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Yuan B, Ma CQ. Perianal tuberculous ulcer with active pulmonary, intestinal and orificial tuberculosis: A case report. World J Radiol 2024; 16:356-361. [PMID: 39239247 PMCID: PMC11372554 DOI: 10.4329/wjr.v16.i8.356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 06/20/2024] [Accepted: 07/18/2024] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND Orificial tuberculosis is a rare type of tuberculosis, which is easy to be misdiagnosed, and can cause great damage to the perianal skin and mucosa. Early diagnosis can avoid further erosion of the perianal muscle tissue by tuberculosis bacteria. CASE SUMMARY Here, we report a case of disseminated tuberculosis in a 62-year-old male patient with a perianal tuberculous ulcer and active pulmonary tuberculosis, intestinal tuberculosis and orificial tuberculosis. This is an extremely rare case of cutaneous tuberculosis of the anus, which was misdiagnosed for nearly a year. The patient received conventional treatment in other medical institutions, but specific treatment was delayed. Ultimately, proper diagnosis and treatment with standard anti-tuberculosis drugs for one year led to complete cure. CONCLUSION For skin ulcers that do not heal with repeated conventional treatments, consider ulcers caused by rare bacteria, such as Mycobacterium tuberculosis.
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Affiliation(s)
- Bao Yuan
- Department of General Surgery, Jiangyin Hospital Affiliated to Nanjing University of Chinese Medicine, Wuxi 214400, Jiangsu Province, China
| | - Chao-Qun Ma
- Department of General Surgery, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
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Xu T, Lai Q, Qu N, Zhang B, Qi Q. Diagnostic Values of Peripheral Blood T-Cell Spot Test for Tuberculosis (T-SPOT.TB) for Spinal Tuberculosis. Surg Infect (Larchmt) 2023. [PMID: 37437114 DOI: 10.1089/sur.2023.089] [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: 07/14/2023] Open
Abstract
Background: The T-cell spot test for tuberculosis (T-SPOT.TB) with false positives and false negatives exists in the diagnosis of spinal infection. The objective of this study was to increase the diagnostic value precision and specificity of T-SPOT.TB in the identification of spinal tuberculosis (TB). Patients and Methods: Fifty-two patients suspected of having spinal TB from April 2020 to December 2021 were included, and all patients received T-SPOT.TB tests and surgical treatment. The composite reference standard was used to diagnose spinal TB. The T-SPOT.TB values were compared according to whether spinal TB was diagnosed, and the optimal cutoff values of diagnosis was determined by receiver operating characteristic (ROC) curve analysis. Results: All patients were followed up for at least one year. The sensitivity, specificity, positive predictive value, and negative predictive value of the T-SPOT.TB test in assisting the diagnosis of spinal TB were 91.67%, 71.43%, 73.33%, and 90.9%, respectively. We determined that the values of early secreted antigen target 6 (ESAT-6) antigen and culture filter protein 10 (CFP-10) antigen were determined to be diagnostic for spinal tuberculosis, with areas under the curve equal to 0.776 and 0.852, respectively; the cutoff values for the diagnosis of ESAT-6 antigen and CFP-10 antigen were calculated as 40.5 spot forming cells (SFCs) per 106 peripheral blood mononuclear cells (PBMCs) and 26.5 SFCs/106 PBMCs, respectively. Follow-up for all patients was 12 months, and in this period, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), visual analog scale (VAS) score, and Oswestry Dysfunction Index (ODI%) were different between groups (p < 0.05). Conclusions: The T-SPOT.TB test is considered a milestone discovery in the diagnosis of TB; there are still many false-positive samples, but the diagnostic specificity was improved in the study, allowing spinal infections to be treated accurately and in a timely manner.
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Affiliation(s)
- Tiantian Xu
- Department of Orthopaedics, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qi Lai
- Department of Orthopaedics, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ning Qu
- Department of Orthopaedics, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Bin Zhang
- Department of Orthopaedics, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qihua Qi
- Department of Orthopaedics, The First Affiliated Hospital of Nanchang University, Nanchang, China
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Hamada Y, Gupta RK, Quartagno M, Izzard A, Acuna-Villaorduna C, Altet N, Diel R, Dominguez J, Floyd S, Gupta A, Huerga H, Jones-López EC, Kinikar A, Lange C, van Leth F, Liu Q, Lu W, Lu P, Rueda IL, Martinez L, Mbandi SK, Muñoz L, Padilla ES, Paradkar M, Scriba T, Sester M, Shanaube K, Sharma SK, Sloot R, Sotgiu G, Thiruvengadam K, Vashishtha R, Abubakar I, Rangaka MX. Predictive performance of interferon-gamma release assays and the tuberculin skin test for incident tuberculosis: an individual participant data meta-analysis. EClinicalMedicine 2023; 56:101815. [PMID: 36636295 PMCID: PMC9829704 DOI: 10.1016/j.eclinm.2022.101815] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 01/06/2023] Open
Abstract
Background Evidence on the comparative performance of purified protein derivative tuberculin skin tests (TST) and interferon-gamma release assays (IGRA) for predicting incident active tuberculosis (TB) remains conflicting. We conducted an individual participant data meta-analysis to directly compare the predictive performance for incident TB disease between TST and IGRA to inform policy. Methods We searched Medline and Embase from 1 January 2002 to 4 September 2020, and studies that were included in previous systematic reviews. We included prospective longitudinal studies in which participants received both TST and IGRA and estimated performance as hazard ratios (HR) for the development of all diagnoses of TB in participants with dichotomised positive test results compared to negative results, using different thresholds of positivity for TST. Secondary analyses included an evaluation of the impact of background TB incidence. We also estimated the sensitivity and specificity for predicting TB. We explored heterogeneity through pre-defined sub-group analyses (e.g. country-level TB incidence). Publication bias was assessed using funnel plots and Egger's test. This review is registered with PROSPERO, CRD42020205667. Findings We obtained data from 13 studies out of 40 that were considered eligible (N = 32,034 participants: 36% from countries with TB incidence rate ≥100 per 100,000 population). All reported data on TST and QuantiFERON Gold in-Tube (QFT-GIT). The point estimate for the TST was highest with higher cut-offs for positivity and particularly when stratified by bacillus Calmette-Guérin vaccine (BCG) status (15 mm if BCG vaccinated and 5 mm if not [TST5/15 mm]) at 2.88 (95% CI 1.69-4.90). The pooled HR for QFT-GIT was higher than for TST at 4.15 (95% CI 1.97-8.75). The difference was large in countries with TB incidence rate <100 per 100,000 population (HR 10.38, 95% CI 4.17-25.87 for QFT-GIT VS. HR 5.36, 95% CI 3.82-7.51 for TST5/15 mm) but much of this difference was driven by a single study (HR 5.13, 95% CI 3.58-7.35 for TST5/15 mm VS. 7.18, 95% CI 4.48-11.51 for QFT-GIT, when excluding the study, in which all 19 TB cases had positive QFT-GIT results). The comparative performance was similar in the higher burden countries (HR 1.61, 95% CI 1.23-2.10 for QFT-GIT VS. HR 1.72, 95% CI 0.98-3.01 for TST5/15 mm). The predictive performance of both tests was higher in countries with TB incidence rate <100 per 100,000 population. In the lower TB incidence countries, the specificity of TST (76% for TST5/15 mm) and QFT-GIT (74%) for predicting active TB approached the minimum World Health Organization target (≥75%), but the sensitivity was below the target of ≥75% (63% for TST5/15 mm and 65% for QFT-GIT). The absolute differences in positive and negative predictive values between TST15 mm and QFT-GIT were small (positive predictive values 2.74% VS. 2.46%; negative predictive values 99.42% VS. 99.52% in low-incidence countries). Egger's test did not show evidence of publication bias (0.74 for TST15 mm and p = 0.68 for QFT-GIT). Interpretation IGRA appears to have higher predictive performance than the TST in low TB incidence countries, but the difference was driven by a single study. Any advantage in clinical performance may be small, given the numerically similar positive and negative predictive values. Both IGRA and TST had lower performance in countries with high TB incidence. Test choice should be contextual and made considering operational and likely clinical impact of test results. Funding YH, IA, and MXR were supported by the National Institute for Health and Care Research (NIHR), United Kingdom (RP-PG-0217-20009). MQ was supported by the Medical Research Council [MC_UU_00004/07].
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Affiliation(s)
- Yohhei Hamada
- Institute for Global Health, University College London, London, United Kingdom
| | - Rishi K. Gupta
- Institute for Global Health, University College London, London, United Kingdom
| | - Matteo Quartagno
- MRC Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Abbie Izzard
- Institute for Global Health, University College London, London, United Kingdom
| | | | - Neus Altet
- Unitat de Tuberculosis, Hospital Universitari Vall d’Hebron-Drassanes, Barcelona, Spain
- Unitat de TDO de la Tuberculosis ‘Servicios Clínicos’, Barcelona, Spain
| | - Roland Diel
- Institute for Epidemiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Jose Dominguez
- Institut d'Investigació Germans Trias i Pujol, CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Amita Gupta
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Edward C. Jones-López
- Division of Infectious Diseases, Department of Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospital, Pune, Maharashtra, India
| | - Christoph Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- German Center for Infection Research (DZIF), Clinical Tuberculosis Unit, Borstel, Germany
- Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany
- Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
- Tuberculosis Network European Trials Group (TBnet), Borstel, Germany
| | - Frank van Leth
- Tuberculosis Network European Trials Group (TBnet), Borstel, Germany
- Department of Health Sciences, VU University, Amsterdam, the Netherlands
- Amsterdam Public Health research institute, Amsterdam, the Netherlands
| | - Qiao Liu
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, Jiangsu Province, PR China
| | - Wei Lu
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, Jiangsu Province, PR China
| | - Peng Lu
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, Jiangsu Province, PR China
| | - Irene Latorre Rueda
- Institut d'Investigació Germans Trias i Pujol, CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Leonardo Martinez
- Department of Epidemiology, School of Public Health, Boston University, Boston, MA, USA
| | - Stanley Kimbung Mbandi
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, and Division of Immunology, Department of Pathology, University of Cape Town, South Africa, Western Cape, South Africa
| | - Laura Muñoz
- Department of Clinical Sciences, University of Barcelona, Barcelona, Spain
| | | | - Mandar Paradkar
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
- Johns Hopkins India, Pune, Maharashtra, India
| | - Thomas Scriba
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, and Division of Immunology, Department of Pathology, University of Cape Town, South Africa, Western Cape, South Africa
| | - Martina Sester
- Tuberculosis Network European Trials Group (TBnet), Borstel, Germany
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
| | | | - Surendra K. Sharma
- Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India
- Department of Molecular Medicine, Jamia Hamdard Institute of Molecular Medicine, Hamdard University, Delhi, India
- Departments of General Medicine & Pulmonary Medicine, JNMC, Datta Meghe Institute of Medical Sciences, Maharashtra, India
| | - Rosa Sloot
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Giovanni Sotgiu
- Tuberculosis Network European Trials Group (TBnet), Borstel, Germany
- Clinical Epidemiology and Medical Statistics Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Kannan Thiruvengadam
- National Institute for Research in Tuberculosis, Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Richa Vashishtha
- Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, United Kingdom
| | - Molebogeng X. Rangaka
- Institute for Global Health, University College London, London, United Kingdom
- School of Public Health, and Clinical Infectious Disease Research Institute-Africa, University of Cape Town, Cape Town, South Africa
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Abstract
Tuberculosis (TB) remains an important problem among children in the United States and throughout the world. There is no diagnostic reference standard for latent tuberculosis infection (also referred to as tuberculosis infection [TBI]). The tuberculin skin test (TST) has many limitations, including difficulty in administration and interpretation, the need for a return visit by the patient, and false-positive results caused by cross-reaction with Mycobacterium bovis-bacille Calmette-Guerin vaccines and many nontuberculous mycobacteria. Interferon-gamma release assays (IGRAs) are blood tests that use antigens specific for M tuberculosis; as a result, IGRAs yield fewer false-positive results than the TST. Both IGRAs and the TST have reduced sensitivity in immunocompromised children, including children with severe TB disease. Both methods have high positive predictive value when applied to children with risk factors for TBI, especially recent contact with a person who has TB disease. The advantages of using IGRAs and diminished experience with the placement and interpretation of the TST favor expanded use of IGRAs in children in the United States. There are now several effective and safe regimens for the treatment of TBI in children. For improved adherence to therapy, the 3 rifamycin-based regimens are preferred because of their short duration. Daily isoniazid can be used if there is intolerance or drug interactions with rifamycins. A TB specialist should be involved when there are questions regarding testing interpretation, selection of an appropriate treatment regimen, or management of adverse effects.
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Affiliation(s)
- Dawn Nolt
- Department of Pediatrics, Division of Infectious Diseases, Oregon Health and Science University, Portland, Oregon
| | - Jeffrey R Starke
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, Texas
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Zhou G, Luo Q, Luo S, Teng Z, Ji Z, Yang J, Wang F, Wen S, Ding Z, Li L, Chen T, Abi ME, Jian M, Luo L, Liu A, Bao F. Interferon-γ release assays or tuberculin skin test for detection and management of latent tuberculosis infection: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2020; 20:1457-1469. [PMID: 32673595 DOI: 10.1016/s1473-3099(20)30276-0] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 03/20/2020] [Accepted: 03/27/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Use of an interferon-γ (IFN-γ) release assay or tuberculin skin test for detection and management of latent tuberculosis infection is controversial. For both types of test, we assessed their predictive value for the progression of latent infection to active tuberculosis disease, the targeting value of preventive treatment, and the necessity of dual testing. METHODS In this systematic review and meta-analysis, we searched PubMed, Embase, Web of Science, and the Cochrane Library, with no start date or language restrictions, on Oct 18, 2019, using the keywords ("latent tuberculosis" OR "latent tuberculosis infection" OR "LTBI") AND ("interferon gamma release assays" OR "Interferon-gamma Release Test" OR "IGRA" OR "QuantiFERON®-TB in tube" OR "QFT" OR "T-SPOT.TB") AND ("tuberculin skin test" OR "tuberculin test" OR "Mantoux test" OR "TST"). We included articles that used a cohort study design; included information that individuals with latent tuberculosis infection detected by IFN-γ release assay, tuberculin skin test, or both, progressed to active tuberculosis; reported information about treatment; and were limited to high-risk populations. We excluded studies that included patients with active or suspected tuberculosis at baseline, evaluated a non-commercial IFN-γ release assay, and had follow-up of less than 1 year. We extracted study details (study design, population investigated, tests used, follow-up period) and the number of individuals observed at baseline, who progressed to active tuberculosis, and who were treated. We then calculated the pooled risk ratio (RR) for disease progression, positive predictive value (PPV), and negative predictive value (NPV) of IFN-γ release assay versus tuberculin skin test. FINDINGS We identified 1823 potentially eligible studies after exclusion of duplicates, of which 256 were eligible for full-text screening. From this screening, 40 studies (50 592 individuals in 41 cohorts) were identified as eligible and included in our meta-analysis. Pooled RR for the rate of disease progression in untreated individuals who were positive by IFN-γ release assay versus those were negative was 9·35 (95% CI 6·48-13·49) compared with 4·24 (3·30-5·46) for tuberculin skin test. Pooled PPV for IFN-γ release assay was 4·5% (95% CI 3·3-5·8) compared with 2·3% (1·5-3·1) for tuberculin skin test. Pooled NPV for IFN-γ release assay was 99·7% (99·5-99·8) compared with 99·3% (99·0-99·5) for tuberculin skin test. Pooled RR for rates of disease progression in individuals positive by IFN-γ release assay who were untreated versus those who were treated was 3·09 (95% CI 2·08-4·60) compared with 1·11 (0·69-1·79) for the same populations who were positive by tuberculin skin test. Pooled proportion of disease progression for individuals who were positive by IFN-γ release assay and tuberculin skin test was 6·1 (95% CI 2·3-11·5). Pooled RR for rates of disease progression in individuals who were positive by IFN-γ release assay and tuberculin skin test who were untreated versus those who were treated was 7·84 (95% CI 4·44-13·83). INTERPRETATION IFN-γ release assays have a better predictive ability than tuberculin skin tests. Individuals who are positive by IFN-γ release assay might benefit from preventive treatment, but those who are positive by tuberculin skin test probably will not. Dual testing might improve detection, but further confirmation is needed. FUNDING National Natural Science Foundation of China and Natural Foundation of Yunnan Province.
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Affiliation(s)
- Guozhong Zhou
- Department of Microbiology and Immunology, Kunming Medical University, Kunming, Yunnan Province, China
| | - Qingyi Luo
- School of Basic Medical Sciences, Department of Medical Imaging, Affiliated Yanan Hospital, Kunming Medical University, Kunming, Yunnan Province, China
| | - Shiqi Luo
- Department of Microbiology and Immunology, Kunming Medical University, Kunming, Yunnan Province, China
| | - Zhaowei Teng
- Department of Orthopedic Surgery, The 6th Affiliated Hospital, Kunming Medical University, Kunming, Yunnan Province, China
| | - Zhenhua Ji
- Department of Microbiology and Immunology, Kunming Medical University, Kunming, Yunnan Province, China
| | - Jiaru Yang
- Department of Microbiology and Immunology, Kunming Medical University, Kunming, Yunnan Province, China
| | - Feng Wang
- Department of Microbiology and Immunology, Kunming Medical University, Kunming, Yunnan Province, China
| | - Shiyuan Wen
- Department of Microbiology and Immunology, Kunming Medical University, Kunming, Yunnan Province, China
| | - Zhe Ding
- Department of Microbiology and Immunology, Kunming Medical University, Kunming, Yunnan Province, China
| | - Lianbao Li
- Department of Microbiology and Immunology, Kunming Medical University, Kunming, Yunnan Province, China
| | - Taigui Chen
- Department of Microbiology and Immunology, Kunming Medical University, Kunming, Yunnan Province, China
| | - Manzama-Esso Abi
- Department of Microbiology and Immunology, Kunming Medical University, Kunming, Yunnan Province, China
| | - Miaomiao Jian
- Department of Biochemistry and Molecular Biology, Kunming Medical University, Kunming, Yunnan Province, China
| | - Lisha Luo
- Department of Biochemistry and Molecular Biology, Kunming Medical University, Kunming, Yunnan Province, China
| | - Aihua Liu
- Department of Biochemistry and Molecular Biology, Kunming Medical University, Kunming, Yunnan Province, China; Yunnan Province Key Laboratory for Tropical Infectious Diseases in Universities, Kunming Medical University, Kunming, Yunnan Province, China; The Institute for Tropical Medicine, Kunming Medical University, Kunming, Yunnan Province, China.
| | - Fukai Bao
- Department of Microbiology and Immunology, Kunming Medical University, Kunming, Yunnan Province, China; Yunnan Province Key Laboratory for Tropical Infectious Diseases in Universities, Kunming Medical University, Kunming, Yunnan Province, China; The Institute for Tropical Medicine, Kunming Medical University, Kunming, Yunnan Province, China.
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Abubakar I, Lalvani A, Southern J, Sitch A, Jackson C, Onyimadu O, Lipman M, Deeks JJ, Griffiths C, Bothamley G, Kon OM, Hayward A, Lord J, Drobniewski F. Two interferon gamma release assays for predicting active tuberculosis: the UK PREDICT TB prognostic test study. Health Technol Assess 2019; 22:1-96. [PMID: 30334521 DOI: 10.3310/hta22560] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Despite a recent decline in the annual incidence of tuberculosis (TB) in the UK, rates remain higher than in most Western European countries. The detection and treatment of latent TB infection (LTBI) is an essential component of the UK TB control programme. OBJECTIVES To assess the prognostic value and cost-effectiveness of the current two interferon gamma release assays (IGRAs) compared with the standard tuberculin skin test (TST) for predicting active TB among untreated individuals at increased risk of TB: (1) contacts of active TB cases and (2) new entrants to the UK from high-TB-burden countries. DESIGN A prospective cohort study and economic analysis. PARTICIPANTS AND SETTING Participants were recruited in TB clinics, general practices and community settings. Contacts of active TB cases and migrants who were born in high-TB-burden countries arriving in the UK were eligible to take part if they were aged ≥ 16 years. MAIN OUTCOME MEASURES Outcomes include incidence rate ratios comparing the incidence of active TB in those participants with a positive test result and those with a negative test result for each assay, and combination of tests and the cost per quality-adjusted life-year (QALY) for each screening strategy. RESULTS A total of 10,045 participants were recruited between May 2010 and July 2015. Among 9610 evaluable participants, 97 (1.0%) developed active TB. For the primary analysis, all test data were available for 6380 participants, with 77 participants developing active TB. A positive result for TSTa (positive if induration is ≥ 5 mm) was a significantly poorer predictor of progression to active TB than a positive result for any of the other tests. Compared with TSTb [positive if induration is ≥ 6 mm without prior bacillus Calmette-Guérin (BCG) alone, T-SPOT®.TB (Oxford Immunotec Ltd, Oxford, UK), TSTa + T-SPOT.TB, TSTa + IGRA and the three combination strategies including TSTb were significantly superior predictors of progression. Compared with the T-SPOT.TB test alone, TSTa + T-SPOT.TB, TSTb + QuantiFERON® TB Gold In-Tube (QFT-GIT; QIAGEN GmbH, Hilden, Germany) and TSTb + IGRA were significantly superior predictors of progression and, compared with QFT-GIT alone, T-SPOT.TB, TSTa + T-SPOT.TB, TSTa + QFT-GIT, TSTa + IGRA, TSTb + T-SPOT.TB, TSTb + QFT-GIT and TSTb + IGRA were significantly superior predictors of progression. When evaluating the negative predictive performance of tests and strategies, negative results for TSTa + QFT-GIT were significantly poorer predictors of non-progression than negative results for TSTa, T-SPOT.TB and TSTa + IGRA. The most cost-effective LTBI testing strategies are the dual-testing strategies. The cost and QALY differences between the LTBI testing strategies were small; in particular, QFT-GIT, TSTb + T-SPOT.TB and TSTb + QFT-GIT had very similar incremental net benefit estimates. CONCLUSION This study found modest differences between tests, or combinations of tests, in identifying individuals who would go on to develop active TB. However, a two-step approach that combined TSTb with an IGRA was the most cost-effective testing option. IMPLICATIONS FOR PRACTICE AND FUTURE RESEARCH The two-step TSTb strategy, which stratified the TST by prior BCG vaccination followed by an IGRA, was the most cost-effective approach. The limited ability of current tests to predict who will progress limits the clinical utility of tests. The implications of these results for the NHS England/Public Health England national TB screening programme for migrants should be investigated. STUDY REGISTRATION This study is registered as NCT01162265. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK
| | - Ajit Lalvani
- Tuberculosis Research Centre, National Heart and Lung Institute, Imperial College London, London, UK
| | - Jo Southern
- National Infection Service, Public Health England, London, UK
| | - Alice Sitch
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Oluchukwu Onyimadu
- Southampton Health Technology Assessment Centre, University of Southampton, Southampton, UK
| | - Marc Lipman
- Respiratory Medicine, University College London, London, UK
| | - Jonathan J Deeks
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Chris Griffiths
- Blizard Institute, Queen Mary University of London, London, UK
| | | | - Onn Min Kon
- Imperial College Healthcare NHS Trust, London, UK
| | - Andrew Hayward
- Institute of Epidemiology and Health Care, University College London, London, UK
| | - Joanne Lord
- Southampton Health Technology Assessment Centre, University of Southampton, Southampton, UK
| | - Francis Drobniewski
- Tuberculosis Research Centre, National Heart and Lung Institute, Imperial College London, London, UK
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7
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Doan TN, Eisen DP, Rose MT, Slack A, Stearnes G, McBryde ES. Interferon-gamma release assay for the diagnosis of latent tuberculosis infection: A latent-class analysis. PLoS One 2017; 12:e0188631. [PMID: 29182688 PMCID: PMC5705142 DOI: 10.1371/journal.pone.0188631] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 11/11/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Accurate diagnosis and subsequent treatment of latent tuberculosis infection (LTBI) is essential for TB elimination. However, the absence of a gold standard test for diagnosing LTBI makes assessment of the true prevalence of LTBI and the accuracy of diagnostic tests challenging. Bayesian latent class models can be used to make inferences about disease prevalence and the sensitivity and specificity of diagnostic tests using data on the concordance between tests. We performed the largest meta-analysis to date aiming to evaluate the performance of tuberculin skin test (TST) and interferon-gamma release assays (IGRAs) for LTBI diagnosis in various patient populations using Bayesian latent class modelling. METHODS Systematic search of PubMeb, Embase and African Index Medicus was conducted without date and language restrictions on September 11, 2017 to identify studies that compared the performance of TST and IGRAs for LTBI diagnosis. Two IGRA methods were considered: QuantiFERON-TB Gold In Tube (QFT-GIT) and T-SPOT.TB. Studies were included if they reported 2x2 agreement data between TST and QFT-GIT or T-SPOT.TB. A Bayesian latent class model was developed to estimate the sensitivity and specificity of TST and IGRAs in various populations, including immune-competent adults, immune-compromised adults and children. A TST cut-off value of 10 mm was used for immune-competent subjects and 5 mm for immune-compromised individuals. FINDINGS A total of 157 studies were included in the analysis. In immune-competent adults, the sensitivity of TST and QFT-GIT were estimated to be 84% (95% credible interval [CrI] 82-85%) and 52% (50-53%), respectively. The specificity of QFT-GIT was 97% (96-97%) in non-BCG-vaccinated and 93% (92-94%) in BCG-vaccinated immune-competent adults. The estimated figures for TST were 100% (99-100%) and 79% (76-82%), respectively. T-SPOT.TB has comparable specificity (97% for both tests) and better sensitivity (68% versus 52%) than QFT-GIT in immune-competent adults. In immune-compromised adults, both TST and QFT-GIT display low sensitivity but high specificity. QFT-GIT and TST are equally specific (98% for both tests) in non-BCG-vaccinated children; however, QFT-GIT is more specific than TST (98% versus 82%) in BCG-vaccinated group. TST is more sensitive than QFT-GIT (82% versus 73%) in children. CONCLUSIONS This study is the first to assess the utility of TST and IGRAs for LTBI diagnosis in different population groups using all available data with Bayesian latent class modelling. Our results challenge the current beliefs about the performance of LTBI screening tests, and have important implications for LTBI screening policy and practice. We estimated that the performance of IGRAs is not as reliable as previously measured in the general population. However, IGRAs are not or minimally affected by BCG and should be the preferred tests in this setting. Adoption of IGRAs in settings where BCG is widely administered will allow for a more accurate identification and treatment of LTBI.
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Affiliation(s)
- Tan N. Doan
- Department of Medicine at The Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
- * E-mail:
| | - Damon P. Eisen
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- Townsville Hospital and Health Service, Townsville, Queensland, Australia
| | - Morgan T. Rose
- Department of Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia
| | - Andrew Slack
- Townsville Hospital and Health Service, Townsville, Queensland, Australia
| | - Grace Stearnes
- Townsville Hospital and Health Service, Townsville, Queensland, Australia
| | - Emma S. McBryde
- Department of Medicine at The Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
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Use of interferon-gamma release assay and tuberculin skin test in diagnosing tuberculosis in Lithuanian adults: A comparative analysis. MEDICINA-LITHUANIA 2017; 53:159-165. [PMID: 28712669 DOI: 10.1016/j.medici.2017.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 02/08/2017] [Accepted: 05/18/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND OBJECTIVE Lithuania belongs to the group of countries with a high-incidence of tuberculosis (TB). Some scientific studies show that the interferon-gamma release assay is more accurate and correlates more highly with TB exposure as compared to the tuberculin skin test (TST). This study aimed at comparing the efficacy between the T SPOT TB and TST for diagnosing TB among Lithuanian adults. MATERIALS AND METHODS Individuals with diagnosed TB, healthcare workers with known risk for TB and individuals without any known risk for TB underwent clinical examinations, interviews about their history of TB exposure and chest radiography. Then the TST and the T SPOT TB were performed on patients. RESULTS A positive T SPOT TB was more common in the group with diagnosed TB compared to healthcare workers and the low risk for TB groups (97.5%, 36.4%, and 0%, respectively, P<0.01). Positive TST results did not differ between the groups with diagnosed TB and the healthcare workers (92.5% vs. 95.5%, P>0.05). Agreement between TST and T SPOT TB was poor (kappa 0.14, P>0.05). T SPOT TB had higher specificity and sensitivity compared to TST (area under the ROC 0.9±0.04, P<0.01, vs. 0.5±0.06, P>0.05). CONCLUSIONS The T SPOT TB showed greater accuracy in diagnosing TB than TST did. Positive T SPOT TB result but not the TST was more common in patients with diagnosed TB.
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Jin T, Fei B, Zhang Y, He X. The diagnostic value of polymerase chain reaction for Mycobacterium tuberculosis to distinguish intestinal tuberculosis from crohn's disease: A meta-analysis. Saudi J Gastroenterol 2017; 23:3-10. [PMID: 28139494 PMCID: PMC5329974 DOI: 10.4103/1319-3767.199135] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND/AIM Intestinal tuberculosis (ITB) and Crohn's disease (CD) are important differential diagnoses that can be difficult to distinguish. Polymerase chain reaction (PCR) for Mycobacterium tuberculosis (MTB) is an efficient and promising tool. This meta-analysis was performed to systematically and objectively assess the potential diagnostic accuracy and clinical value of PCR for MTB in distinguishing ITB from CD. MATERIALS AND METHODS We searched PubMed, Embase, Web of Science, Science Direct, and the Cochrane Library for eligible studies, and nine articles with 12 groups of data were identified. The included studies were subjected to quality assessment using the revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. RESULTS The summary estimates were as follows: sensitivity 0.47 (95% CI: 0.42-0.51); specificity 0.95 (95% CI: 0.93-0.97); the positive likelihood ratio (PLR) 10.68 (95% CI: 6.98-16.35); the negative likelihood ratio (NLR) 0.49 (95% CI: 0.33-0.71); and diagnostic odds ratio (DOR) 21.92 (95% CI: 13.17-36.48). The area under the curve (AUC) was 0.9311, with a Q* value of 0.8664. Heterogeneity was found in the NLR. The heterogeneity of the studies was evaluated by meta-regression analysis and subgroup analysis. CONCLUSIONS The current evidence suggests that PCR for MTB is a promising and highly specific diagnostic method to distinguish ITB from CD. However, physicians should also keep in mind that negative results cannot exclude ITB for its low sensitivity. Additional prospective studies are needed to further evaluate the diagnostic accuracy of PCR.
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Affiliation(s)
- Ting Jin
- The First People's Hospital of Xiaoshan District, Hangzhou, Zhejiang, China
| | - Baoying Fei
- Department of Gastroenterology, Tongde, Hospital of Zhejiang Province, Zhejiang, China,Address for correspondence: Prof. Baoying Fei, Department of Gastroenterology, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, China. E-mail:
| | - Yu Zhang
- First School of Clinical Medicine Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xujun He
- Department of Gastroenterological Laboratory, Zhejiang Province People's Hospital, Zhejiang, China
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Leung CC, Chan K, Yam WC, Lee MP, Chan CK, Wong KH, Ho PL, Mak I, Tam CM. Poor agreement between diagnostic tests for latent tuberculosis infection among HIV-infected persons in Hong Kong. Respirology 2016; 21:1322-9. [PMID: 27121551 DOI: 10.1111/resp.12805] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 03/10/2016] [Accepted: 03/14/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND OBJECTIVE The tuberculin skin test (TST), T-Spot.TB (T-Spot) and QuantiFERON-TB Gold-In Tube (QFT) were compared in diagnosing latent tuberculosis infection (LTBI) among human immunodeficiency virus (HIV)-infected persons. METHODS Human immunodeficiency virus-infected persons without previous history of tuberculosis or LTBI were simultaneously tested by TST, T-Spot and QFT annually and followed up for tuberculosis. RESULTS Among 110 HIV-infected subjects with 85% previous TST screening coverage, 75% on anti-retroviral therapy, well-preserved median CD4 count (414/μL) and low median viral load (<75/μL), baseline TST, T-Spot and QFT were positive in 5.5%, 5.6% and 4.9%, respectively, with almost complete discordance of positive results. Among 91 (83%), 66 (60%) and 26 (24%) subjects successfully undergoing the first, second and third annual retesting, TST, T-Spot and QFT were, respectively, positive in 11/123 (8.9%), 13/173 (7.5%) and 21/182 (11.5%) on retesting, with similar discordance of positive results. There was no significant association with the concurrent CD4 count or viral load. Conversion occurred in 11/123 (8.9%), 8/160 (5.0%) and 18/168 (10.7%) of TST, T-Spot and QFT, respectively, and none was associated with changes in CD4 count or viral load. More than half of the positive T-SPOT and QFT results reverted to negative on follow-up. None of these tests picked up the single case of culture-confirmed tuberculosis observed after 798 person-years of follow-up. CONCLUSION Major discordance in positive results, high reversion rates and low tuberculosis incidence among test-positive subjects cast serious doubt on the utility of the currently available LTBI tests in the annual screening of HIV-infected persons in an intermediate tuberculosis burden area.
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Affiliation(s)
| | - Kenny Chan
- Special Preventive Programme, Centre for Health Protection, Department of Health
| | - Wing Cheong Yam
- Centre of Infection and Department of Microbiology, Queen Mary Hospital, The University of Hong Kong
| | - Man Po Lee
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong, China
| | | | - Ka Hing Wong
- Special Preventive Programme, Centre for Health Protection, Department of Health
| | - Pak Leung Ho
- Centre of Infection and Department of Microbiology, Queen Mary Hospital, The University of Hong Kong
| | - Ida Mak
- TB and Chest Service, Centre for Health Protection
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Lee P, Leung CC, Restrepo MI, Takahashi K, Song Y, Porcel JM. Year in review 2015: Lung cancer, pleural diseases, respiratory infections, bronchiectasis and tuberculosis, bronchoscopic intervention and imaging. Respirology 2016; 21:961-7. [PMID: 26998678 DOI: 10.1111/resp.12779] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 02/23/2016] [Indexed: 12/18/2022]
Affiliation(s)
- Pyng Lee
- Division of Respiratory and Critical Care Medicine, National University Hospital, Singapore
| | - Chi Chiu Leung
- Department of Health, TB and Chest Service, Hong Kong, China
| | - Marcos I Restrepo
- South Texas Veterans Health Care System ALMD, San Antonio, Texas, USA
| | - Kazuhisa Takahashi
- Department of Respiratory Medicine, Juntendo University, Graduate School of Medicine, Tokyo, Japan
| | - Yuanlin Song
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - José M Porcel
- Pleural Medicine Unit, Arnau de Vilanova University Hospital, Lleida, Spain
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