Bone and joint tuberculosis in paediatrics: a 13-year retrospective study

Introduction. Bone and joint tuberculosis (BJTB) is rare in developed countries, particularly in the paediatric population.Hypothesis/Gap Statement. The clinical features and sequelae of paediatric BJTB in Europe are not well characterized and should be assessed to achieve a better approach.Aim. To assess the management and outcomes of paediatric BJTB.Methodology. Longitudinal observational study of all paediatric patients (0-17 years old) diagnosed with BJTB between 2008 to 2020 in a tertiary-care hospital.Results. We identified 18 patients with BJTB, with a median age of 10 years (IQR 6-14.8), 66.7 % male. Most (72 %) were diagnosed after 2015 and were foreign-born (88.9 %), mainly from Portuguese-speaking African countries, and none had HIV. The most common symptoms were pain (77.8 %), fever (50 %) and bone deformity (44.4 %). Spinal TB (STB) affected 13 (72.2 %) and extra-spinal TB (ESTB) 9 (50 %) patients, and 4 (27.7 %) had both conditions. Diagnostic positive procedures included positive nucleic acid amplification technique (NAAT) (44.4 %), Mycobacterium tuberculosis isolation (44.4 %) and compatible histology (33.3 %). All completed antituberculous drugs for a median of 12 months (IQR 12-13) and nine (50 %) had surgery. Overall, acute complications occurred in 16 (88.9 %) patients - 11/13 (84.6 %) with STB and 5/5 (100 %) with ESTB - and included abscesses, spinal compression, spine deformity and pathological fractures. Sequelae were still present at the 12-month follow-up in seven cases (46.7 %), and were more common in foreign-born patients sent to Portugal to receive medical treatment (66.7 vs 20 %).Conclusions. Paediatric BJTB is difficult to diagnose and has high morbidity, requiring long-term follow-up. Over the last decade, foreign-born TB seems to be increasing, with still longer treatment courses and more acute complications and sequelae.

Use of Xpert MTB/RIF and Xpert Ultra in extrapulmonary tuberculosis

INTRODUCTION

Tuberculosis (TB) remains a major global health burden. There still remains a large gap between the notified and estimated incident cases. Extrapulmonary (EP) TB represents 15% of all TB cases and the diagnosis is more challenging due to the paucity of the organism. Smear microscopy is often insensitive and culture methods are prolonged. With the introduction of Xpert MTB/RIF and more recently Xpert Ultra, this has changed TB diagnostics by providing a rapid accessible platform to diagnose TB and identify rifampicin resistance within 2 h.

AREAS COVERED

The diagnostic accuracy and the clinical role of Xpert MTB/RIF and Xpert Ultra in the different forms of EPTB.

EXPERT OPINION

Whilst significant advances have been made in TB diagnostics, there is still a need to optimize the diagnostic yield of Xpert MTB/RIF and Xpert Ultra in EPTB samples. Research is needed to facilitate standardization and optimal preparation of samples as well as understanding the role of Xpert MTB/RIF and Xpert Ultra in different burden settings. Alongside the current GeneXpert platform, the launch of rapid second-line drug resistance polymerase chain reactions and whole genome sequencing may help tackle the global health burden with a more comprehensive diagnostic approach and appropriate treatment.

The diagnostic value of Red Flags in thoracolumbar pain: a systematic review

PURPOSE

Red Flags (RFs) are signs and symptoms related to the screening of serious underlying pathologies mimicking a musculoskeletal pain. The current literature wonders about the usefulness of RFs, due to high false-positive rates and low diagnostic accuracy. The aims of this systematic review are: (a) to identify and (b) to evaluate the most important RFs that could be found by a health care professional during the assessment of patients with low and upper back pain (named as thoracolumbar pain (TLP)) to screen serious pathologies.

MATERIALS AND METHODS

A systematic review of the literature was conducted. Searches were performed on seven databases (Pubmed, Web of Science, Cochrane Library, Pedro, Scielo, CINAHL, and Google Scholar) between March 2019 and June 2020, using a search string which included synonyms of low back pain (LBP), chest pain (CP), differential diagnosis, RF, and serious disease. Only observational studies enrolling patients with LBP or CP were included. Risk of bias was assessed with the Newcastle Ottawa Scale and inter-rater agreement between authors for full-text selection was evaluated with Cohen's Kappa. Where possible the diagnostic accuracy was recorded for sensitivity (Sn), specificity (Sp), and positive/negative likelihood ratio (LR+/LR-).

RESULTS

Forty full-texts were included. Most of the included observational studies were judged as low risk of bias, and Cohen's Kappa was good (=0.78). The identified RFs were: advanced age; neurological signs; history of trauma; malignancy; female gender; corticosteroids use; night pain; unintentional weight loss; bladder or bowel dysfunction; loss of anal sphincter tone; saddle anaesthesia; constant pain; recent infection; family or personal history of heart or pulmonary diseases; dyspnoea; fever; postprandial CP; typical reflux symptoms; haemoptysis; sweating; pain radiated to upper limbs; hypotension; retrosternal pain; exertional pain; diaphoresis; and tachycardia. The diagnostic accuracy of RFs as self-contained screening tool was low, while the combination of multiple RFs showed to increase the probability to identify serious pathologies.

CONCLUSIONS

Despite the use of single RF should not be recommended for the screening process in clinical practice, the combination of multiple RFs to enhance diagnostic accuracy is promising. Moreover, the identified RFs could be a baseline to develop a screening tool for patients with TLP.Implications for rehabilitationDifferential diagnosis and screening for referral are mandatory skills for each healthcare professional in direct access clinical settings, and should be the primary step for an appropriate management of a patient with signs and symptoms mimicking serious pathologies in thoracolumbar region.Clinical reasoning and decision-making processes are essential throughout all phases of a patient's pathway of care. By which, the use of single Red Flag (RF) as a self-contained screening tool should not be recommended. The combination of multiple RFs promises to increase diagnostic accuracy and could grow into an excellent screening tool for thoracolumbar pain.