Of 137 included children (median age: 8.1 years; 33.3% with HIV infection), 14 (10.2%) were diagnosed with TB, 10 (71.4%) by ST and 12 (85.7%) by SI. Among 105 children with both ST and SI performed, 5 (4.8%) versus 4 (3.8%) were smear positive using ST and SI, respectively (McNemar P = 1.00). Nine (8.6%) in each group had positive cultures (P = 1.00). Of 64 children tested with XpertMTB/RIF, 3 (4.7%) of the ST group versus 4 (6.3%) of the SI group were TB positive (P = 1.00). No adverse serious events were reported. ST could not be performed in 22 of 137 (16.1%) children because they were unable to swallow the capsule. CONCLUSIONS TB detection yield was comparable between ST and SI. The tolerability of ST in young children might be improved by the reduction of the size of the capsule.
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Galli L, Lancella L, Garazzino S, Tadolini M, Matteelli A, Migliori GB, Principi N, Villani A, Esposito S. Recommendations for treating children with drug-resistant tuberculosis. Pharmacol Res 2016; 105:176-82. [PMID: 26821118 DOI: 10.1016/j.phrs.2016.01.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 01/13/2016] [Accepted: 01/15/2016] [Indexed: 10/22/2022]
Abstract
Tuberculosis (TB) is still one of the most difficult infectious diseases to treat, and the second most frequent cause of death due to infectious disease throughout the world. The number of cases of multidrug-resistant (MDR-TB) and extensively drug-resistant TB (XDR-TB), which are characterised by high mortality rates, is increasing. The therapeutic management of children with MDR- and XDR-TB is complicated by a lack of knowledge, and the fact that many potentially useful drugs are not registered for pediatric use and there are no formulations suitable for children in the first years of life. Furthermore, most of the available drugs are burdened by major adverse events that need to be taken into account, particularly in the case of prolonged therapy. This document describes the recommendations of a group of scientific societies on the therapeutic approach to pediatric MDR- and XDR-TB. On the basis of a systematic literature review and their personal clinical experience, the experts recommend that children with active TB caused by a drug-resistant strain of Mycobacterium tuberculosis should always be referred to a specialised centre because of the complexity of patient management, the paucity of pediatric data, and the high incidence of adverse events due to second-line anti-TB treatment.
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Affiliation(s)
- Luisa Galli
- Department of Health Sciences, University of Florence, Pediatric Infectious Diseases Division, Anna Meyer Children's University Hospital, Florence, Italy
| | - Laura Lancella
- Unit of General Pediatrics and Pediatric Infectious Diseases, IRCCS Bambino Gesù Hospital, Rome, Italy
| | - Silvia Garazzino
- Pediatric Infectious Diseases Unit, Regina Margherita Hospital, University of Turin, Turin, Italy
| | - Marina Tadolini
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Alberto Matteelli
- World Health Organization, Global Tuberculosis Programme, Geneva, Switzerland
| | - Giovanni Battista Migliori
- World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy
| | - Nicola Principi
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Villani
- Unit of General Pediatrics and Pediatric Infectious Diseases, IRCCS Bambino Gesù Hospital, Rome, Italy
| | - Susanna Esposito
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
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Jenum S, Dhanasekaran S, Lodha R, Mukherjee A, Kumar Saini D, Singh S, Singh V, Medigeshi G, Haks MC, Ottenhoff THM, Doherty TM, Kabra SK, Ritz C, Grewal HMS. Approaching a diagnostic point-of-care test for pediatric tuberculosis through evaluation of immune biomarkers across the clinical disease spectrum. Sci Rep 2016; 6:18520. [PMID: 26725873 PMCID: PMC4698754 DOI: 10.1038/srep18520] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 11/09/2015] [Indexed: 02/07/2023] Open
Abstract
The World Health Organization (WHO) calls for an accurate, rapid, and simple point-of-care (POC) test for the diagnosis of pediatric tuberculosis (TB) in order to make progress "Towards Zero Deaths". Whereas the sensitivity of a POC test based on detection of Mycobacterium tuberculosis (MTB) is likely to have poor sensitivity (70-80% of children have culture-negative disease), host biomarkers reflecting the on-going pathological processes across the spectrum of MTB infection and disease may hold greater promise for this purpose. We analyzed transcriptional immune biomarkers direct ex-vivo and translational biomarkers in MTB-antigen stimulated whole blood in 88 Indian children with intra-thoracic TB aged 6 months to 15 years, and 39 asymptomatic siblings. We identified 12 biomarkers consistently associated with either clinical groups "upstream" towards culture-positive TB on the TB disease spectrum (CD14, FCGR1A, FPR1, MMP9, RAB24, SEC14L1, and TIMP2) or "downstream" towards a decreased likelihood of TB disease (BLR1, CD3E, CD8A, IL7R, and TGFBR2), suggesting a correlation with MTB-related pathology and high relevance to a future POC test for pediatric TB. A biomarker signature consisting of BPI, CD3E, CD14, FPR1, IL4, TGFBR2, TIMP2 and TNFRSF1B separated children with TB from asymptomatic siblings (AUC of 88%).
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Affiliation(s)
- Synne Jenum
- Department of Global Public Health and Primary Care, University of Bergen, and Department of Medical Microbiology, Vestre Viken Hospital Trust, Drammen, Norway
| | - S. Dhanasekaran
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, N-5021, Norway
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Aparna Mukherjee
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Kumar Saini
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Sarman Singh
- Division of Clinical Microbiology & Molecular Medicine, Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Varinder Singh
- Department of Pediatrics, Kalawati Saran Children Hospital, New Delhi, India
| | - Guruprasad Medigeshi
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Marielle C. Haks
- Department of Infectious Diseases Group, Immunology and Immunogenetics of Bacterial Infectious Disease, Leiden University Medical Center, The Netherland
| | - Tom H. M. Ottenhoff
- Department of Infectious Diseases Group, Immunology and Immunogenetics of Bacterial Infectious Disease, Leiden University Medical Center, The Netherland
| | | | - Sushil K. Kabra
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Christian Ritz
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark
| | - Harleen M. S. Grewal
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, N-5021, Norway
- Department of Microbiology, Haukeland university hospital, University of Bergen,N-5021, Norway
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16
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Salazar-Austin N, Ordonez AA, Hsu AJ, Benson JE, Mahesh M, Menachery E, Razeq JH, Salfinger M, Starke JR, Milstone AM, Parrish N, Nuermberger EL, Jain SK. Extensively drug-resistant tuberculosis in a young child after travel to India. THE LANCET. INFECTIOUS DISEASES 2015; 15:1485-91. [PMID: 26607130 DOI: 10.1016/s1473-3099(15)00356-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 09/14/2015] [Accepted: 09/21/2015] [Indexed: 02/07/2023]
Abstract
Extensively drug-resistant (XDR) tuberculosis is becoming increasingly prevalent worldwide, but little is known about XDR tuberculosis in young children. In this Grand Round we describe a 2-year-old child from the USA who developed pneumonia after a 3 month visit to India. Symptoms resolved with empirical first-line tuberculosis treatment; however, a XDR strain of Mycobacterium tuberculosis grew in culture. In the absence of clinical or microbiological markers, low-radiation exposure pulmonary CT imaging was used to monitor treatment response, and guide an individualised drug regimen. Management was complicated by delays in diagnosis, uncertainties about drug selection, and a scarcity of child-friendly formulations. Treatment has been successful so far, and the child is in remission. This report of XDR tuberculosis in a young child in the USA highlights the risks of acquiring drug-resistant tuberculosis overseas, and the unique challenges in management of tuberculosis in this susceptible population.
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Affiliation(s)
- Nicole Salazar-Austin
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alvaro A Ordonez
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alice Jenh Hsu
- Department of Pharmacy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jane E Benson
- Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mahadevappa Mahesh
- Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Jafar H Razeq
- Maryland Department of Health and Mental Hygiene, Laboratories Administration, Baltimore, MD, USA
| | - Max Salfinger
- National Jewish Health Mycobacteriology Laboratory, Denver, CO, USA
| | - Jeffrey R Starke
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Aaron M Milstone
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Hospital Epidemiology and Infection Control, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nicole Parrish
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eric L Nuermberger
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sanjay K Jain
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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17
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Singh S, Singh A, Prajapati S, Kabra SK, Lodha R, Mukherjee A, Singh V, Hesseling AC, Grewal HMS. Xpert MTB/RIF assay can be used on archived gastric aspirate and induced sputum samples for sensitive diagnosis of paediatric tuberculosis. BMC Microbiol 2015; 15:191. [PMID: 26420261 PMCID: PMC4589030 DOI: 10.1186/s12866-015-0528-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 09/22/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) in children is neglected, mainly due to lack of sensitive diagnostic tools. Recently Xpert MTB/RIF assay has revolutionized the diagnostic field, but its usefulness in pediatric TB has not been reported from India and no report is available on its use on long term archived samples. METHODS We recruited 130 pediatric patients with probable intrathoracic tuberculosis and their gastric aspirate (GA) and induced sputum (IS) samples on 2 consecutive days were collected between January 2009 and December 2012. All samples (n = 520) were subjected to smear examination, BACTEC-MGIT culture and in-house multiplex PCR. An aliquot of each sample was stored at -80 °C and tested in Xpert MTB/RIF assay in 2013. RESULTS Sample wise and patient wise detection rate of smear microscopy was 4.4 % and 10 %, while for BACTEC-MGIT culture this rate was 24.4 % and 46.9 %, respectively. Of the 130 day 1 GA samples, 31.5 % and 27.7 % day 2 GA samples were culture positive. Only 17.7 % GA samples were positive on both days. Of the 130 IS samples collected on day 1 and day 2, 15.4 % and 23.1 % samples were culture positive. A combination of GA and IS yielded best results. Combining both GA and IS, the overall sensitivity of Xpert MTB/RIF on smear and culture positive samples was 95.6 %. In smear negative and culture positive samples its sensitivity was 62.5 %. The duration of sample storage impacted the Xpert MTB/RIF test performance (p = 0.0001). In smear positive samples stored for 650-849 days, its sensitivity was 85.7 % and 77.1 % for IS and GA samples which dropped to 33.3 % and 50 %, respectively, if stored for more than 1050 days. DISCUSSION Confirmatory diagnosis of tuberculosis particularly in children is a medical challenge. No laboratory or radiological test can reach to a satisfactory level of diagnostic sensitivity. However, in this study we found that combination of multiple samples and multiple diagnostic tests can give much better yield, though not optimum. In present study, combination of 2 gastric aspirates (GA) and 2 induced sputum (IS) samples collected on two consecutive days, and tested on three diagnostic methods yielded a significantly high detection rate. Despite long term storage, the overall sensitivity of Xpert MTB/RIF on smear and -culture positive samples remained very high. But after storing these samples under subfreezing conditions the sensitivity of Xpert MTB/RIF decreased significantly. This is expected because even if the sample is smear and culture positive, the count of surviving mycobacteria goes down, after several years this count can reach to a undetectable level. CONCLUSION This report shows that smear and culture positive samples stored at subfreezing conditions for several years can be used in the Xpert MTB/RIF assay, while maintaining appreciable diagnostic test sensitivity and specificity.
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Affiliation(s)
- Sarman Singh
- Division of Clinical Microbiology and Molecular Medicine, Department of Laboratory Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
| | - Amit Singh
- Division of Clinical Microbiology and Molecular Medicine, Department of Laboratory Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
| | - Suneel Prajapati
- Division of Clinical Microbiology and Molecular Medicine, Department of Laboratory Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
| | - Sushil K Kabra
- Department of Paediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
| | - Rakesh Lodha
- Department of Paediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
| | - Aparna Mukherjee
- Department of Paediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
| | - Varinder Singh
- Department of Paediatrics, Kalawati Saran Children Hospital, New Delhi, 110 001, India.
| | - Anneke C Hesseling
- Paediatric Research, Desmond Tutu TB Centre, University of Stellenbosch, Stellenbosch, South Africa.
| | - Harleen M S Grewal
- Department Clinical Science, Infection, University of Bergen, Bergen, Norway.
- Department of Microbiology, Haukeland University Hospital, Bergen, N-5021, Norway.
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18
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Triasih R. Newer Diagnostic Tests for Pulmonary Tuberculosis in Children. Indian J Pediatr 2015. [PMID: 26220244 DOI: 10.1007/s12098-015-1848-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
It has been well recognized that the diagnosis of pulmonary tuberculosis in children is often compromised by non-specific symptoms, paucibacillary nature of the disease, and the difficulty in collecting the specimen. Consequently, most tuberculosis cases in children are not confirmed, due to which the estimation of the global burden of tuberculosis in children may be inaccurate. There has also been a common misperception that diagnosis of tuberculosis and collecting respiratory specimen in children is always difficult. Because of this, microbiological confirmation of tuberculosis in young children is not routinely attempted in most endemic areas. With the emergence of HIV-related tuberculosis disease and drug-resistant tuberculosis, the availability of accurate, rapid and child friendly diagnostic tools to identify Mycobacterium tuberculosis in respiratory specimen are urgently required in endemic settings. There have been a large number of studies evaluating new diagnostic tests for tuberculosis in the past decade, but few have been evaluated in children. This review will address the developments in respiratory specimen collection and laboratory diagnostic tests of tuberculosis, with a focus on those that have been evaluated in children.
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Affiliation(s)
- Rina Triasih
- Department of Pediatrics, Dr. Sardjito Hospital/Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia,
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19
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Venturini E, Remaschi G, Berti E, Montagnani C, Galli L, de Martino M, Chiappini E. What steps do we need to take to improve diagnosis of tuberculosis in children? Expert Rev Anti Infect Ther 2015; 13:907-22. [PMID: 25938981 DOI: 10.1586/14787210.2015.1040764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Tuberculosis still represents a big global public health challenge. The diagnosis of tuberculosis and the differentiation between active and latent tuberculosis remain difficult, particularly in childhood, because of the lack of a gold standard test for diagnosis. In the last decade, novel diagnostic assays have been developed. Among immunologic tests, new assays based on the measurement of different cytokines released by specific T cells in response to Mycobacterium tuberculosis antigens, other than INF-γ, have been investigated. Promising results rely on nucleic acid amplification techniques, also able to detect drugs resistance. Innovative research fields studied the modifications of CD27 expression in T cells as well as different host gene expression in response to M. tuberculosis. Further studies are needed to assess the diagnostic value and the accuracy of these new assays.
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Affiliation(s)
- Elisabetta Venturini
- Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy
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20
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Abstract
Tuberculosis (TB) in children is a common cause of morbidity. Diagnosis is difficult because of paucibacillary nature of illness and difficulty in obtaining appropriate samples. Children presenting with poor weight gain, fever with or without cough for more than two weeks or contact with an adult in family with pulmonary tuberculosis should be investigated for TB. In all suspected cases of tuberculosis initial investigations include radiograph of chest (CXR) and Mantoux test. If CXR is suggestive of TB, an ambulatory gastric aspirate and induced sputum for acid fast bacilli (AFB) smear may be carried out in two days. Children with AFB positive or abnormal CXR with positive Mantoux test should be started on Antitubercular therapy (ATT). Rest of the patients require more investigations and should be referred to a specialist. All children with newly diagnosed tuberculosis should be treated with 6 mo of ATT (two months with 4 drugs, followed by four months with 2 drugs). Children on ATT should be monitored for improvement in symptoms and weight gain along with side effects of medications. CXR should be done after completion of treatment.
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21
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Lodha R, Mukherjee A, Singh V, Singh S, Friis H, Faurholt-Jepsen D, Bhatnagar S, Saini S, Kabra SK, Grewal HMS. Effect of micronutrient supplementation on treatment outcomes in children with intrathoracic tuberculosis: a randomized controlled trial. Am J Clin Nutr 2014; 100:1287-97. [PMID: 25332327 DOI: 10.3945/ajcn.113.082255] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Micronutrients play an important role in immune function. To our knowledge, there have been no comprehensive studies on the role of micronutrient supplementation in children with tuberculosis. OBJECTIVE We assessed the effect of micronutrient supplementation in children treated with antituberculosis therapy (ATT). DESIGN A randomized, double-blind, placebo-controlled trial that used a 2 × 2 factorial design was undertaken at 2 teaching hospitals in Delhi. Children with newly diagnosed intrathoracic tuberculosis were enrolled, and they received ATT together with daily supplementation for 6 mo with either zinc alone, micronutrients without zinc, micronutrients in combination with zinc, or a placebo. Main outcomes were weight gain and an improvement in a chest X-ray (CXR) lesion assessed at 6 mo of treatment. RESULTS A total of 403 children were enrolled and randomly assigned. A microbiological diagnosis of tuberculosis was confirmed in 179 children (44.4%). The median (95% CI) increase in weight-for-age z score at 6 mo was not significantly different between subjects who received micronutrients [0.75 (0.66, 0.84)] and those who did not receive micronutrients [0.76 (0.67, 0.85)] and between subjects who received zinc [0.76 (0.68, 0.85)] and those who did not receive zinc [0.75 (0.66, 0.83)]. An improvement in CXR was observed in 285 children, but there was no difference between those receiving zinc and no zinc or between those receiving micronutrients and no micronutrients after 6 mo of ATT. However, children who received micronutrients had a faster gain in height over 6 mo than did those who did not receive micronutrients (height-for-age z score Δ = 0.08; P = 0.014). CONCLUSIONS Micronutrient supplementation did not modify the weight gain or clearance of lesions on CXR in children with intrathoracic tuberculosis. However, micronutrient supplementation during treatment may improve height gain in children with intrathoracic tuberculosis. This trial was registered at clinicaltrials.gov as NCT00801606.
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Affiliation(s)
- Rakesh Lodha
- From the Department of Pediatrics (RL, AM, SB, S Saini, and SKK) and Division of Clinical Microbiology & Molecular Medicine, Laboratory Medicine (S Singh), All India Institute of Medical Sciences, New Delhi, India; the Department of Pediatrics, Kalawati Saran Children Hospital, New Delhi, India (VS); the Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark (HF and DF-J); and the Department of Clinical Science, Infection, University of Bergen, Bergen, Norway (HMSG)
| | - Aparna Mukherjee
- From the Department of Pediatrics (RL, AM, SB, S Saini, and SKK) and Division of Clinical Microbiology & Molecular Medicine, Laboratory Medicine (S Singh), All India Institute of Medical Sciences, New Delhi, India; the Department of Pediatrics, Kalawati Saran Children Hospital, New Delhi, India (VS); the Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark (HF and DF-J); and the Department of Clinical Science, Infection, University of Bergen, Bergen, Norway (HMSG)
| | - Varinder Singh
- From the Department of Pediatrics (RL, AM, SB, S Saini, and SKK) and Division of Clinical Microbiology & Molecular Medicine, Laboratory Medicine (S Singh), All India Institute of Medical Sciences, New Delhi, India; the Department of Pediatrics, Kalawati Saran Children Hospital, New Delhi, India (VS); the Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark (HF and DF-J); and the Department of Clinical Science, Infection, University of Bergen, Bergen, Norway (HMSG)
| | - Sarman Singh
- From the Department of Pediatrics (RL, AM, SB, S Saini, and SKK) and Division of Clinical Microbiology & Molecular Medicine, Laboratory Medicine (S Singh), All India Institute of Medical Sciences, New Delhi, India; the Department of Pediatrics, Kalawati Saran Children Hospital, New Delhi, India (VS); the Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark (HF and DF-J); and the Department of Clinical Science, Infection, University of Bergen, Bergen, Norway (HMSG)
| | - Henrik Friis
- From the Department of Pediatrics (RL, AM, SB, S Saini, and SKK) and Division of Clinical Microbiology & Molecular Medicine, Laboratory Medicine (S Singh), All India Institute of Medical Sciences, New Delhi, India; the Department of Pediatrics, Kalawati Saran Children Hospital, New Delhi, India (VS); the Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark (HF and DF-J); and the Department of Clinical Science, Infection, University of Bergen, Bergen, Norway (HMSG)
| | - Daniel Faurholt-Jepsen
- From the Department of Pediatrics (RL, AM, SB, S Saini, and SKK) and Division of Clinical Microbiology & Molecular Medicine, Laboratory Medicine (S Singh), All India Institute of Medical Sciences, New Delhi, India; the Department of Pediatrics, Kalawati Saran Children Hospital, New Delhi, India (VS); the Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark (HF and DF-J); and the Department of Clinical Science, Infection, University of Bergen, Bergen, Norway (HMSG)
| | - Shinjini Bhatnagar
- From the Department of Pediatrics (RL, AM, SB, S Saini, and SKK) and Division of Clinical Microbiology & Molecular Medicine, Laboratory Medicine (S Singh), All India Institute of Medical Sciences, New Delhi, India; the Department of Pediatrics, Kalawati Saran Children Hospital, New Delhi, India (VS); the Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark (HF and DF-J); and the Department of Clinical Science, Infection, University of Bergen, Bergen, Norway (HMSG)
| | - Savita Saini
- From the Department of Pediatrics (RL, AM, SB, S Saini, and SKK) and Division of Clinical Microbiology & Molecular Medicine, Laboratory Medicine (S Singh), All India Institute of Medical Sciences, New Delhi, India; the Department of Pediatrics, Kalawati Saran Children Hospital, New Delhi, India (VS); the Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark (HF and DF-J); and the Department of Clinical Science, Infection, University of Bergen, Bergen, Norway (HMSG)
| | - Sushil K Kabra
- From the Department of Pediatrics (RL, AM, SB, S Saini, and SKK) and Division of Clinical Microbiology & Molecular Medicine, Laboratory Medicine (S Singh), All India Institute of Medical Sciences, New Delhi, India; the Department of Pediatrics, Kalawati Saran Children Hospital, New Delhi, India (VS); the Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark (HF and DF-J); and the Department of Clinical Science, Infection, University of Bergen, Bergen, Norway (HMSG)
| | - Harleen M S Grewal
- From the Department of Pediatrics (RL, AM, SB, S Saini, and SKK) and Division of Clinical Microbiology & Molecular Medicine, Laboratory Medicine (S Singh), All India Institute of Medical Sciences, New Delhi, India; the Department of Pediatrics, Kalawati Saran Children Hospital, New Delhi, India (VS); the Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark (HF and DF-J); and the Department of Clinical Science, Infection, University of Bergen, Bergen, Norway (HMSG)
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